Belly Tales

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.

Last week I had an exam in Neonatology, and my teaching project and a presentation in Neonatology all due at the same time, so it was a bit hectic. This week, the only thing on my plate is a few modules and some studying for the upcoming final exams, and a write-up of my teaching presentation, so I’m taking a justified, (albeit brief) break, and blogging for a delicious change.

I was looking back over some of the posts I’d written about hospital birth over the past year and a half, and I feel that the time has come to eat some crow. Not a huge amount of crow—not a grilled crow steak with onions and salad and the works, but maybe a crow kebab or crow pie appetizer. I think I was feeling very burned out this past summer, very very tired of all of the hospital birth BS, and I think a lot of that had to do with how very tired I was of working as a nurse. I was (and am) ready for change, and ready to be working as a midwife, and now that I’m actually more than halfway through my IP clinical rotation, and am finally (FINALLY!!!) catching babies, it’s as if a large piece of the puzzle has fallen into place. Suddenly, everything feels right in the universe, and I’ve been so ridiculously happy lately, now that I am actually doing what I have wanted to do for so long—this glorious, miraculous, beautiful work that has called to me for over 5 years now. So, the burned out feeling is gone, and in it’s place is a refreshing sense of growth, because I am learning so much right now, and heading in such a fantastic direction, and things finally feel like they’re moving. It’s slowly dawning on me that school will in fact be over (probably much sooner than I’m ready for), and that I will indeed be a midwife someday (really, truly!!).

The point being, the hospital where I’m currently doing my clinical rotation flips a lot of the hospital-birth stereotypes on their heads, and maybe this has a lot to do with the fact that midwives are employed by this hospital, and respected by this hospital (and the OB Dept., which says a lot right there), and do a lot of the work of running the labor and delivery floor. I can only write from my experience, and this is what I’ve seen: 3 years of working as an L&D nurse in two seperate hospitals, and I’d say that at least 90% - 95% of all births involved an epidural. A woman without an epidural was either making a huge and difficult point to labor “naturally”, or had simply managed to show up to the hospital fully dilated and unable to recieve one in time before she delivered. I can’t say that the majority of births I’ve seen have had at least a 1st degree laceration, but I do feel that at work, an intact perineum is often a rarity, and a very pleasant surprise. Women, as a rule, are not allowed to eat or drink during labor. The squat bar often sat gathering dust in a corner, the birthing balls were rarely (if ever) used, and getting a woman out of bed was always a very rare and unexpected treat, that often required a lot of fighting for. It was never the norm.

And this is not to say that there are no fights to be fought at the hospital where I am currently doing my clinicals, but I’ve been paging through my delivery book (21 births so far, believe it or not!!!) and noticing that more than halfof the woman I’ve worked with haven’t had any analgesia or anesthesia on board (14 out of 21, to be exact). The majority of them have had intact perineums. I’ve used the squat bar more times in the past 7 weeks than I have used it or seen it used in the past year at the hospital where I’m working. The women on the floor are almost always given clears to drink, which is a much better deal than being NPO (i.e., not allowed to eat or drink anything), and some women are even allowed to eat some lunch in the early part of their labor or induction. And while getting a woman out of bed still causes a lot of eyebrows to be raised, I’ve seen it happen at least 4 times so far, and once we even got the woman out of bed, off the monitor, and into the shower, where she would have remained if only someone could have stayed in the room with her to fend off the anxious nurses trying to get her back on the monitor.

Oh, and VBACs! Did I mention that this hospital does VBACs? And not just attempted VBACS, but actual, squalling-baby-born-vaginally type VBACs?? Very very pleasant surprise. I think I can possibly count on one hand the number of successful VBACs I’ve seen at Tried and True Hospital.

And have I mentioned lately how much I’m enjoying my clinical rotation so far? And these births!! All these beautiful births!! I’ve caught so many babies so far! I feel so blessed, and so lucky, despite the exhaustion and over-worked brain and tired legs and mounds of homework. I stayed late one night and caught three babies in a row, one right after the other—women I’d been laboring with all day, and had been examining all day, and watching as their cervixes changed from 2 cm to 6 cm to fully dilated, and was then lucky enough to be able to catch all of their babies. Afterwards, at around 2:00 in the morning, as I was finally leaving, I stopped by the postpartum room of the first woman I had delivered that night (she was a successful VBAC!!) to say goodbye. She had been wearing a gorgeous woven cloth rosary around her neck throughout her entire pregnancy and birth, and she pulled it off and gave it to me, and I walked down to the lobby with tears in my eyes, cradling the beautiful rosary. It is such an honor, and such a gift, to be able to be with women at the moment of their births, and to be able to catch their babies. Some days I can’t believe my luck and good fortune, because that’s really what it feels like to me. I am such a lucky woman! This really is the best job in the world.

Here’s a newsflash: In a sytematic review of the literature in this month’s JAMA, researchers have recently found that routine episiotomy offers no benefit to women, and may in fact do more harm than good. Reuters picked up the article here.

I have never understood routine episiotomy, and in my work as a nurse, every time a doctor picks up the bandage scissors to make a cut (even the smallest of cuts), I find myself internally wincing. Sadly, that amounts to a lot of wincing in the course of a work week. According to Reuters, one-third of all women in the U.S. have an episiotomy during childbirth, although some doctors and hospitals perform the procedure on as many as three-quarters of all women giving birth. Three quarters of all women! True, episiotomies can be life-saving in rare cases of shoulder dystocia or true CPD, but how often do those cases occur? An episiotomy is a deep muscle cut, inevitably weakening the pelvic floor (as was pointed out in the above systematic review). Often even the smallest of episiotomies is extended during the course of delivery, growing from a small cut to a large 2nd or 3rd degree laceration, which then requires extensive suturing. There’s no reason for routine episiotomies. If a woman’s perineum is properly supported and protected during crowning, and if the baby is delivered s l o w l y, and with care, it’s possible to keep her from tearing at all—or if she does tear, it’s a superficial tear, rather than a deep muscle cut; harder to repair, true, but infinitely better for the strength and integrity of her pelvic floor. It’s a rare thing to see a doctor being that patient on a consistent basis, although it certainly does happen from time to time. (I can think of one doctor on my unit, for example, who has a nearly perfect intact perineum rate, but in the way she practices I’d say she’s much more like a midwife than a doctor.)

Change is slow, and it takes a long time for medical practitioners to learn new habits and skills. If an OB has been cutting routine episiotomies all his life, he may never change his practice. But having a review like this come out in a magazine as important and influential as JAMA is a step in the right direction. For years doctors were taught that episiotomies were necessary more often than not. Now, thanks to “new” research like this, maybe doctors will eventually be taught that episiotomies are never necessary, except in true emergencies. One can only hope.