H
istorically, an episiotomy,
which is an incision
made between the anus
and vagina, was thought
to be the lesser of two evils. While it
does cause discomfort and scarring,
can cause infection, and is certainly
an impediment to an early return to
sex, the greater evil was thought to
be a very damaging and uncontrolled
tear that might otherwise damage
the major anal muscles. For this
reason, an episiotomy was carried
out routinely, especially for first-time
mums.
But then people – quite rightly,
in my opinion – started asking
questions, and in 2000 and 2005
two major studies indicated that, in
fact, in an uncomplicated delivery
the chance of a major tear was quite
small and certainly didn’t justify
a routine episiotomy and all the
negatives that come with it.
As a result, The World Health
Organization, the Royal College of
Obstetricians and Gynaecologists
and The American College of
Obstetricians and Gynecologists
now all recommend a “restrictive”
approach to an episiotomy. Under
a restrictive approach, doctors
will typically only recommend an
episiotomy when: there is foetal
distress and there is no time to wait;
forceps or a vacuum are needed to
assist in the delivery; the mother
doesn’t feel a sufficient urge to push
(for example, with an epidural);
the perineum is very tight (possibly
because of an earlier scar); or there
are early signs of tearing.
In Hong Kong, the restrictive
approach met with resistance because
it was thought that Chinese women
had a shorter perineal length, and
were therefore more likely to suffer
a major tear. However, a 2009 study
by doctors at the Prince of Wales
Hospital showed that, in fact, perineal
length was not related to the risk of a
perineal tear. The study also showed
that when a restrictive approach
was taken, the episiotomy rate was
reduced from 73 to 27 per cent, and
among those who didn’t have an
episiotomy, no one suffered a major
tear.
There are steps you can take to
reduce your chance of an episiotomy
– assuming your doctor or midwife is
willing to take the restrictive approach.
1.
Discuss your pain relief method
with your doctor or midwife. A full
epidural will increase the need for
an episiotomy: because you cannot
control or feel the urge to push, it is
more likely the doctor will need to use
forceps or a vacuum, which usually
do require an episiotomy. However,
epidurals can sometimes be managed
so the effect wears off by the time you
need to push.
2.
Work with your midwife or doctor
to control the birth, pushing and
waiting at the right times. If you
don’t feel the urge to push, it’s often
because your body is saying, “Stop,
give me time to stretch.” You should
also be using this rest time to regain
your energy for when you do need to
push, reducing the need for medical
assistance.
3.
Find positions where you have
more control when pushing and can
clearly feel the urges. There are also
positions that help reduce the urge,
and your midwife might suggest such
positions if she feels your cervix, or
later the perineum, is not quite ready
to take the strain.
4.
Touching the perineum with your
own hand when the head is crowning
helps you get a better feeling of the
actual progress of the head coming
down. Sometimes the counter-
pressure will help you feel more
confident in the process and your
ability to push, which can reduce
both your need for an episiotomy and
the risk of severe tearing.
5.
Perineal massage can help,
especially if there is previous scarring.
It can also help increase your
confidence as you get to know your
own body better. Ask you prenatal
experts for guidance.
6.
Most importantly, try to be calm
and patient during your delivery and
let nature help you through.
An episiotomy is one of the most common medical interventions
during childbirth, and it’s also one that concerns most mothers-to-be.
Here’s what you need to know, writes midwife
Hulda Thorey.
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