The World Health Organization (WHO) states, “Limiting the use of episiotomy to strict indications has a number of benefits: less…trauma, less need for suturing and fewer complications…. Routine episiotomy, or liberal use of episiotomy, is unfortunately very common, both in under-resourced settings and in some developed countries….There are…strong reasons to counteract the overuse of episiotomy…”*

Many Obstetrics Behind the Times

This medical intervention has been done routinely for decades.  However, those who stay current with scientific research have all but abandoned the procedure.  Sadly, I find it lingering on as a matter of routine in the practice of several of the local obstetricians I have personally spoken to.  I also receive similar feedback from many of my clients who have asked me about the procedure after discussing it with their doctors in both Saudi Arabia and in Egypt.

East vs. West

Although too many women are still being cut in the West, there is growing consumerism in this regard, as women have become educated on the subject over the past years.  These women seek out doctors who do not cut as a matter of routine and often refuse the procedure all together.  However, in Arabia I find that most doctors still cut routinely and the local women simply accept the cut as a matter of fact, barely giving the issue a second thought.

I recently discovered a blatant illustration of the differing practice of the West and Middle East in this regards.  First, while watching a Canadian midwifery training video, the instructor was displaying the many instruments that may be used during birth. When she came to episiotomy scissors she made a side comment, “I know nobody does episiotomies anymore, but we have to carry them in case of an emergency.”

I was almost in tears as I heard her make that statement so casually.  Her words rang through my head as I recalled my interactions with obstetricians in Egypt and Saudi Arabia.  I practically cried as I thought to myself, “If only that were the case over here!”

My memory of conversations on this side of the globe include:

“Aisha, truly, you are special to have never had an episiotomy…” counseled my obstetrician in Egypt after discussing the matter during one of my prenatal visits.

“One hundred percent of first-time mothers must have an episiotomy,” confidently declared a doctor in a Saudi clinic.

“My doctor told me Arab women have less collagen in their skin than Western women and therefore always need to be cut,” lamented one of my childbirth students in Riyadh.  (I would have liked to ask the doctor for the scientific proof to back that up!)

This is not to say that ALL doctors in the West are good nor all in the East are bad.  You can find both categories everywhere.  But I think it’s accurate to say that more doctors routinely cut in Arabia than in the West.

But I haven’t lost faith.  I was pleased to find an article, Hospital Slashes Episiotomy Rate, which provides a ray of hope in the Middle East.  I also know of at least one local midwife who doesn’t cut as a mater of routine, masha’Allah.

Ignoring the Evidence

I don’t even want to think of how many women around the globe are cut during their births as a matter of course.  From my perspective this is a tragedy, as there is plenty of scientific evidence that indicates that the intervention should be used sparingly, not routinely.

I recently asked a local midwife about her experience with Arab women, as my student’s doctor commenting about there being a difference in skin texture had me perplexed.  She told me that in her fifteen years as a delivering midwife in Saudi, she has not seen any difference between the anatomies of Arab women as compared to Westerners.  She said the need for episiotomy should come down to individual assessment of the elasticity of the tissues, the size of the baby, how much physical preparation the mother has done in this regards for her birth, the control with which she is pushing, and the caregivers skill at assisting the woman to birth without significant tearing of the tissues.  In her personal practice, she has found no difference based on ethnicity or race alone.

In fact, I feel that any doctor who says that 100% (or any other high number) of women of any category (first-time mothers, Arabs, etc.) need an episiotomy is simply treating patients as a matter of protocol.  It’s quite obvious that such a doctor is not treating each woman as an individual, nor assessing the situation on an individual basis.  Personally, I’d run in the opposite direction from such a doctor, as I feel that birth should be cared for on an individual basis and not as a matter of routine.

My Perspective Cut vs. Tear

When I teach childbirth classes I give women specific postures and exercises to increase the elasticity of the subject tissues and I discuss with them the risk of tearing if an episiotomy is refused.

The way I see it is that an episiotomy is a guaranteed trauma with a need for stitches and painful healing after birth; whereas taking the risk of tearing gives a possibility of no trauma at all, or slightly mild trauma, which may not even need stitching (minor skin laceration).

Even if the woman tears significantly, it’s usually not any worse than had she been cut.  Of course doctors may argue that a straight cut is easier to repair, but frankly I am more concerned with the woman’s wellbeing than I am ensuring that the doctor has an easy job!

Another common retort by obstetricians is that a cut will control the direction of the tear.  Again, without a cut, she may not tear at all and with a cut there is a weakening of the tissue integrity that often leads to a tear that extends the incision even further.

Additionally, I have a personal friend who confided that she had an episiotomy with her first birth and she refused one for her second.  With the second birth she encountered the dreaded upwards tear.  She told me that the pain from the tear, even though it was in a much more sensitive area, was far less than the previous episiotomy.  She had no regrets about refusing the procedure for her second birth.

Ways to Prepare

So this leaves me to counsel you on what you can do to avoid being cut during birth.  The American Academy of Husband-Coached Childbirth® publishes a paper titled “What can I do to avoid an episiotomy?”  It includes several tips for expectant mothers.  I’ve listed them here, along with a few of my own:

1. 1. 1.  Good Nutrition to ensure healthy tissue elasticity.
   2. 2.  Squatting Exercises to stretch the tissues before birth.
   3. 3.  Exposure to Air to keep the tissues healthy.
   4. 4.  Daily Kegel Exercises (see Lifelong Pregnancy Exercise)
   5. 5.  Avoid Soap as it dries tissues (cleanse with plain water instead).
   6. 6.  Lotion and Massage to soften tissues and help mother become comfortable with her own anatomy.
   7. 7.  Talk to Your Doctor in Advance about your desires and preparations to avoid episiotomy.
   8. 8.  Be Patient during birth.  An episiotomy can speed up the delivery by a few contractions, but it isn’t worth the resulting pain and recovery trauma.
   9. 9.  Pull Your Knees Back (or Squat) during birth.  Do not spread your legs wide open (which also means stay out of stirrups!).
   10. 10.  Push With Self Control at the moment of birth to ensure you gently ease the baby’s head out and stop for the shoulders to naturally rotate during the subsequent contraction.
   11. 11.  Remind Your Doctor at the Time of Birth; don’t assume they recall your wishes in this regards (also have your companion watch and advocate for no cuts during the birth).
   12. 12.  Don’t Take Medicinal Pain Relief, as it prevents you from being able to push with self control.

Notes of Exception

It is important to note that in cases of emergency (such as a baby in severe distress or in need of assisted delivery with vacuum extraction or forceps) an episiotomy may be warranted.  But such instances are rare.

Also, for women who have undergone female circumcision, their case should be evaluated carefully to determine if the procedure significantly altered the opening of the birth canal or the available elasticity of the tissues.

Additionally, for those women that opt for epidural or other medicinal pain relief, they should consider the fact that their inability to feel the pushing phase of their birth may result in increased incidence of severe tearing as they are not able to assess how strongly to push, nor can they sense the moment the head passes through the opening to stop their pushing and await rotation of the shoulders.  They are therefore more likely to inadvertently injure themselves with uncontrolled pushing.

Conclusion

In the end, your doctor has the most power over whether or not you will be cut.  Your job includes:

1. 1.  Educating yourself on how to prepare your body so that you don’t “need” the cut.
2. 2.  Be a good consumer by finding a doctor who does not routinely cut
3. 3.  Learning how to cope with your labor and birth without medicinal pain relief so that you can push with self control when the time comes.

In the end, you are the one who has to live with the consequences of your birth experience.  Whether or not you have an episiotomy is not the end of the world, but it will surely make a difference in how you feel about your birth as well as how much pain and healing you’ll need to do afterwards.

Reference:

*Liljestrand J. Episiotomy for vaginal birth: RHL commentary (last revised: 20 October 2003). The WHO Reproductive Health Library; Geneva: World Health Organization.

©2011 aisha_alhajjar@yahoo.com, All Rights Reserved  (All writings are the original work of Aisha Al Hajjar and are based on her personal research, experiences, and opinions; they do not necessarily reflect the views of any organization or this publication.)