episiotemy vs tearing..

[asset1]

I had 3rd degree tears with DS (ventouse). Due with DD in 12 days time and very keen not to repeat the experience. MW recommended that I have an episiotemy to avoid tearing. She said that by cutting to the side IYSWIM it would avoid tearing towards the anus... I'm keen to try other things as well, Iv'e heard all fours is a better position to avoid tearing. anyone have any experience with this?

Hiya,
research seems to show that episiotomy in general DOESN'T seem to reduce the number of 3rd degree tears, is more painful and takes longer to heal than a tear. I know your case is special because of a previous bad tear, but if I was you I'd get a second opinion on what your midwife has recommended. You could try posting on the UK midwifery site to see what other experienced midwives feel.

Re, all fours, I know midwives who feel that all fours positions are more likely to result in a bad tear than recumbent positions, but personally I think that this is the case it might well be down in part to too much coached pushing and general poor management of second stage, or some midwives not having the skills to birth women effectively in anything other than recumbent positions.

Are you able to consider a waterbirth, because being in water seems to help at the moment of crowning - maybe because it softens up the perineum and allows more stretching, or maybe it's because mums do things in their own way - pushing more effectively - when their 'bits' are underwater and not being interfered with too much by the midwife.

If you're not able to birth in water I think the key is to keep a good wide angle between your legs and your body - ie, if you are in all fours don't be levering your body backwards so that you're putting pressure on your perineum (sorry - I've explained that really badly - what I mean is that you need to have more than a right angle between your body and your thighs. You can achieve this by pulling out the head of the bed, piling lots of pillows on it and leaning over it. Alternatively you could try lying on your left hand side (left lateral) if you're tired).

I also wonder if perineal massage would help you? There's no evidence that it makes a difference for 2nd time mums (there is for first timers), but I can't see what harm it would do. It might help you feel more confident and relaxed at the moment of crowning if you've got in touch with that part of your body, and the stretching, burning sensation that goes with crowning, so you can let go and gently 'breath' your baby out as slowly as possible.

I also

I had a 2nd degree with DS1 in water and a little nick with DS2 in water.
I was scared of tearing but scared stiff of having to have an episiotomy so put in my plan with DS1 (didn't bother with DS2) that I would do anything to avoid one.
I was more afraid of this than actually giving birth/crowning.

When you tear, your body will tear as much as it needs to, if it needs to.
When you are cut, the tissue is also crushed by the scissor cutting action which causes more bruising.

From what I have heard, although the edges of tears make it harder to repair, tears heal better as they are more natural iyswim? I have not had to have a cut luckily so could not personally compare the two, but my 2nd degree was not as bad afterwards as I thought it would be.

if it helps at all - i thought that episiotomy was my biggest nightmare, and then ended up having it with DS1. I had an epidural, ventouse, and was aparently going to tear straight through to the anus (ouch eye-watering TMI) The episiotomy was not as bad as i expected, healed neatly and quickly. With DS2 who was born far too quickly, i had lots of small but excruciating tears, which were far more distressing.
Amazingly (!) i have a third child, easy peasy - not a scratch. Admit that i must have been stretched to bggry by the other two so she being the smallest of them all just slithered out. I did not tense or push at all to deliver her, just let my body do the work. wish i had known that much sooner

Have had 1 episiotomy with ds1 and 1 second degree tear with ds2 (both ventouse - episiotomy under epidural after loooooooong labour, tear after quick labour with no pain relief. Both healed equally well (the tear a bit better actually). I was surprised when I was told I'd torn as I didn't actually feel it .

Would second recommendation for perineal massage (although I didn't do it ). Your second labour is likely to be easier than your first so you may well not tear, or not so badly. Can't advise against apisiotomy as such but I don't think I would set out to have one.

If you can stay upright or kneeling as much as possible to allow gravity to help you.

My last child was 10lb 1oz and I didn't tear because I spent all my time stood up hanging off the sink in the delivery room and then knelt down on the floor hanging onto the bed to deliver her.

Hi asset1 - I would never recommend an elective episiotomy, as there are many factors which cause 3rd degree tear, but in your case it is almost certainly the ventouse, which doesnt give the perineum time to stretch naturally, and possibly the doctor not lifting babys head up as it came out, or tearing the peri with the shoulders. Ive seen this happen many times

From my experience (and there may be many who disagree), the best results after having had a 3rd degree with the first baby, is to deliver sitting up at 45 degrees, (as this will slow down the delivery of the head) and if it looks like a bad tear is happening, then a small episiotomy to direct it away from the anus, (and its very unusual to have to do this.)

Most of the time the peri is intact or a small tear - never had a repeat 3rd degree in over 20 years of delivering babies!

What I find is not so good are the more upright positions, such as squatting, standing, all fours etc, as the birth is quicker and much less controlled, also, its virtually impossible to do an epis in a squatting position!

Water is also a good option, as it helps the skin to stretch, but again, its not easy to slow down the birth, and impossible to do an epis.

But Im sure your midwife will help guide you and please discuss your fears with her when you go into labour.

Good luck!

Thanks all. that's really useful. I was dubious about the episiotemy thing - I remember from NCT classes before DS1 that tears can heal better, but the combination of another (potentially) big baby and quick labour (DS was only 4 hours of full on labour) scares me a bit.

mintpurple - really reasurring about never having a repeat 3rd degree! so when you say sitting up at 45 degrees, what does that mean? leaning forward on a bed, sitting on the edge of a chair....??

Also not 100% confident in either my MW or the hospital I'll probably be at, just get the feeling everyone is too busy to pay too much attention to individual cases. So want to be really clear about what I want/need before getting there.

I had a 3rd degree tear with a venteuse delivery for ds1 too. DS2 slid out just fine - just to confirm that it won't necessarily happen again. I didn't do anything unusual re birthing positions - I was on hands and knees most of the time - not a classic position, but it suited us!

Really interesting thread

I had a bad 3rd degree tear, but it actually healed surprisingly well

Part of me feels that when I have another child I would rather let things happen naturally and if I tear again then so be it

SIL has just had an episiotomy and seems to be in a lot more pain than I ever was with my tear

Mintpurple your post was really interesting

asset1 - semi recumbant is traditionally sitting up on a hospital bed, propped up with pillows at about a 45 degree angle. You can also get this position on a beanbag or a comfy chair. Doesnt really matter what you sit on as long as its leaning backwards at roughly 45 degrees.

If you can imagine sitting in a beanbag, watching tv, then thats pretty close to semi recumbant.

Remember that this is far from the best position in which to have a baby, as you are acting against gravity and reducing your pelvic outlet to some degree, but in this case, with a second baby which generally delivers much easier than a first, you want to slow things down a lot to let the peri and the soft tissues slowly stretch.

As notquitegrownup says though, it will probably be ok in any position, as it was most likely the ventouse and the doc being a little heavyhanded that caused the 3rd degree tear in the first place.

If you had had an unassisted birth, you may have had a second degree tear, but very unlikely a third.

With an elective episiotomy you will DEFININTELY have some perineal trauma which will require suturing. If you don't then there's a chance you will get away with it and only get a tiny tear or none at all, or a something which requires suturing