Because many practitioners will continue to perform episiotomies despite the recommendations, it's important to discuss your doctor's or midwife's position on the procedure well before you go into labor, preferably at one of your first visits. If you have a birth plan, your wish to avoid an incision unless absolutely necessary can be a part of it. If you are uncomfortable with your doctor's stance, don't hesitate to switch to one whose ideology matches yours. It can also help to remind your practitioner of your desire when you get to the hospital. Increasingly, women's births are attended by M.D.s that they haven't met, says Dr. Signorello.
Midwives are often more concerned with restricting the use of episiotomies during normal births.
In fact, one of the hallmarks of good midwifery practice is keeping the perineum free from injury, Dr. Graham says. To accomplish this, many use techniques such as carefully orchestrating a woman's pushing in the second stage of labor or massaging the perineum during birth to avoid tears or the need for an incision. Perineal massage is also something women can do themselves in the last months of pregnancy. A recent study in the American Journal of Obstetrics and Gynecology found that 24 percent of first-time mothers who performed prenatal perineal massage did not tear, while only 15 percent of those who didn't massage kept their perineums intact. Our own informal poll of nurses indicated that few, if any, of their patients had tried the technique, let alone heard of it.