nurse-midwife, I have been quietly approached by a few courageous women
after birth, who have come to me complaining that their stitches are pulling
or that it hurts them down there when they breathe deeply, that the stitches
on their perineum look puckered, the sides are not matched, or one of the
labia majora is smaller or missing and the skin feels thicker than it used
to be. If the woman complains within the first 5 days after birth, I can
undo her stitches, and let the body heal itself in a more correct position
than it would have with the stitches that the doctor put in. After a week or
two, the skin heals the way it is sewed up and is no longer easy to open. If
the woman experiences dyspareunia, the medical term for painful intercourse,
eventually she might look for a plastic surgeon to perform surgery
under anesthesia to return function to the perineum.
No one knows how often this happens in Israel because there is no long
term research studying the woman`s assessment of the return of function to
the perineum following birth complicated by a repair of an episiotomy or
repair.of a tear. In a well-controlled study in The British Medical Journal
1994;308:887-91 a study was done in England looking at the risk factors and
outcome of the obstetrician`s repair of women with 3rd degree tears at
birth. The most impressive outcome of this research paper for me, was that
"Although 47% of women with a 3rd degree tear said they had defecatory
symptoms (incontinence of fecal matter and inability to delay bowel action
for more than 5 minutes) 2-6 months after delivery, NONE OF THEM HAD SOUGHTMEDICAL ATTENTION! In other words, if researchers had not contacted them, no one would have known that they were soiling their underwear on a daily basis.
As an American trained Certified Nurse Midwife,who is trained to sew up episiotomies and tears, I must unfortunately say that I have NEVER seen an obstetrician in Israel sew up an episiotomy or
tear properly. Apparently, this is not something that is taught in Israel
with the necessary care. By properly, I mean, first sewing the deep tissues
with single, unconnected stitches- a knot and cutting the thread after each
stitch. Afterwards, the skin should be sewed up the same way a plastic
surgeon or a seamstress would sew a seam that shows- with continuous small careful stitches that carefully match up the two opposing sides.
A friend of mine, who is in her fifth year of medical school in Israel,
and is rotating through the maternity ward, was asked this week, to sew up a
woman`s episiotomy, without (proper) training or preparation. (Vivienne-
edit this for accuracy- as you like, I am referring to your friend`s
I have seen women sewed up so tight, it was obvious that they could never
have comfortable intercourse again. And I have heard many obstetricians in
Israel joke about adding one more stitch for the husband`s pleasure. Little
does he or she realize, that the woman will probably refuse intercourse
altogether and the extra stitch actually seriously impairs the husbands sex
Clearly, this is not solely a cosmetic issue. It is not like stitching a
cut on an arm or a bruise from a fall. It requires much more care than is
being given. This needs to be more than a casual procedure, but one that
needs fastidiousness and accuracy. OK is not good enough. Closing the wound
is not good enough. This should be considered as a proper reconstruction and
not merely closing a wound.
The best way around this problem is to hire a private nurse-midwife who
is skilled at avoiding episiotomy and tears. At Shaarei Zedek and Hadassah
Ein Kerem, the labor and delivery room policy requires the nurse midwives to
cut an episiotomy on all first births. Alternatively, Ilana Shemesh, a nurse
midwife who delivers privately at Misgav Ladach, has an episiotomy rate of
1% for the last consecutive 500 hospital births she has done, 200 of those
were first births. In other words, she saved 198 women from the 10 days of
pain that it takes to heal and possibly long-term discomfort from improper
repair. In addition, not one of her clients suffered a 3rd degree or 4th
degree tear involving the anus. By the way, a woman, anesthetized by
Epidural anesthesia, who does not feel the urge to push,is also more likely
to get an episiotomy.
The good news is, learning to stitch is quite easy. It would not take
much time to teach all Israeli obstetricians or midwives to stitch up the
perineum properly. Change can come from various directions- ideally both
from the medical management and medical schools as well as from the women
themselves, who can start demanding proper surgical procedure be adhered to.
The purpose of this article is to let women feel that they are not alone.
This problem is probably rampant. Women deserve that proper effort be made
to ensure that function if returned to the delicate parts of their body.
This could be done easily and effortlessly. It is a matter of a little
knowledge and caring.