Enema before delivery?! Apparently it's "standard" at my hospital

[gherkins]

Hi,

Just got back from my 2nd antenatal class, and we were told by the midwife leading the class that women delivering at our hospital will be given an enema when they arrive at hospital.

Is this usual? I've never heard of this happening before. Well, actually my Mum said she was given one before having me, but that was back in the 70s! I had no IDEA this was standard - first I'd heard about it

Is this really standard procedure? If so, what's it like?

I'm rather morbidly fascinated

I would be on a plane at eight months to a country where you are not required to shit on command and then perform a fitness test when you are in transition TBH

Naetha - that's interesting. Anything that can delay the dreaded poo-after-childbirth has gotta be a good thing! Nice to hear one person with a positive story on enemas.

It isn't standard practice to perform a routine episiotomy. If you require an instrumental delivery (forceps or ventouse) then it may be necessary to have one. From a midwife's point of view I would only consider one if the perineum wasn't stretching up enough to allow the baby's head to crown or if the perineum appeared to be tearing in such a fashion that it would lead to a very nasty tear.

whomovedmychocolate made me snort with laughter

ok I'm confused now! Does the strength or weakness of your pelvic floor muscles (which I understand to be inside you) have no relation on whether you tear or not? Of course as you all say it's the perenium (sp?) that actually tears, which is not the same as the pelvic muscles.

I thought the point of kegels and pelvic floor exercises was to prevent tearing. So strong muscles help you stretch to accommodate the baby coming through? And if they are weak, you'll tear?

If your muscles are not 'examined' () before you actually deliver the baby (i.e. before you crown) how can a midwife know if you'll tear... ? Or do they only usually cut you in the UK if, during crowing, it's obvious you are about to imminently tear in the perenium area?

Basically - what is NORMAL ?! I need to know what happens in a normal blooming country!

Enemas and episotomies definitely not standard practice in the UK for the reasons outlined already. A tear all the way to the anus would be extremely rare (although I'm not a HCP and can't point you to research on this!) so it sounds like scaremongering to me.

AFAIK things like enemas and episotomies are for the convenience of the staff (a straight incision is generally easier/faster to stitch that a tear) rather than in the best interests of the mother.

Sounds like a pretty old-fashioned view of childbirth and I personally would prefer to give birth in a place that where the staff listened to me and had my (and the baby's) best interests at heart!

in standard terms?

1. an enema would only be offered if a woman was very constipated.

1. episiotomy - more difficult. the midwife would be watching your perineum stretch as the head comes down and also the baby's heatrate.

if the baby needs to come out quickly - if the HR was vey low and not recovering - the midwife might consider an episiotomy.

if ventouse was needed - if babes head was not coming down quickly enough or if forceps were needed - again an episiotomy.

if the perineum was 'rigid' and babe's head couldn't stretch it to come out again - episiotomy considered.

if mum is knackered and simply can not do any more - again considered.

if the perineum looks like it is going to rip in the wrong direction or starts to tearin the middle (risking extending to the anus) episiotomy to minimise tear is considered.

but each and every single woman (and her perineum) is assessed and considered at the time - not cut just to avoid a tear or cut because it is her first baby or cut because it is the way things are done.

gherkins where in the middle east are you? There are doulas working in various regions - often to support ex-pats like you navigate their way through the often over-medicalised system.

As everyone is indicating the info you are getting is factually incorrect and all these interventions are unnecessary.

Let me know where you are and if it's of interest to you I can suggest a few doulas for you to talk to (you can always have a chat without obligation).

Failing that I'm happy to chat to you on the phone (I'm a UK doula) if that would be helpful.

The Royal College of Obstetricians and Gynaecologists' Q&A on spisiotomy refer to a 2009 Cochrane systematic review (Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD000081. DOI: 10.1002/14651858.CD000081.pub2.) which found that:

"Restrictive episiotomy policies appear to have a number of benefits compared to policies based on routine episiotomy. There is less posterior perineal trauma, less suturing and fewer complications, no difference for most pain measures and severe vaginal or perineal trauma, but there was an increased risk of anterior perineal trauma with restrictive episiotomy."

and to the NICE guideline on Intrapartum Care (National Collaborating Centre for Women?s and Children?s Health. Intrapartum Care: care of healthy women and their babies during childbirth. London: RCOG Press, 2007. www.nice.org.uk/nicemedia/pdf/CG55FullGuideline.pdf) which makes the following recommendations:

"- A routine episiotomy should not be carried out during spontaneous vaginal birth.

• Where an episiotomy is performed, the recommended technique is a mediolateral episiotomy originating at the vaginal fourchette and usually directed to the right side. The angle to the vertical axis should be between 45 and 60% at the time of the episiotomy.

• An episiotomy should be performed if there is a clinical need such as instrumental birth or suspected fetal compromise."

The NICE guidelines are what should be standard policy at all UK hospitals.

Thanks for all the detailed info. Good to hear about what should be standard. It's all very helpful.

Yes - this is certainly a place where things appear to be done for the convenience of the staff, rather than the comfort of the woman.

It's funny - most women who've had babies here say it was fine though. Perhaps I need to delve deeper and ask about unwanted enemas and episiotomies though!

AFAIK pelvic floor exercises are more to do with preventing stress incontinence during and after pregnancy rather than crowning/preventing tears.

You could look into perineal massage instead as that can help reduce the risk of tearing. Check out this excellent NHS guide to perineal massage (opens as a pdf).

NICE guidelines don't even mention enemas, except to say "While the rituals of
perineal shaving and the administration of enemas, previously performed to reduce contamination of the genital tract during birth, have been discredited..." which makes it fairly clear that they routine enemas (i.e. unless there is severe constipation) are emphatically not standard policy in the UK, and so far from being standard policy that NICE doesn't even feel the need to explain why not.

Surely whether or not you tear has to do with how stretchy your skin is? I don't think it has anything to do with how strong your pelvic floor is?

Thanks everyone for your posts. So helpful. I'm going to do some more research and delve a little deeper.

The midwife made it sound as if the pelvic exercises are to prevent tearing, whereas I thought it just helped - as you say Flip - with bladder issues, and I guess help as you physically push the baby out in terms of muscle power.

She didn't mention perineal massage - will investigate and ask her about that.

Rebecca - thanks for your post, I have messaged you

It's bedtime here, so it's over and out from me tonight. Thanks for all the advice!

lal123 that's what I thought!

tearing may not be pre-asessable - how can they assess the exact position of the foetus? the speed of the last cont-x? how well you will stretch? these things are all unknowns until the baby pops out.

women tend to be happy if they come out with a baby - and blank out the gory details.

No definitely not standard. I have given birth in the UK and elsewhere. In the UK no enema and no episiotomy but had both with the other one. Quite humiliating tbh (the enema, not the episiotomy), they put it in themselves, just thinking about it makes me want to cry.

The info you've been given so far wouldn't inspire me with confidence that the hospital was practicing up to date, evidence-based medicine.

Do they have any figures on birth outcomes like hospitals in the UK produce (e.g. % of VBs, Emergency or Elective CSs, instrumental deliveries, episiotomies, epidurals). These can be quite enlightening. If it turns out that most VBs at the hospital end up with episiotomy and forceps delivery, you may want to ask further questions and/or rethink your plans...

There's 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.

There are still valid reasons for doing an episiotomy sometimes (someone has already listed them, I think). Preventing tearing normally isn't one of them.

I think you should come home for the delivery!

Regarding episiotomy - can I boast about the unenviable and say I've had three - two to the right and one to the left! That was the last one. One of my many reasons for no more children is that there's no place left to cut!

yuck. i wouldn't want one. i had one when i had a colonoscopy a couple of years ago and all the poo doesn't come out in one neat and tidy episode - i was running to the loo every 10 minutes for about 2 - 3 hours. would not fancy that during labour....

I would seriously consider coming home for the birth. I'd be worried about how out of date other areas of their practise/protocols may be.

sounds a nightmare carda - last thing you'd need.

i never had one and never had any accidents in labour or urge to go. i did however end up begging the midwife to empty my bladder with a catheta (sp) because between every contraction i was squatting on a cowboy hat convinced i was desperate to pee but not being able to get it out. she took pity on me.

oh and i had to have an episiotomy and they bodged the repair so ridiculously that it was impossible for it to heal. i had to go back for a secondary repair which thankfully was a success.

and that happened here in UK, with a registrar in theatre.

try not to panic too much, meet the obstetricians, visit the hospital, talk to people who've given birth there etc.

Just to add, considering the last posts, when I had the enema before labour I needed just one toilet trip and that was it. And the episiotomy was fine too, no problems as such.

There have been MN threads before comparing childbirth in different countries, and the Middle East came out as very interventionist (Saudi especially)... IF you are at one of the top hospitals. For the peasant women in the hovels of Cairo or Sana it's a Get On With It Yourself game, of course.

I think a lot of the MiddleEast hospitals are very heavily American influenced (and patronised), and episiotomies are still very standard in the USA, :( so the hospitals offer what most of the women would expect "at home".