The best way to avoid an episiotomy is simple. Tell your birth practitioner not to cut you. Tell them that there is no research showing medical benefits to episiotomy. The past 50 years of research is summarized below showing no medical benefits to episiotomy. It would be best to find a practitioner with a record of episiotomy rate of less than 1%. And it is also important to push the head and shoulders out physiologically, according to how your body tells you to push and not excessively fast or powerfully.
The use of routine episiotomy has been shown to be harmful and should be discontinued.
The practice of routine episiotomy is grounded on several theories proposing benefits (Pritchard, 1980) which have been unequivocally refuted by randomized controlled studies. Thacker (1983) reviewed and summarized all english language medical literature from 1860 - 1980 that included results about episiotomy and concluded that the majority of research was unable to prove an advantage to episiotomy. In another exhaustive review of the literature, Eason and Labrecque (2000) showed that avoiding episiotomy leads to a significant decrease in perineal trauma. Not only is there no evidence-based support for routine episiotomy, but research evidence has revealed additional drawbacks. Episiotomy is associated with 2 to 3% extensions of the cut into the rectal tissue and muscles. Median episiotomy clearly promotes anal tears (Klein MC etal 1994, Labrecque etal 1997, Shiono etal 1990, Signorello 2000, Sultan etal 1993). Medial lateral episiotomy still has its proponents. In a review of 5,524 anal tears in Holland deLeeuw (2001) concludes that medial lateral episiotomy "strongly" protects against damage to the anal sphincter during delivery. Infact, deLeeuw`s nonrandom, voluntarily recorded births had a 1.00% rate of anal ruptures with no episiotomy versus a 0.56% rate of anal ruptures with medial lateral episiotomy, with an overall episiotomy rate of 35.4%, 96% of them being medial lateral episiotomies. Therefore, he is proposing to perform episiotomy on 35% of women to protect 0.44% of women from having an anal tear, less than half of whom, he writes, will "have anorectal complaints". This is outrageous in light of the fact that episiotomy causes "more bleeding, more pain, more permanent vaginal deformity, more temporary, and long-lasting difficulty with sexual intercourse" compared with a natural tear (Wagner 1999). Episiotomy is associated with increased blood loss and increased infections of the perineum which sometimes lead to rehospitalization (Thacker SB and Banta HD, 1983). Two large randomized controlled trials of liberal versus restricted use of medial lateral episiotomy show no prophylactic effect of the liberal use of medial lateral episiotomy (Sleep J etal 1984, Argentine 1993). Moller Bek (1992) found that liberal use of the medial lateral episiotomy (84.9%) increased the risk of anal sphincter damage.
Episiotomy on one’s first birth makes one more likely to tear, rather than deliver over an intact perineum on the second birth if no episiotomy is cut. Martin etal (2001) in a retrospective cohort study of 3,769 women found that the risk of tearing on the second birth was higher in women with a previous episiotomy (45%) than in women with a spontaneous second-degree laceration on first birth (36%). He writes, "Avoiding episiotomy, in addition to increasing the rate of intact perineum reduces the severity of perineal trauma" at the next birth.
Episiotomy is indicated in the final minutes of the second stage of labor in certain cases of fetal distress. There is not enough research to say exactly how much faster the delivery occurs when episiotomy is used. In Klein`s 1992 randomized controlled study, first-time mothers in the liberal-episiotomy group had an average of nine minute shorter second stage than first-time mothers in the restrictive-episiotomy group. How much an episiotomy shortens second stage on average on a first birth has never been studied, but the above evidence would imply, not more than 9 minutes.
The continued routine practice of episiotomy, particularly for first births, has motivated some women to seek alternate ways to avoid episiotomy and perineal trauma. Perineal massage before birth has not been shown in the literature to decrease the amount of perineal trauma at birth. Massaging and stretching the perineum during the pushing stage of labor has been shown to be clearly harmful and ineffective and should not be done(W.H.O. 1996). Hot packs on the perineum at birth also have not shown benefit, and perhaps are associated with slightly more tearing, though more research is needed. For the past 2 years, hundreds of women have practiced with a silicon inflatable perineal dilator called ‘Epi-No birth trainer’ in an attempt to prevent perineal trauma at birth. The dilator is practiced with at home before labor begins. It is inserted into the vagina by the pregnant woman herself, pumped up and pushed out, every day in a 10 minute practice session during the last 2 -3 weeks of pregnancy. She attempts to increase the size that she inflates the silicon balloon to in each practice session. The balloon can be inflated to 10 centimeter diameter which imitates the diameter of the fetal head at birth. At the end of the 10 minute practice session, she pushes the balloon out of her vagina. The intended result is to stretch the perineum before labor in order to prevent perineal trauma during delivery, making a first birth more like a second birth, as well as prepare the woman for the sensations and actions of pushing and birth. The device is also used to strengthen the ”Kegel” muscles in order to prevent urinary incontinence after birth or in older women. This product is legally sold in the US since it received clearance from the FDA in September, 2001.
I called the first 270 women to buy the Epi-No device in Israel and found from telephone interviews: After practicing with Epi-No, women having their first births in public hospitals had an episiotomy rate of 27% and a tear rate of 28% (12% second degree tears and 16% first degree tears - one stitch). The episiotomy rate in the same hospitals for women not using the device is presently 51%. 27% episiotomy rate is higher than would be expected if evidence-based protocols were in place, but an 50% decrease in the episiotomy in hospitals today. The World Health Organization`s recommend an episiotomy rate of 10% (WHO 1996). Exceptional episiotomy rates of 0.5% (for homebirths) / 1%( for hospital births)(Slome 2002), 1.4 % (Aikins Murphy1998), 3.8% (Janssen 2002), and 4 %(Wagner 1994) have been documented by motivated one-to-one care midwife practices and might be a goal to aspire to. The national episiotomy rate for the Netherlands is 8%(Wagner, 1999).
The most impressive result is, although the device demanded significant expenditure, time and discomfort, 98% of the users were very enthusiastic about the device during the phone interview and recommend that women use it probably because they felt empowered from having participated in preparation for birth. Only 5 women were negative about it. They said that it hurt a lot to use it and it didn`t help. The rest, including women who had episiotomies, said things like: "It gave me confidence." or "It taught me how to push".
Three possible theories for how the Epi-No worked:Epi-No practice may increase intact perineal outcomes in primiparous women by shortening second stage because it helps teach the woman how to push and/or by stretching the perineum before birth and/or it may empower women to participate in the decision not to perform episiotomy.
Aikins Murphy P, Feinland JB(1998) Perineal Outcomes in a homebirth setting.
Argentine Episiotomy Trial Collaborative Group.(1993) Routine vs selective episiotomy: a randomised controlled trial. Lancet 342(8886-8887):1517-8.
Belizan JM and Carroli G (1998) Routine episiotomy should be abandoned. BMJ 317:1389.
Carroli G and Belizan J (2000) Episiotomy for vaginal birth. Cochrane Database Syst Rev (2) CD 000081.
de Leeuw JW, Struijk PC, Vierhout ME, Wallenburg HC (2001) Risk factors for
third degree perineal ruptures during delivery. BJOG 108(4)383-7.
Eason E and Labrecque M (2000) Preventing perineal trauma during childbirth:A
systematic review. Obstet Gynecol 96(1):154. (email@example.com)
Goldberg J, Holtz D, Hyslop T, Tolosa J (2002) Has the Use of Routine Episiotomy Decreased? Examination of Episiotomy Rates from 1983-2000. ObGyn
Klein M, Gauthier R, Jorgensen S etal (1992) Does Episiotomy Prevent Perineal Trauma and Pelvic Floor Relaxation? Curr Clin Trials 1992; i:document 10.
Klein MC, Gauthier RJ, Robbins JM, Kaczorowski J, Jorgensen SH, Franco ED, Johnson B, Waghorn K, Gelfand MM, Guralnick MS, et al.(1994) Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation.Am J Obstet Gynecol 171(3):591-8
Janssen PA, Lee SK, Ryan EM, Etches DJ, Farquharson DF, Peacock D, Klein MC (2002) Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. CMAJ 166(3) 315-323.
Hillebrenner J, Wagenpfeil S, Schuchardt R, Schelling M, Schneider T (2000) Erste klinische Erfahrungen bei Erstgebarenden mit einem neuartigen Geburtstrainer Epi-No (First clinical experiences with the new birth trainer Epi-No in primiparous women. Z Geburtshilfe Neonatol 205(1):12-9.
Labrecque M, Baillargeon L, Dallaire M, Tremblay A, Pinault JJ, Gingras S.(1997) Association between median episiotomy and severe perineal lacerations in primiparous women. Can Med Assoc J.156(6):811-3.
Martin S, Labrecque M, Marcoux S, Berube S, Pinault J (2001) The association
between perineal trauma and spontaneous perineal tears. J Fam Pract 50(4)333-337.
Moller Bek K, Laurberg S (1992) Intervention during labor: risk factors associated with complete tear of the anal sphincter. Acta Ob Gyn Scand 71:520.
Mor, Y( 1989) The 1984 National Perinatal Census. Israel J of Med Science 25:629-633.
Pritchard JA and MacDonald PC (1980) Williams Obstetrics, 16th Edition. Appleton-Century-Crofts, N.Y.
Shiono P, Klebanoff MA, Carey JC. (1990) Midline episiotomies: more harm than good? Obstet Gynecol 75(5):765-770.
Signorello L Harlow B Chekos A Repke J(2000) Midline Episiotomies and Anal Incontinence. BMJ 320:86-90.
Sleep J, Grant A, Garcia J, Elbourne D, Spencer J, Chalmers I (1984) West Berkshire perineal management trial.Br Med J (Clin Res Ed) 289(6445):587-90.
Slome J (2002) A midwife`s private practice in Israel. British J of Midwifery 10(4)224-9.
Sultan AH, Kamm MA, Bartram CI, Hudson CN(1993) Anal sphincter trauma during instrumental delivery. Int J Gynaecol Obstet 43(3):263-70.
Thacker SB and Banta HD(1983) Benefits and risks of episiotomy: an interpretive
review of the English language literature 1860- 1980. Obstet Gynecol Surv 38(6): 322-338.
Wagner M(1999) Episiotomy: a form of genital mutilation. Lancet 353:1977-8.
Wagner M(1994) Pursuing the birth machine: the search for appropriate birth technology. Sydney: ACE Graphics.
World Health Organization (1996) Care in Normal Birth. A Practical Guide. World Health Organization, Geneva
Zalcberg S, Berg A, Yuval D, Ivancovsky M (1999) Giving Birth in Israel: Findings from a 1995 Survey of Maternity Patients with Comparisons to 1993. JDC Brookdale Institute Research Report. JDC Brookdale Institute, Jerusalem.