Comments on: My first episitomy http://www.bellytales.com/2008/02/23/my-first-episitomy/ The Diary of a New Midwife Fri, 29 Aug 2008 04:02:38 +0000 http://wordpress.org/?v=2.0.4 by: angiethemidwife http://www.bellytales.com/2008/02/23/my-first-episitomy/#comment-133493 Sat, 12 Apr 2008 17:41:51 +0000 http://www.bellytales.com/2008/02/23/my-first-episitomy/#comment-133493 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 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

]]> by: Student Midwife http://www.bellytales.com/2008/02/23/my-first-episitomy/#comment-133205 Fri, 11 Apr 2008 11:55:08 +0000 http://www.bellytales.com/2008/02/23/my-first-episitomy/#comment-133205 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. 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.

]]> by: darkdaughta http://www.bellytales.com/2008/02/23/my-first-episitomy/#comment-118064 Fri, 29 Feb 2008 02:32:51 +0000 http://www.bellytales.com/2008/02/23/my-first-episitomy/#comment-118064 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? 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?

]]> by: doctorjen http://www.bellytales.com/2008/02/23/my-first-episitomy/#comment-117728 Thu, 28 Feb 2008 01:43:20 +0000 http://www.bellytales.com/2008/02/23/my-first-episitomy/#comment-117728 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!" 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!”

]]> by: The Midwife http://www.bellytales.com/2008/02/23/my-first-episitomy/#comment-117603 Wed, 27 Feb 2008 18:24:37 +0000 http://www.bellytales.com/2008/02/23/my-first-episitomy/#comment-117603 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. 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.

]]> by: doctorjen http://www.bellytales.com/2008/02/23/my-first-episitomy/#comment-117423 Wed, 27 Feb 2008 05:18:19 +0000 http://www.bellytales.com/2008/02/23/my-first-episitomy/#comment-117423 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! 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!

]]> by: SNM http://www.bellytales.com/2008/02/23/my-first-episitomy/#comment-117391 Wed, 27 Feb 2008 02:41:45 +0000 http://www.bellytales.com/2008/02/23/my-first-episitomy/#comment-117391 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. 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.

]]> by: quiltingmidwife http://www.bellytales.com/2008/02/23/my-first-episitomy/#comment-117335 Tue, 26 Feb 2008 21:32:17 +0000 http://www.bellytales.com/2008/02/23/my-first-episitomy/#comment-117335 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. 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.

]]> by: Morag http://www.bellytales.com/2008/02/23/my-first-episitomy/#comment-117070 Tue, 26 Feb 2008 03:09:00 +0000 http://www.bellytales.com/2008/02/23/my-first-episitomy/#comment-117070 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. 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.

]]> by: mandiezd http://www.bellytales.com/2008/02/23/my-first-episitomy/#comment-117013 Mon, 25 Feb 2008 22:35:14 +0000 http://www.bellytales.com/2008/02/23/my-first-episitomy/#comment-117013 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. 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.

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