My first episitomy

I cut my very first episiotomy last week. It was my 70th delivery. Somehow, somewhere in the back of my mind I was thinking that my first episiotomy would come after a hundred births, at least….probably more. After all, there are absolutely no advantages to cutting routine episiotomies, and it seems like the reasons you’d actually need to cut one are few and far between. At the same time, I’ve been dreading this for quite some time. Back in January I had a rather scary and traumatic delivery where nearly everything that could have possibly torn on the woman did indeed tear: cervix, perineum (3rd degree laceration), bilateral sulcus tears, clitoris, labia and periurethrea. In retrospect, this had a lot more to do with the woman’s tissue integrity and nutritional status than it did with how I managed (or mismanaged) her birth, but I got some flack from a few of the doctors I work with regarding the blatant lack of episitomy with that delivery (it was a 9lb.13oz. baby, for the record, although none of us were anticipating such a large baby). The woman needed to be brought back to the operating room and sedated in order to complete the repairs, and I was called to the operating room by the doctors to watch some of the repair (I’m not sure if this was their well-intentioned way of teaching me how to do difficult repairs like this, or if it was their way of rubbing my nose in my mistakes, to teach me an altogether different sort of lesson). In any case, the question they kept asking was: why didn’t you cut an episiotomy?

Well, I didn’t cut one because it had never occurred to me that she would tear so badly (and in retrospect, if I had cut an episitomy, I’m pretty sure it would have been a 4th degree laceration rather than a 3rd, especially given how poor her tissue integrity was), and I’ve never seen any reason to cut an episiotomy just because you think it’s going to be a big baby (I’ve seen plenty of 9+ lbs. babies delivered over intact perineums, so why in the world would you actually cut??). Not to mention that the baby delivered so quickly that I barely had time to get my gloves on, let alone pick up a pair of scissors. I told the doctors that I had never cut an episiotomy before. I meant that I had never yet cut an episotomy, not that I never would cut one, but one of the doctors in particular thought that I was stating that I would never EVER cut an episiotomy, ever, and this person was so upset by this that they brought it to the attention of my supervisor. Anyway, to make a very long story short, the cutting (or not cutting) of episiotomies had been on my mind for awhile, and I knew that I would probably end up cutting one eventually, but I wasn’t sure when, and I was dreading it.

Just saying that makes it feel like some kind of rite of passage. Is that really the case? Does it have to be that way? Do all midwives have to cut an episiotomy at some point in their careers? Are there any midwives out there who have never cut an episiotomy, ever? I feel like in the case of hospital midwifery, the need for episiotomies is probably much more prevalent simply because the large number of interventions create more situations which call for episiotomies (and by this I mean situations which truly require an episiotomy, as opposed to routine episiotomies that are cut simply to speed up the birth process, or for convenience sake, etc., although those certainly occur more frequently in hospitals anyway).

I am learning that the trick about obstetrics has everything to do with making the right intervention call at the right time. I think this might be more true of hospital births than homebirths simply because of the time pressures which are always nipping at your heels in a hospital, and the fact that so many interventions are available in the hospital setting v. the homebirth setting, and that each intervention then begets even more interventions in that notorious slippery-slope fashion. In any case, it all comes down to judgement; to knowing when something is needed versus when it’s superfluous, and this is such a delicate skill to learn, especially because the line between necessary and unecessary can be razor thin, and becuase it often fluctuates and changes throughout the birth, so that something which was unnecessary 10 hours ago when the tracing was gorgeous suddenly seems brutally necessary 12 hours later, when the tracing has changed. The judgement comes in anticipating these changes—at least as many of them as can be anticipated (which, given how unpredictable and fluid birth can be…is not actually that many). And of course, your experience affects your judgement, too. If you’ve seen several serious obstetric emergencies unfold before your eyes, if you’ve ever seen a baby or woman die, if you’ve been sued…your judgement calls are going to be very different from those who have never experienced any of these things.

Navelgazing Midwife was recently talking about this in two of her posts: The Myth of the Vertex and The Gray, Grey Messenger: Trust. Part of what you’re relying on in your care provider—be she midwife or doctor—is her judgement. That’s why she’s there. In the case of homebirth, it’s really obvious: the midwife is the guardian watching from the birth from the corner of the room. So long as everything is progressing smoothly, she won’t lift a finger to intervene, but if things begin to slide off the road of normalcy and something more is needed, you really want her to step in at that time and do what needs to be done. Ideally, in a relationship based on trust, if she says “we need to go to the hospital now”, you’ll believe her and trust her and call the ambulance, because you know she wouldn’t even be suggesting it if that weren’t truly the case. The reason she’s there is because she’s seen hundreds (maybe thousands of births) and she knows when things are normal versus when something needs to be done. The Myth of the Vertex in particular speaks to this. Just because the baby’s head is down does not necessarily gaurantee that everything will proceed smoothly to a vaginal birth. When everything doesn’t go exactly to plan, it’s not a betrayal on the part of the midwife, it’s her responding to the changing circumstances of the birth by doing what needs to be done—recognizing the change, and knowing what needs to happen next. That’s her job. That’s her judgement call right there. That’s why she’s there. That’s what you’re paying her for.

I know this sounds very defensive. To be honest, I feel incredibly defensive about this. I feel like I need to stand up on stump and say: I cut an episiotomy, but here are all my reasons for doing so, and I really think it was what was needed at the time. That’s how strongly I feel about episiotomies. It wasn’t a phony episiotomy. It wasn’t cut just to cut one. I feel like I need to somehow justify this act to the woman, her family, the universe. I didn’t want to cut it! But in this situation, I think she absolutely needed one. She’d been pushing for over 2.5 hours, the baby had been sitting on the perineum at +3 station (i.e. the point where the head remains under the pubic bone in between pushes, and crowning is usually imminent) for the past half hour without crowning, and the baby’s heart rate was really starting to reflect the baby’s exhaustion, with variable decels that were deepening with each contraction into the 60s. She was exhausted herself after a long, hard primip labor. She had had some stadol earlier in the labor, but never an epidural, and she was feeling the burn and sting of crowning but couldn’t manage to push the baby past that point. Even after I cut the episiotomy, the baby still didn’t come out right away. We tried the Ritken maneuver, but that still didn’t bring the baby’s head up and out. Finally, in the end she needed a vacuum to help deliver the baby (and if I hadn’t cut an episiotomy, the doctor would have at this point to apply the vacuum).

Ugh. Having just typed all of that out…it suddenly seems pathetic: my sad attempt to try to justify why I cut an episiotomy. I’m sure someone will call me on it and say, bold as brass: she didn’t need one, you were wrong to cut one. Maybe I was. Or maybe I’m making way too big a deal of this? I don’t know why I’m typing all of this out, why I feel the need to hyper-analyze my defensiveness—in essence, defend my defensiveness. I made a judgement call, I cut an episiotomy, I think it was necessary. That should be that. And yet, as a midwife, I view myself as a defender of intact perineums everywhere. I feel like I let this woman down in some way. I feel that so clearly and so strongly, and yet, at the same time I find myself praying that I will always be able to make the right judgement call at the right moment—that in the future, when a woman really does need an episiotomy, I won’t hesitate. I’ll do what needs to be done.

This is a messy post, as Dark Daughta would say. In her book, that’s actually a compliment. I never promised I’d have all of the answers. My response to my first episiotomy has been very complex; it’s kind of taken my by surprise, how much this has affected me. How I feel about it has been varying tremendously from day to day, minute to minute. I promised to chronicle my adventures as a new midwife— the good, the bad, the ugly, the messy….so here you go. I’m still trying to figure out how I feel about this one. It’s all a work in progress.

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10 Comments

  1. Posted February 25, 2008 at 4:35 pm | Permalink

    The very reason I went to a midwife was her feeling that it was her job to “protect intact perineum’s everywhere!” She is an amazing care giver, and I trust her knowledge and instinct (through 4 pregnancies- 2 natural births, 1 emergency section, and one VBAC). Even though you are a new midwife, I would imagine that your patients feel the same about you, and know you would not intervene unless you felt it truly necessary. I’d like to suggest your trust in yourself, and your knowledge to direct you in when to intervene and when not to.

    Love your blog, and I am living vicariously through you, as it is my hearts desire to be a CNM.

  2. Posted February 25, 2008 at 9:09 pm | Permalink

    Phew. So, I can report that neither of my preceptors have never cut an epis in more than about 1000 births. That said, they are homebirth midwives and their clientèle tend to be well nourished, healthy women whose tissue integrity tends… well.

    The (doozy!) tears from that previous birth and the crappy Doc’s nose rubbing (not cool) in the back of your head are a powerful motivator. I also sympathize with the situation of a baby hanging out under the pubic bone with decels into the 60′s. Thats some SLOOOOW tracing to be listening to. I think I’d have be cutting an epis too, if it seemed like it might have helped any. :)

    I hope you don’t feel you have to cut another one for many many more births. Your discomfort shows that it wasn’t a decision made lightly. Your status as a defender of perineums is intact (no pun intended) as far as I’m concerned!

    Bottom line, that woman got a vaginal birth – and you helped…

    Great post.

  3. quiltingmidwife
    Posted February 26, 2008 at 3:32 pm | Permalink

    When I was a SNM (not too long ago), I was actually told that I had to cut an epis to graduate. That was the only epis I’ve ever cut.

    The way I make myself feel at least a little better about it – and I hear and see my same reactions in your post – was that I was with a preceptor who cut an epis on every primip. Yes, she was a midwife, but she still did routine epis. So I told myself that this young woman would have had the epis done to her, no matter what. I was the one holding the scissors, but if I had refused, my preceptor would have stepped in and cut it herself. And I guess I did at least have the chance to do one with someone watching and making sure I did it right. And, yes, she ended up with a 3rd degree tear.

    So at least take some comfort in the fact that she had an epis from someone who thought about it and cared enough to feel bad about it afterwards, but still did what was probably the right thing at the time. And you are right, she probably would have had one done with the vacuum, anyway.

  4. SNM
    Posted February 26, 2008 at 8:41 pm | Permalink

    As a current SNM, I have cut (have been told to cut) more that I choose to share.
    Today the weight of it hung too heavy on my mind and I fell into the arms of a fellow SNM and sobbed. She said, “I know. I know.” This is me saying the same words that comforted me this morning to you- I know. I love you and I know.

  5. doctorjen
    Posted February 26, 2008 at 11:18 pm | Permalink

    I just found your blog and have been enjoying it. I did want to comment on “needing” an episiotomy, though. I know you are in a hospital setting, as am I, and I agree with you that in the hospital there is often a cascade of interventions going on that all seem to lead to one another. I’m a family doc who attends about 70 births a year, and I haven’t cut an episiotomy in over 150 births.
    Your docs who were harrassing you over not cutting the lady with the baby have no data to back themselves up whatsoever. There is absolutely no evidence that cutting reduces perineal trauma. That woman may well have ended up with a 4th degree extension and all those other tears as well.
    Also, you don’t need an episiotomy for a vacuum assist. The vacuum does not increase the diameter of the fetal head, and although it might be a bit tricky to apply without cutting, it’s very workable. I’ve had quite a few vacuums over intact perineums.
    I have one suggestion for your client who was nearly there for so long. I encourage any one who is getting to the point where it’s looking more urgent that we need the baby out, or who has a baby hovering on the brink of born for a long time, to get up and squat. I always have a trial of squatting before using vacuum, too, and almost always squatting does the trick. I find that most clients with epidurals, even, can manage a supported squat with the squat bar, although they sometimes need a helpful nurse or two, or partner to help if their legs are really jelly from an epidural. I ask my clients to give a good solid 3-5 contractions pushing in a full squat if the babe is hovering at that +3,but not quite crowning stage for a long time, and if there is no change at all, then we move on, but so far it’s worked for almost everyone. I know it’s hard to move a woman with an epidural, 2 IV lines, monitor cords, a foley catheter, and what-have-you, but once you do it a few times you get in a groove and it seems normal. Move the mama, move the monitor, and voila! off you go. My nurses looked at me like I had six heads the first time I suggested such a thing, but they got over it when I kept insisting and now the nurses are often initiating moving the client before I even suggest it!

  6. The Midwife
    Posted February 27, 2008 at 12:24 pm | Permalink

    Squatting. What a genius idea. Why didn’t I think of that at the time? I have pushed w/ many women in squat before, and it usually works wonders for bringing the head out, but I’ve never actually delivered a baby in a squat before. Next time this happens to me, I’ll do that first before cutting an epis. Thank you so much for the suggestion!

    It’s also good to know that vacuum does not necesarily mean epis, although if the doctor applying the vacuum thinks the two go hand in hand, I’m not sure how to change that (vacuum assisted delivery is beyond our scope of practice in this setting, so whenever a vacuum is needed, it’s no longer the midwife’s delivery).

    And thank you *all* for your comments and honesty. I cna’t believe episiotomies are still *required* in some midwifery programs. Oye! I feel for you as well. There should be a post-episiotomy support group that exists in every setting to supply tissues and group hugs to the folks that had to cut them.

  7. doctorjen
    Posted February 27, 2008 at 7:43 pm | Permalink

    Another suggestion? Since you are a new-ish birth attendant, I’d try to catch as many babies in upright positions as you can manage. Anyone who is willing to squat, hands and knees, stand, what-have-you. Do as many easy births upright as you can and it helps you become comfortable with differnet positions and not feel out of sorts as baby comes. You will feel at first like you don’t know where to put your hands, and that is fine – just put them under the baby and don’t let it fall on it’s head, the perineum will take care of itself.
    I know for myself, that when I was done training and having to do whatever my teachers told me, I wanted to encourage my clients to birth upright, but at first it seemed like they all “wanted” to be lying down. I realized how much what we do in the hospital encourages this position, and also how much cultural conditioning women have, so I started talking all during prenatal care about upright positions like that’s the most normal way to have a baby. I also started suggesting it to every client, and making it easy for them to move when they wanted to. I didn’t stick any fingers in the vagina while moms were pushing, I didn’t focus a light on the perineum, I didn’t break down the bed. I would do other things while clients pushed – rub their back, bring them water, knit if they didn’t need me, and take the focus off every one in the room standing around staring up the crotch. Soon, my clients started agreeing to squat, or birth hands and knees, or climb out of the bed and squat on the floor, and after a while it became second nature. Now, it is odd for me to have a birth with a lying-down mother!
    I know it’s hard with a mom with an epidural, but it can be done. I also know it’s hard to change the birth culture and nurses and other staff sometimes are uncomfortable with what looks like a non-standard birth position, but you just approach them with confidence (just like your preceptor chased off the doc who was insisting on pitocin for the lady with the long posterior labor – who, for pete’s sake, as I read it, pushed her baby out in under 2 hour!)
    Now, the folks I have who are most surprised when a mama births squatting are the grandmothers in the room supporting their daughters. They always say things like “they didn’t do it that way in my day,” although some of them say “oh, I wish they would have let ME do that!”

  8. Posted February 28, 2008 at 8:32 pm | Permalink

    You know? I think that you’re a wonderful midwife. You’re thinking. You’re asking questions? You feel but you don’t let the fact that you feel cloud your judgment. But you don’t let the fact that you have judgment and medical experience stop you from critiquing your own actions. Hugs to you. That sounded really hard. I think that any woman who encounters a midwife like you will know you to be a continued guardian of birth. You tried. You knew when to call it a day. You’ve incorporated what happened with the birth where the woman ripped. Shmolee was 10lbs 6oz and I didn’t rip. Both my births were extremely fast 1:45 and 2:30 respectively. Nothing ripped. I guess I’m just saying you couldn’t have known. You tried. More hugs. You know I’m not a midwife. As a supporter of midwifery and a consumer I appreciate your willingness to self interrogate. I think you’re a wonderful gem – a professional who dares to bring every bit of knowledge, intuition, emotion, integrity to bear in the service of her work. More hugs. Have you cried?

  9. Student Midwife
    Posted April 11, 2008 at 5:55 am | Permalink

    I just wanted to say that you should be proud of yourself for your decision making skills. I’m a student midwife, now 2 months into my education and training, so I have yet so much to learn. The thought of having to do an epis makes my skin crawl. I’m hoping that I won’t have to do one at all to be honest but I hope that if I do find myself in the position of deciding should I? or shouldn’t I? that I will be able to make as sound a decision as you seem to have been able to. I like the advice of Doctorjen too. Valuable information.

  10. angiethemidwife
    Posted April 12, 2008 at 11:41 am | Permalink

    hello there…. i am a student at the university of washington and i graduate in june. i’ve been reading your blog for some time and i thank you for your humble voice and non-militaristic tone.

    anyway, i wanted to share with you a few reflections about your first episitomy. i spent a summer working with midwives in russia. there, they cut all the time. i think where it was common to routinely cut episitomies here they are just starting in with that practice.

    i cut my first midline two weeks ago and she she extended into a 3rd degree. in that situation, she truly needed an episitomy. fetal descent was obvious, but the baby crowned for about 20 minutes. during that time it was very easy to palpate an inner ring of stiff tissue that didn’t allow the baby to descend further. my preceptor pinched the skin between her forefinger and thumb, and then ran the tissue between her fingers almost like she was milking the tissue. it softened slightly but it was so tight. i could barely get a finger in on either side of the baby’s head.

    so i cut… about a 1 cm midline, and the baby was born with the next contraction. his head had a capput on it from where some of the his head got past the tight ring. one of the reasons i cut rather than let her tear was because the tightness extended up to her urethra and my preceptor thought she might tear up instead of into her perineum.

    in your situation, it sounds like the woman had poor tissue integrity and would have torn regardless of an epis or not. i think we all take ownership in our clients and especially when they tear. it is hard not to ask ourselves if we could have done anything different. sometimes women just blow out their bottoms and it does not matter what we do.

    i remember caring for a woman in russia. as her baby was being born, i felt her perineal tissue explode under my hands. the midwives there were quick to say that it was her poor tissue integrity and health constitution that caused the tearing.

    i am sorry the physicians gave you such a hard time. we never get a redo…. and who knows if anything would have been different if you chose another management plan. that being said, in your other birth where you cut, you obviously chose that other plan and needed a vacuum anyway. i think you are asking the right questions. in my opinion episitomies should be cut when perineal tissue impairs fetal descent and there is a reasonable risk of tearing into the urethra. i think you saw that it wasn’t the perineal tissue that was holding up the baby, it was something else, that is why she needed the vacuum.

    Regardless of midwifery sound knowledge and skill, physician preference and style can interfere with our evidence based management plans.

    i wish you all the best and am looking forward to continued reading.

    will you be at conference this year?

    angie

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