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Episiotomy: A Cut Above?

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Let me throw these two words at you: fecal incontinence.

petrified pregnant woman infront of a doctor

Teresa Strasser: Now that I'm seven months pregnant, I have finally gotten around to taking a break from worrying about what kind of mother I'm going to be in order to get to the urgent business of stone-cold panicking about how this kid is getting out of me, and what damage he might do as he leaves. At my last doctor visit, we had the episiotomy talk, and now I can't stop thinking about the potential slicing of my privates, or the uncontrolled tearing, or the aforementioned fecal freaking incontinence, which happens to some women after childbirth.

According to Rod Stewart, "the first cut is the deepest," but I think it's safe to say any cut that might lead to bowel leakage is the deepest, at least emotionally and spiritually.

First and second trimester concerns seem almost quaint in their solvability. Nauseous? Enjoy some ginger chews and pop some B-12. Leg cramps? Stretch your calves before bed and eat a banana. Your baby's head is too big to exit your vagina? Slice open the area between your anus and vulva, stitch it back up, and hope you don't end up with the inability to control the seepage of gas and stools from your bowels due to a torn sphincter.

Perhaps I was intentionally fuzzy on the episiotomy thing. I wasn't ready to know about my perineum. Call it squeamishness, or emotional immaturity, or just ignorance.

That is, until last week, when my doctor told me that he was a big fan of cutting, that most women will tear, and if you do a preemptive cut, you can control the severity and direction, keeping the tear away from the bad place. Fecal incontinence and severe, lingering sexual pain averted.

Sounded reasonable to my husband and me, until we got home and consulted a few pregnancy books, most of which suggest that cutting is old-school, and that perineum massage during labor can help the vaginal opening stretch, leading to just a small tear or no tear at all. Friends who have had babies are all over the place, some insisting, like my doctor, that cutting saves you from a jagged tear, others saying a rip is more natural and heals more easily.

I'm in labial limbo -- okay, not precisely, but alliteration is so seductive.

At times, I feel guilty for making such a big deal out of this cut/tear thing when I'm bringing a person into the world. Why should I care so much about my little old vagina and anus? That's when I come to my senses. This is a big deal. Fecal incontinence hangs in the balance. I have no idea which is best, and I assume it depends on you, your baby, your labor, and I also assume that you probably want a doctor who hopes for a tear but makes a cut if need be.

I haven't figured out what to do about this yet. I comfort myself with the notion that just as boots are made for walking and kidneys are made for filtering, vaginas are made for stretching. I should be fine.

Sometimes, this is obvious, and other times, 'tain't.


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20 comments so far | Post a comment now
Anonymous July 16, 2009, 3:31 PM

If this is your first baby and you have a doctor who still believes that most women need to be cut, you WILL be cut. I’ll put 100bucks on it.

The only time that it’s too late to change doctors/midwives is after the baby is born. I changed and before my records werre transferred, the baby was born. Best decision I ever made.

It’s not too late for you to run, not walk (ok, you can waddle!) to the nearest OB who says, “Well, I rarely cut, but if it’s necessary, I can do it.”

Ady July 16, 2009, 3:43 PM

When I had my daughter in no way was I planning to have an episiotomy, but it became necessary. It wasn’t that bad, the area was sore but that’s to be expected. My doctor was very professional and precise in sewing the cut, my midwife later said that there was barely a scar left. I wouldn’t know because I was too scared to look at the stitches in the first place. I was worried by looking it screw me up somehow lol.

amber July 16, 2009, 4:00 PM

My doctor didn’t discuss an episiotomy with me before hand, and I ended up having one. It was probably a good thing since my little boy weighed 9lbs 9oz. I thankfully didn’t have any problems and I have a very light scar, but this is definately up to you

Maggie July 16, 2009, 4:16 PM

I have 2 kids and one doctor gave me an episiotomy and the other let me tear all to hell and the episiotomy was about a million times better in the healing process. A million. And no lasting side effects. That’s my 2cents

Stephanie O July 16, 2009, 5:01 PM

When I researched this (6 years ago), I found data that said higher order tearing (reaching or through the anus) *increased* when an episiotomy is cut. As in it makes it worse. If you think about it in a “material properties” way, if you’re stretching something (imagine fabric) and then cut it, is in more or less likely to tear? You create a stress concentration point when you cut. (sorry - geek here)

To be fair to your doc, is explanation about controlling the *direction* of tearing is the *only* sensible explanation of why someone might consider cutting. I still would try to avoid it (I think it’s required if they have to use forceps, for example). An episiotomy by definition is a second degree tear, (through skin and muscle) and if you don’t cut you may only have a first degree tear (skin only), or none at all if you’re lucky.

And if we’re throwing anecdotes around, my friend found her natural tear (kid #2) much much easier to recover from than her episiotomy with #1. Anecdotes, IMO, are not useful for decisions like this.

Just FYI - I heard you on Adam’s podcast so I checked out the blog and loved it. You’re awesome, you’re a great mom already, the baby will be great and get here somehow and you’ll all be fine, however it happens. We are lucky to live in a time when childbirth is exceptionally safe for mom and baby. Hormones make it hard, but try not to get too obsessed with the minutiae. :) Good luck!

Sara July 16, 2009, 5:06 PM

It doesn’t matter what your doctor says about it, if you don’t want one, make it clear (PRIOR to going into labor and then PRIOR to having the head halfway out) that you do not want one unless the tearing is going to be horrible.

Doctors are shying away from routine episiotomies for good reason now - no you don’t want to “tear all to hell” (to quote the previous comment), but perineal massage DOES work. I had a very small episiotomy to limit the direction in which I tore, and was happy - but made it clear up front that was the only condition under which I wanted one.

Pregnant women sometimes forget that THEY, not the doctor, are the ones having a baby and it is not an illness - the doctor is there to guide the process, not run the show.

Christina Gleason @ Cutest Kid Ever July 16, 2009, 5:07 PM

I had a birth plan in which I stated that I didn’t want an episiotomy. My husband was gracious enough to go through that whole perineal massage thing with me in my last trimester to make me… stretchier down there. But in the end, I had a nasty tear. What made it worse was that it I healed wrong and I had to have it surgically opened back up again three months later for it to heal properly. I hurt for three months, still sitting on my little donut cushion and using my squirt bottle in the bathroom. If I could go back, I’d opt to have a clean cut made by a doctor and take the “no episiotomy” part out of my birth plan.

Heather July 16, 2009, 5:10 PM

You are MUCH more likely to end up with a 3rd or 4th degree if you have an episiotomy. This is very clear from research. It is ridiculous to consider an episiotomy unless the baby is in distress and needs to be delivered immediately.

C July 16, 2009, 5:49 PM

I was so relieved after prolonged pushing when my midwife RELUCTANTLY performed the episiotomy. I just couldn’t push enough to get that noggin through. Nothing was tearing on its own, and the perineal stretching or whatever they did down there didn’t get the job done. I had no problems with my episiotomy healing.

Char July 16, 2009, 6:00 PM

I’ve been having my husband give me perineum massages every day starting at 30 weeks (5 minutes per session). I am hoping that this will help strengthen and stretch my perineum. Also I’ve been reading that a lot of bad tearing happens if the woman is on an epidural. The reason being is that she cannot feel herself push naturally and she overcompensates, resulting in a tear.

Martha July 16, 2009, 9:52 PM

Tearing is the best way to go. I only needed one stitch and didn’t even feel the tear.

Shannon July 16, 2009, 11:15 PM

I never even thought to discuss whether or not I wanted to have an episiotomy with my docter last year before I had my son. After 18 & 1/2 hrs of labor and almost 2hrs of pushing I had an episiotomy on the bottom and top of my vagina and I STILL RIPPED! My son was in a little distress though and was coming out facing up instead of down. My docter also had to use forceps to get him out (he was 21 inches long and 7lbs 9oz). I didn’t feel much though during all of that since I had the epidural (thank god). All that really matters is your baby to be and getting he or she here as safe as possible. By the way it took about 5 weeks to heal and 2 weeks before I was walking normal again. Your vagina will be HUGE after giving birth but will look normal within a few weeks. Practice your kegels regualry too and your sex life should return to normal too. It took us about 4 & 1/2 months before our sex life was back to normal and probably would have been sooner had I practiced my kegels more and also had more sleep. Good Luck!

Heather July 17, 2009, 12:39 AM

Why do women act so surprised when they “STILL RIP” after getting an episiotomy?? Of course you do! The integrity of the skin is gone and it is a lot easier to tear. That is why extensive tears are so much more common in women who get episitomies. We know that for 30 years worth of research.

Mary O'Dwyer July 17, 2009, 4:08 AM

Hi Teresa, Research shows lying your back to deliver, having an epidural and episiotomy increase the risk of more severe tearing and a higher rate of post delivery pain with intercourse.The researchers who looked at at how woman are birthed stated’Routine and overuse of episiotomy for birth will cause increases in pelvic floor problems’Cutting can potentially lead to a worse tear. Perineal massage,and taking time to deliver in a position using gravity (not on your back)lessens the risk of tearing.
Mary O’Dwyer(Pelvic Floor PT)
www.holditsister.com

anonymous  July 17, 2009, 8:17 AM

oh boy I have wondered this my self which is better?? I have had two children… ones three and ones three months… With the first child they cut and you know it wasnt bad it didnt hurt and the baby came right on out with out too much difficulty. Afterwards it was fine the day they sent me home I was able to go shopping for all the last minute baby supplies and it healed with out a problem…. My second pregnancy was much different. I had a old school doctor who wanted to let everything happen naturally. So I tore naturally and wowzers I mean it felt like a granade went off in my underwear. I tore all the way up to my clitoris and for the next two weeks everytime I urinated it felt like fire from hell shooting out of me. It got to the point that I did not even want to pee. Then I had to go get two surgries to put my vagina back to place… So I feel cutting is the best way to go. Good luck

ashley July 17, 2009, 10:02 AM

Wow!! I guess I was just lucky. I didn’t tear or rip or have an episiotamy with my first!! I had to have a c-section with my 2nd b/c she was breach. Anyhow, my cousin just had her first last April and she tore north, south, east, and west (that’s how she put it) she had to have an unbelievable amount of stitches. We don’t think it would’ve been so bad had she had an episiotamy. Her Dr. did some things wrong, not giving her one was one thing and another was stitching her up too much and stitching her shut which she realized 5 weeks later!! It was horrible. Good luck to you!!

cherie July 17, 2009, 12:40 PM

I think there has also been talk of using a lubricant to ease delivery and reducing tears or need of cutting, also the longer you have sex during a healthy pregnancy the easier delivery. I would change doctors or get a mid-wife and the doctor could step in if needed. One old school doctor (who has since died) would cut women and then sew them up tight for their husbands pleasure and threaten retardation if some women didn’t have C-Sections, that was 30 years ago.

Anonymous July 17, 2009, 6:20 PM

does it really cause pooping problems?

Anonymous July 17, 2009, 7:56 PM

My son wouldn’t come out. They tried the vacuum and he was still stuck. So they cut me. After that, I ended up with a third degree tear. Cutting DOES NOT necessarily save you from a worse tear - BELIEVE ME!!! It was actually so bad, and I was losing so much blood that they couldn’t repair it in the delivery room. I then spent 2 1/2 hours in the OR with a specialist repairing the damage.
That being said, after months of recovery (literally, MONTHS. I couldn’t have sex with my husband until my son was 4 months old without MAJOR pain!), it’s all better now. I have some scar tissue, but it all looks and feels basically the same. I don’t have any “fecal” issues, although passing gas is a little… um… weirder than before. I’ll leave it at that.

Chas September 11, 2010, 12:36 PM

The episiotomy scar makes for a lovely, little, intimate sign or souvenir that marks you as a fertile woman. Fertility being sexy, I find that little pink line to be very appealing - it’s a sexy, little, interesting and intimate detail of a woman’s body that bears caressing with a fingertip, or the tip of a tongue. :)


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