Do I have to have an episiotomy?

[mum2oneloudbaby]

I had a 2nd degree tear extending to the anal sphincter with my first birth. I then suffered some incontinence in the following year which has since got much better.

I have had scans done during this pregnancy and they have come back all clear everything in tact so I am planning to have a VB.

What has me worried is that the consultant was quite insistent that to avoid tearing again I should have an episiotomy. The thought of it just makes me [urgh] and to be quite frank I don't think it makes much sense making a major cut when I might not need it!

With DD I only had G&A pain relief and would like the same again but if they do an episiotomy could this lead to further pain relief/intervention?

Have you refused one? Did you meet resistance from MWs?

There's very strong evidence that episiotomy does not prevent tearing. There's even some research suggesting that it increases the chance of experiencing third and fourth degree tears.

This is one of the reasons why episiotomy rates have been falling in the past few decades.

Are there particular reasons why your doctor thinks that your case might be different? Ask him why he thinks that episiotomy might have a protective effect for you in terms of tearing when it doesn't in general.

There are still valid reasons for doing an episiotomy sometimes (i.e. when you need to get the baby out ASAP with or without forceps). Preventing tearing normally isn't one of them.

The consultant said it was just to prevent tearing. Other than the fact I had quite a bad tear and a long labour the birth of DD was quite straightforward, G&A only no forceps, ventouse, dd was never distressed it was quite a positive birth.

Everything you have said makes common sense to me. Obviously medically I can't comment but to my mind if you cut something you give it a weak point to tear along.

I was told i would have an episiotomy (first child anything goes) I was allowed to tear and tore a blood vessel, cue the crash button. No advice really just an example - go with your gut instincts. I don't believe it would lead to any more pain relief either way.

i had a second degree tear with my first

i had homebirths for my second and third babies and didn't tear at all. they were big babies with big heads too!

so... no, you don't have to have an episiotomy.
there are definitely people who believe it's better to tear anyway as it heals better naturally (jagged edges knit together better or something)

i think it's something you should put in your birth plan though.
an experienced midwife i think should be able to help you get through the crowning part very slowly and help you to reduce your chances of tearing.
you could also say that if they feel that you have a very strong chance of tearing you would like them to do an episiotomy (or not!)

remember... all any HCP can do is advise you. ultimately the decision is yours

oh and to add... if they do need to do an episiotomy they'd either just do it, or they'd give you a local anaesthetic

by the time they get to needing an episiotomy you're presumably most of the way there, so i don't think it would lead to any kind of cascade of intervention

Mmmmm. I'm a little concerned by your statment about ?faecal? incontinence and the fact that you are still suffering this as a result of your previous birth injury.

Nice guidelines are that anyone with previous serious tear with ANY degree of incontinence should be recommended/offered an elective cs.

I am in this situation myself, and have opted for the elective.

Obviously it is an individual choice, but have you looked into all the pros and cons of another VB (whether or not you tear again), I mean the long term problems? I was told any incontinence symptoms WOULD get worse after menopause, and avoiding more injury to the area (which can happen even without a tear), was really important in terms of my quality of life issues 10 or 15 years down the line.

I know a CS is a major op, and it was not a decision I took lightly, but after reading into the pros and cons for a few days, the thing that decided me was that bowel repair ops are difficult and often give less than perfect results, even with repeated "revisions" (obviously for some they will work fine and have perfect results first time), and many women are left with ongoing problems (this is fairly common). With a CS, there is a very low chance of any complication which requires a second op to fix it, and if you do get one of those rare problems, revision surgery is less complex and more successful than with failed bowel surgery.

Interestingly, though my consultant said I had "clear clinical indications" for having an elective, and I am very happy with my decision to have one, every MW I have seen since has asked me if I want them to talk to the consultant to see if I can have a VBAC instead - it appears to me as if the consultants are looking at the long term issues and the overall risks, but the MW are looking only at the short term risks so see the elective as being a bad idea.

Obviously that's just my view, and it's your decision.

On the episiotomy issue, I'd say no (unless it was to help with forceps) - and they can't force one on you if you don't consent.There's a lot of evidence to show they can increase the risk of tearing - is your consultant fairly old and/or out of date?

That's very interesting oldmum42 the consultant never even suggested an elcs as the scans came back in tact and colorectal surgeon said it should not have an impact on delivery choice.

Maybe I should have asked more questions it just seemed to be a straight forward decision as far as the consultant was concerned a vb nothing else discussed.

The NICE guidelines on this are fairly recent - previously (before more extensive studies had been done), it was thought rather stupid to undergo a major op to avoid a tear, but there is more info now, and the situation is complex as the long term issues were not being looked at.
Unfortunately I think some consultants are not following the guideline and offering women the choice (or informing them of the potential problems they may experience in later life).

It's good that your scans came back ok, but you DO have symptoms, which means there is some damage there, obviously not serious damage, or the scans would have shown it, but surely all the more reason to consider you options to avoid further damage?

My consultant didn't even send me for scans - he asked about my symptoms and when I said "not terrible by any means, but I have to be really careful if I feel the urge to go, I need to go RIGHT NOW, though only first thing in the morning, hardly ever a problem otherwise" he just said these symptoms WILL get worse after menopause, you have a clear clinical indication for Elective section, to avoid further damage.

As I said, of course it's your choice, but I'd be talking to my consultant again if I were you - read up on the topic first, and see what the response is. Remember, it is the job of the Dr or MW to tell you what your options are, and what the pros and cons of each choice is - it is not their job to make that decision for you!

Do bear in mind that there is huge pressure on maternity services to reduced the number of C Sections because of the cost implications. So if women are not asking it is unlikely they are going to be offered despite the possibility of long term health problems - the cost of which will not be coming out of maternity services.

Very good point GAILFORCE!

DH (doctor) sees this kind of budget manipulation costing the NHS a huge amount of money all across the service.

Thanks for your input oldmum42 and gailforce1.

Having now had a few days to mull over this I am waiting for a call back from the consultant. I had pretty much prepared myself for a cs prior to the appt but I am useless in these medical appointments and it's not until afterwards I always think of what I should have discussed. Plus, the consultant was not easy to talk to and he kept talking to my husband!

Do you have a link to the NICE guidelines oldmum42? I've tried to find them but to be quite frank how anybody can find anything on that website is beyond me.

would def avoid unless forceps are necessary - which is a whole other ball game in itself with forceps sometimes causing nerve pain etc - go natural, wait as long as possible for labour to start, try not to go down the induced route - if those indications present themselves and if u have discussed the situation before hand switch to a cs but presence of mind firmly needed at that point, dw had option of cs given to her as she wasnt dialating whilst being induced but we stupidly waited another two hrs by time she was fully dialated registrar steemed in with forceps and she still recovering 4 months later