When Should I Have an Episiotomy?

One day at the state fair, I ran into a former client who complained about how uncomfortable and "disfigured" she felt one year after her birth experience. In the stroller sat her contented, sleeping baby '- the healthy "outcome," as researchers refer to babies born without incident. Yet it was clear that the outcome had not been so positive for this mother.

This client (let's call her Meghan) had suffered no complications during her pregnancy or labor except for the final few minutes, when, due to a three-hour pushing stage, an episiotomy had been cut. As she made one last expulsive effort, her baby crowned and the eight-and-a-half-pound newborn slid into the world. As the baby was admired, dried off and put to breast, I had a feeling that not all was well with Meghan's bottom. The telltale pop and the streaking of blood over the baby's head suggested perineal laceration.

The following conditions sometimes result in perineal laceration:
-- Nulliparity (no previous full-term babies)
-- A large baby
-- Uncontrolled pushing
-- Upright positioning (like squatting)
-- The use of instruments such as forceps or vacuum in delivery
-- Poor tissue (caused by anemia or malnourishment, and also seen in very pale-skinned women)
-- Malpresentation or malposition (breech or persistent posterior)

Midwives have known for a century that one of the greatest risk factors for laceration is episiotomy, and there is now a growing body of evidence to support this belief. An episiotomy is an incision made in the perineum (the area between the vagina and rectum) in order to enlarge the birth canal.

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