Tuesday, January 11, 2011

That Cut

It does not surprise me how often the conversation turns to "the stitches" when women get together to chat about their births. It is not just the shocking assault on a very intimate part of our bodies but it just plain hurts!!

So the big question I am so frequently asked is " Was it necessary?" The simple answer is, possibly. As I covered previously, routine episiotomies were introduced without any research on the heresay of mainly one individual who thought they were a good idea.

An episiotomy creates an injury that is equivalent to an extensive tear that is called "second degree" as it involves not just skin ( first degree ) but muscle as well.  A second degree tear may be small or large.  So what could be the advantage of creating a fairly serious " artificial tear "?

The debate continues to rage over what are the proper indications to perform one. The main reason sited, that a cut "protects the perineum from third degree tears ( real nasty tears that run into your anus )and prevents incontinence", has been disproven by research.  Another is that a cut is easier to sew up than a tear.  Can I say I have not found any experienced attendant who finds this an issue.  Having selected perineal integrity as my main area of interest during my time as a midwife I found my observations did not support many popular theories.  The cutting of an episiotomy during birth often lead to worse tearing as the baby would generally emerge in an uncontrolled rush.  The best outcome was always a slow, slow delivery of the head with the woman upright and bottom in the air.  However, there are still occasions when I still perform an episiotomy during a birth.

The most important reason is that the baby is seriously distressed and needs to get out and fast.  If the baby is being held up by the perineal floor there is no alternative.  Another is that the perineum begins to swell and begins a tear in the middle ( button hole tear ) before the baby is low enough to put it under much pressure.  By cutting a fairly modest episiotomy and carefully and slowly delivering the babies head I could actually reduce the amount of damage that took place.  An unusual one is that the woman is circumcised and cutting the scar tissue is the only way to allow the baby out. Except for this unusual situation, it is rare for a perineum to be so resistant as to prevent a birth but occasionally it is seen. The old idea that most episiotomies are performed to save time, prevent the attendant from having to explain why they couldn't prevent a tear and that it makes the obstetrician appear as if they have done something useful as they often appear only for the birth does, in my opinion, hold some water.  

The good news is that the current trend is to reduce the routine episiotomy rate.  Research has been called for to determine if it really is helpful when using forceps or if cutting an episiotomy does protect the premature babies head during birth. So lets hope this trend continues as looking after a new baby is hard enough without being unable to sit down or walk in comfort.