If you are planning on a vaginal birth,whether or not to have an episiotomy is an important decision to consider. While all women know that child birth is painful, the thought of having her vaginal area cut or torn is very frightening. It is best to know all the options available before labor begins, so that your birth plan expresses your specific wishes.

Episiotomies
Are episiotomies necessary? Many women today say no. Episiotomies used to be done routinely during a vaginal child birth by the doctor or midwife as a way to help the woman avoid getting a tear.

There are two main types of episiotomies – the midline and the mediolateral. The midline is when the doctor makes the incision straight down towards the anus, and the mediolateral is an incision made diagonally to help avoid a later tear into the anal area.

Episiotomies are said to have both positive and negative aspects

The benefits can include:

• Faster birth
• Prevention of tearing
• Protection against incontinence
• Protection against pelvic floor relaxation
• Faster rate of healing than tears

The negative aspects can include:

• Infection
• Increased pain
• An increase in 3rd and 4th degree vaginal lacerations (euphemistically called extensions)
• Longer healing times
• Increased discomfort when intercourse is resumed

Many midwives believe that there are better ways to avoid a tear than getting an episiotomy. These might include:

• Good nutrition (healthy skin stretches more easily)
• Kegels (exercise for your pelvic floor muscles)
• Prenatal discussion with your care provider about episiotomy
• Prenatal perineal massage
• A slowed second stage (controlled pushing)
• Warm compresses, perineal massage and support during delivery

Tearing
Many organizations that do not consider episiotomies as necessary believe that it is better for a woman to tear, but is it really? Some make the argument that not every woman will tear, and that those that do may only tear a tiny bit, resulting in only one or two stitches, vs. the 10, 20 or even more needed with an episiotomy. Not every woman will tear during delivery, and so some women may have episiotomies unnecessarily.

There is a negative side to allowing your body to tear naturally as well. Both episiotomies and tears are considered by degrees. The most common is the second degree tear or cut, which extends halfway back to the woman’s anus. The least common, but most painful, is the fourth

Both options today are acceptable in the medical field, and episiotomies are actually done less routinely than they used to be on pregnant women. It is best for a woman to research both options before she goes into labor so that she can choose which one she prefers while writing out her birth plan, and talking to the doctor at delivery.

By Heather HillIf you’re like me when I was pregnant, you are probably being bombarded with information. Between reading and getting so much advice about everything from what to feed your baby to which diaper cream to use, you might find that you have more questions than answers. You are also probably wondering about what to expect on the BIG day.

One subject that can generate a lot of opinions is episiotomies. Do you need one? Do you even want one? First of all, let’s define the word: An episiotomy is a cut made by a physician in the lower opening of the mother’s vagina during delivery in the attempt to ease the passage of the baby through the vagina. Most episiotomy cuts are done straight down into the perineum, the area between the vagina and the anus.

OK, now that you know what it is, I bet you are wondering why doctors perform the episiotomy procedure. Traditionally, episiotomies were done by doctors when forcep delivery was a common practice. A cut enabled the doctor’s forceps to fit into the vagina in order to remove the baby.

According to a Centers for Disease Control’s 2001 study, forcep deliveries have decreased from a rate of 17.6 percent of all deliveries in 1980 to only four percent of all deliveries in the year 2000. Episiotomy rates, however, have not followed this same trend. Episiotomies have dropped to 32.7 percent of all deliveries versus 64 percent in 1988.

So, I bet you are wondering why doctors would still perform an episiotomy given that forcep deliveries are now done so infrequently.

Most of the reasons for the persistence of this procedure are based on incorrect information. Some doctors believe that an episiotomy will protect the pelvic floor against damage. A 2005 study published in the Journal of the American Medical Association, as well as other recent studies, proves this to be an incorrect assumption. These findings also show no evidence that a cut in the perineum “protects” the pelvic floor muscle.

Another frequently cited reason for doing an episiotomy is the belief that a natural tear repairs more slowly than a doctor-performed cut. This is untrue. A natural tear will actually heal much better than an episiotomy. Tearing is much safer than a cut; and while many people think that an episiotomy is easier to repair than a tear, this is not true, according to a 1987 study by J.M. Thorp and other doctors writing for the publication Obstet Gynecol.

Here’s another reason against cutting the skin to allow the baby’s head to pass during birth: Think of your skin as a cotton sheet. If you use scissors to create a physical cut, the fabric will rip and tear more easily. The last thing you want, therefore, is for a doctor’s cut to your vaginal area to continue to tear with the stress and strain created by the force of a baby being born, thus potentially injuring you or damaging your perineum. Use this analogy to think about how your skin tears, and you may decide that you don’t want or need an episiotomy. Always discuss this topic in depth with your caregiver.

As is always the case with many invasive procedures, episiotomies bring several risks to the mother. Infection, bleeding, hematoma, and post-partum pain are merely a few of the risks. Another interesting fact is that some studies have also shown that women who tear naturally during childbirth return sooner to sexual intercourse after giving birth than women who are “cut” by their physicians. (This finding was reported by P.G. Larsson and other doctors in a 1991 edition of Gynecol Obstet.)

Now that you know that routine episiotomies are not always necessary, there are some very rare cases where an episiotomy is necessary. Discuss these reasons with your caregiver so that you are prepared and educated in advance of your baby’s birth.

Do you want to know how to avoid an episiotomy? You can prevent the need for an episiotomy in several ways.

First and foremost is to become educated on the topic, including all the pros and cons of the procedure.

In addition, at the time of your delivery, ask your caregiver to instruct you on your pushing at the time of crowning. If a mom has instruction in controlled pushing, the vaginal skin will stretch naturally to accommodate the baby. This goes back to the thought that your body knows what to do.

You might also try the following suggestions:

Birth plans have become the next “big thing” for pregnant women who decide that they want to maintain some control in the labor and delivery of their unborn child, as well as in the post-partum care both she and her baby receive in the hospital. Some people do not know how to create a birth plan, or why creating a birth plan is an important aspect of their pregnancy.

When a laboring woman arrives at the hospital, there can be limited time to get her feelings regarding how she wants her labor to progress across to the nurses on duty. Birth plans are generally written by the pregnant woman, sometimes with the assistance of her labor partner several weeks prior to delivery. It should then be taken to your doctor or midwife at one of your prenatal appointments to go over your wishes and make sure that your provider is aware of any concerns you might have.

Flexibility
One thing to keep in mind when creating your birth plan is to maintain flexible. Even if you have the textbook perfect labor and delivery, chances are that something in your birth plan will not be able to be accomplished or achieved. It might be because of your hospital, or it might be as simple as you originally saying that you do not want pain medication, just to change your mind half way through labor. If you remain flexible regarding what you wrote in your birth plan, the day of delivery will go much smoother.

Creating your Birth Plan
So how do you create a birth plan? You can use our customized birth plan creator, or you can create one from scratch. If you create one from scratch, be sure to remember to include everything that you deem important.

Pain Medication
When doing your birth plan be sure to mention your wishes on pain medication. Do you want pain medication or not? If you do want pain medication, how much and what kind do you want? If you want medication, do you want to have just a shot through your IV of something to just dull the pain a bit, or do you want an epidural which will go in your back and pretty much get rid of all pain and contractions that you feel? Do you want the doctor or midwife to suggest to you medication, or not mention it at all?

Episiotomy or Tearing
Also, when creating your birth plan, be sure to let everyone know what you will prefer when it comes to having an episiotomy. An episiotomy is when the doctor or midwife cuts the perineal area that goes from your vagina to your rectum an inch or two before the babies head comes out in order to help the head come out easier. Some women prefer to be cut; other women prefer to tear naturally. Many women’s activist groups these days are promoting tearing vs. no episiotomy because some women won’t tear at all, or only tear a tiny bit, making the healing time less painful than it would have been with an episiotomy.

Visitors
Let the nurses know in your birth plan who you want to be allowed in the room and when. Some women are fine with having everyone in at once, and others prefer to only have their birth partner, or have other visitors come in one at a time. You might want the interaction and distraction during the early stages of labor, but not want a bunch of people in the room towards the end. There are also times when you may not want your parent or an in-law in the room at all, but you do not want to be the bad guy. Buy writing these wishes down in your birth plan, it enables your nurse to tell people who can and can not go in and when, and also makes the nurse be the “bad guy” so you don’t have to concentrate on those issues when you should be concentrating on pushing your baby out.

Immediately After Birth
Assuming you have a vaginal birth, you should include in your birth plan your wishes for the baby immediately after birth. Some women will choose to bank their babies cord blood and will have that set up ahead of time. Others want to make sure the cord stops pulsating before it is cut, letting the baby get the remaining nutrients that are important for their health. If you are breastfeeding, you may want to be allowed to nurse immediately, vs. having to wait several minutes for your baby to get cleaned up a bit and get eye drops. Your baby is most alert in the 30 minutes or so right after birth so it is an important time for you to be able to nurse and bond.

Just incase a c-section becomes a necessity, you should list your wishes for the baby while they are finishing up your surgery, in your birth plan. Put down whether or not you want your baby accompanied at all times by your birth partner. Let them know ahead of time your wishes on them giving your baby a bottle of sugar water or formula while you are in recovery. Make it clear if you want your baby brought to you in recovery or if you want to wait till you get back to your room.

Postpartum Care
Part of your birth plan includes your post-partum care. Most hospitals support and encourage your baby staying in your room with you at all times, vs. going to the nursery at night or while you sleep. You can make it clear in your birth plan what your preference is. Whether or not you want to room-in, or if you just want your baby brought to you for feedings letting you rest as much as possible. You can also list whether or not you want your birth partner to be allowed to stay the night.

Feeding
In your birth plan you will list your intentions on feeding your baby. You can state whether or not you plan on breastfeeding, and if you do breastfeed how often and when you want to do it. That is important in the instance that you choose not to have your baby rooming in with you, but instead in the nursery. You should make it clear if you want to feed the baby on demand, when the baby is hungry, or if you prefer to feed the baby on your schedule, allowing the nurses in the nursery to give the baby formula when he gets hungry.

Miscellaneous
There are always other things you might think of when it comes to your hopes and wishes for a happy and healthy labor and birth. Things like taking pictures, video taping, having music playing, moving around, being allowed to take a bath or shower during labor, etc. If any of these things are important to you, or you can think of others, be sure to list them in your birth plan for the nurses and your doctor or midwife. Happy birthing!