How can I avoid an episiotomy?

Starting around the 34th week of your pregnancy, try daily prenatal massage of the perineum (the area around your vagina). Perineum massage may increase the stretching ability of the area, decreasing the chance of an episiotomy and less chance of natural tears. (There is no medical evidence that this technique avoids an episiotomy, but it can't hurt if you want to try).

With clean hands and trimmed nails, try this technique yourself, or have your partner do it for you. Tip: If you do it yourself, use a mirror to help familiarise yourself with your perineal area:

• Sitting in a warm comfortable area, spread your legs apart in a semi-sitting position. Using Vitamin E oil (from punctured Vitamin E capsules) or pure vegetable oil, put a small amount on your fingers and thumbs and around your perineum.
  
  
• Place your thumbs about 1 inch (or just past your first knuckle) inside your vagina and spread your legs. Press down toward the rectum and toward the sides at the same time. Gently and firmly continue stretching until you feel a slight burn or tingling.
  
  
• Hold this stretch for about 2 minutes, or until the tingling fade.
  
  
• Now slowly and gently massage the lower part of the vaginal canal back and forth, hooking your thumbs onto the sides of the vaginal canal and gently pulling these tissues forward. This is what your baby's head will do during delivery. Continue for 3-4 minutes.
  
  
• Finally, massage the tissues between the thumb and forefinger back and forth for about a minute.
  
  
• Do be gentle, as a vigorous touch could cause bruising or swelling in these sensitive tissues. During the massage avoid pressure on the urethra (urinary opening) as this could induce irritation or infection.
  

Perineum massage is not for everyone and it may not help in every case. So, the most important thing you can do is to choose a midwife or doctor who is experienced and comfortable delivering babies without cutting an episiotomy. Discuss with your doctor what your expectations and choices are should in advance so that when the time comes they can follow your wishes.

What are the advantages and disadvantages of an episiotomy?

As with everything there are disadvantages and advantages to an episiotomy. An episiotomy is the most common operation in obstetrics; in many hospitals, a majority of first-time mothers get episiotomies.

It has long been thought that episiotomy prevented trauma to the perineum and improved the long-term function of the pelvic musculature. However, recent studies have shown that this is simply not true. Episiotomies do not prevent pelvic floor relaxation and do not prevent serious perineal damage. In fact, research shows that midline episiotomies tend to increase the average depth of perineal injury and substantially increase the risk of damage to the anal sphincter and the rectum (which can cause a lot of discomfort and, at times, long-term problems, such as anal incontinence). Besides increasing the incidence of serious lacerations, episiotomy is associated with increased pain postpartum, increased sexual discomfort when intercourse is resumed, and increased blood loss at the time of delivery.

Some women who do not receive an episiotomy will end up with spontaneous perineal lacerations, but studies show in general, these women also experience less pain after delivery and stronger pelvic floor musculature at three months postpartum than women who underwent episiotomies.

There are times when performing an episiotomy can be justified. Delivering a baby over an intact perineum requires slightly more time during the second stage of labor (the pushing stage), as the midwife or doctor must allow adequate time for the mother's vagina and perineum to gradually stretch.

Occasionally, the fetus simply cannot tolerate the extra time needed for the vagina to stretch naturally, and an episiotomy is used to expedite delivery.

Episiotomy is also common when more room is required for manipulation, such as for a vaginal breech delivery or the delivery of a very large infant. Plus an episiotomy is often performed before the application of forceps or a vacuum extractor. On rare occasions, the maternal tissue is either so swollen or otherwise compromised that it cannot stretch well and episiotomy is needed.

If you'd like to avoid an episiotomy, it's important to speak to your healthcare provider early on about your feelings regarding the procedure. Also, ask your care provider about her experience delivering babies over intact perineums and the episiotomy rate in the practice.