Newsgroups: sci.med
Subject: Re: Episiotomy...What my doctor said...Is this true? 
From: RGINZBERG@eagle.wesleyan.edu (Ruth Ginzberg)
Date: 11 Nov 92 20:42:05 EDT
Distribution: world
Organization: Philosophy Dept., Wesleyan University
X-News-Reader: VMS NEWS 1.20In-Reply-To: oispeggy@ubvmsd.cc.buffalo.edu's message of 11 Nov 92 16:06:00 GMTLines: 109

From a non-MD who has been an outspoken critic of standard obstetrical
practices for over 20 years (when they really were worse than they are now):

In <BxK7E0.5q2@acsu.buffalo.edu> oispeggy@ubvmsd.cc.buffalo.edu writes:

> cut.  He said that even without an episiotomy, the muscles are 
> often damaged (sometimes to the point of breaking).  According to 

If you make that "often" a "sometimes" I'd agree w. it.  See stats below.

> him, even if there is no tear there are invisible injuries to the 
> muscles that will not heal as well as an episiotomy. Thus a woman 

Again, make that "are" a "can be" and this is correct.

> can avoid an episiotomy and end up with weaker perineum muscles than 
> she would have had if she had an episiotomy.  Does this make 
> sense to anyone??????  Didn't make any sense to me.  Plus I've 

It is possible.  You don't see the muscles from the outside;  visible layer of
skin might be intact at the same time that there is damage to deeper tissues. 
I am agreeing that this is POSSIBLE, though I think its likelihood is probably
somewhat less than many pregnant women come to believe.

> read that an episiotomy can tear even further than the actual 
> incision, like through the rectum. 

Yes, this is possible, & it is one of the less fun complications.  It is not
what usually happens, or what is supposed to happen;  if it does, it is
(technically) a surgical complication, not a normal course of events.

The greatest risk factor for tears is the administration of pitocin in doses
high enough to shorten the second stage of labor to less than 20 minutes in a
primapara, or any method of early induction of labor before the cervix is
"ripe".  In other words, the best way to avoid tears is to have a long, slow
labor no sooner than nature intended it.

> I also said that would not want an episiotomy automatically done. 
> Instead I would want to wait and see if a tear started.  If it 
> started and got to a certain size, then I'd consider an 
> episiotomy.  He said that tears do not develop gradually.  They 
> happen all at once, so unless you have an episiotomy ahead of 
> time forget it - the tear will happen so fast it will be too late 
> to do anything.  This makes no sense to me either.  I mean, 

This is mostly correct.  If you are going to tear at all, it will be from the
pressure of the baby's head on the perineum, *not* from the uterine
contractions.  So once the tear is started, it *IS* more likely to just go
rrrrrrrriip like a piece of cloth, & to tear further than (maybe) the doc would
have made the incision.  However, the likelihood of tearing at all is nowhere
near 100%.

> doesn't it tear bit by bit with each contraction?  

no, not usually.  The perineum will become very white & shiny & then nearly
transparent as it is stretched to its greatest amount of "give".  It always
*looks* as though its going to tear any second, but it doesn't tear nearly so
often as it *looks* as though its going to.  But when it goes, it goes all at
once.

> Also, anyone have any statistics on episiotomy and homebirths or 
> births in other countries with lower rates?

Statistics from 1723 births managed by midwives in Tennessee from October
8, 1970 thru Dec. 31, 1989:

	Total Births:				1723	100%
		primaparas			 746	 43%
	Home Births:				1650	 95.8%
	Hospital Births:			  73	  4.2%
		C-secs				  25	  1.4%
		Births w. anesthesia		  26	  1.5%
		Forceps				   8	  0.46%

	[stats about presentations omitted]

	Twins (including one fetal death in utero;
		no cesarean deliveries)			8 sets

	Meconium Staining (6 of those babies had respiratory
		distress syndrome; mortality: 0) 140	  8.1%

	Maternal Mortality			   0
	Neonatal Mortality			  10	(5 per 1000)
	Perinatal Mortality			  18	(10.4 per 1000)

	Intact Perineums			1220	 70.8%
		1st degree lacerations		 228	 13.2%
		2nd degree lacerations		 271	 15.7%
		3rd degree lacerations		   4	  0.2%

	(third degree lacerations are the ones that involve the
		rectal sphincter;  you really don't want those)

    [stats about pregnancy complications & congenital abnormalities omitted]

	Apgar scores (recorded for 1310 births)
			10/10			 583	 44.5%
			 9/10			 287	 22.0%
			 8/10			 122	  9.3%
			 < 8			 318	 24.3%


(source: Ina May Gaskin, Head of Midwifery and Birth
Education Services, The Farm, Summertown, TN  38483)

------------------------
Ruth Ginzberg <rginzberg@eagle.wesleyan.edu>
Philosophy Department;Wesleyan University;USA