THE DANGERS OF EPISIOTOMY
Joanna's Plea: I am still in pain and it has now been 16 years. If there are any alternative therapists who can offer suggestions to help me, I would appreciate it!
Female Circumcision and Episiotomy are BOTH Mutilation!
It isn't just a bit 'sore'
According to J Int Med Res. 1987 Mar-Apr;15(2):89-95, 'Pain after episiotomy is severe in many patients.'
According to : East Afr Med J. 2003 Jul;80(7):351-6, complications included asymmetry (32.9%), infection (23.7%), partial dehiscence (14.5%), skin tags (7.9%), haemorrhage (5.3%) and extension of the incision (1.3%).
According to J Adv Nurs. 2003 Aug;43(4):384-94, 'There were significantly higher scores for overall incidence and severity of pain on the first day, and pain incidence and severity at 1 week in the episiotomy group. Significantly fewer women in the episiotomy group were able to do chores and to sit/stand up comfortably in the first postpartum week.'
According to Obstet Gynecol. 1999 May;93(5 Pt 2):800-2, 'In the past 2 years, we treated three women with fourth-degree lacerations or episiotomy infections presenting with persistent pain and drainage not responding to standard treatment. CASES: These women were referred for evaluation 5 weeks, 3.5 months, and 2 years postpartum. After diagnosing fistula-in-ano, we treated them with fistulotomy and curettage.'
According to Prof Care Mother Child. 1994 May;4(4):100-4, Episiotomy is one of the commonest surgical procedures in the UK. Many women suffer pain for several days sometimes weeks afterwards and dyspareunia may be a problem.
In Anaesth Intensive Care. 1984 May;12(2):137-9, the authors discuss using pethidene in an epidural drip for pain relief of episiotomy, so clearly they understand the severe nature of the pain.
'Epidural pethidine was compared with epidural saline for relief of pain from episiotomy wounds. Pethidine 25 mg administered by the lumbar epidural route produced significant analgesia.'
Tumours at the Episiotomy Site
According to Reprod Med. 2007 May;52(5):456-7, two women developed 'painful, traumatic neuroma' at the site of their episiotomy. These are cancerous tumours.
The authors state:
'It is extremely difficult to address the extent of the problem in vulvar pain syndromes.'
Tumours caused by episiotomy are also mentioned in Geburtshilfe Frauenheilkd. 1996 Oct;56(10):566-8.
Damaging of the Pelvic Floor
According to Obstet Gynecol. 2004 Apr;103(4):669-73, 519 first time mothers were enrolled in the study. Of these, 254 women had episiotomies and the other 265 women had either an intact perineum or a natural tear.
'perineal pain was significantly higher in the episiotomy group and is associated with a lower pelvic floor muscle strength compared with spontaneous perineal lacerations and with more dyspareunia and perineal pain.'
Impact On Mother And Baby Bonding
According to J Adv Nurs. 2003 Aug;43(4):384-94, 'Mean time from delivery to maternal rest and time taken to bond with the infant were significantly longer in the episiotomy group. Episiotomy should not be used unless indicated. Measures should be taken to avoid perineal trauma during labour, establish bonding between mother and infant as soon as possible, and minimize perineal discomfort after delivery.'
Impact On Sexual Relationship
According to Rev Enferm. 2001 Jun;24(6):461-3, episiotomies and their size have a direct relation to the amount of time after childbirth that a woman abstains from intercourse. 'its purpose was to discover the differences among episiotomies, large, small and with tears, and their effects during puerperium, in order to make professionals aware of the importance of pain and the consequences of a episiotomy. 82% of the women contacted by telephone responded to this questionnaire. 74.4% of these patients had undergone a right mediolateral episiotomy; 12.2% of these patients had undergone a left mediolateral episiotomy. The delay in starting to have sexual relations was significant among those women who underwent a large episiotomy.'
Tears in the Rectum and Vagina Caused By Episiotomy
According to Birth. 1999 Mar;26(1):11-7, The full extent of genital tract trauma in spontaneous births is not well documented. The purpose of this study was to describe the range and extent of childbirth trauma and related postnatal pain.
Eighty-five percent of all women experienced some form of trauma, with first- or second-degree perineal lacerations occurring in two-thirds of women and outer vaginal tears occurring in one-half. Tears to the rectum and vaginal vault were more common with episiotomy.
According to Z Geburtshilfe Neonatol. 1997;201 Suppl 1:55-62, 'Many benefits claimed for episiotomy are not sufficiently proven. In recent literature, some of them are questioned and some have been disproven. 2. Episiotomy, especially median episiotomy, has a higher risk of third-degree lacerations. Mediolateral episiotomy is more often followed by postpartum pain and impaired wound-healing. 3. Typical, albeit rare complications of episiotomy and third-degree lacerations are incontinence for stool and flatus, and-very seldom-fistula formation.'
Skin Lesions and Long Term Bleeding
According to Acta Obstet Gynecol Scand. 1995 May;74(5):361-6, 'We describe a number of patients with persistent symptoms of vaginal discharge and discomfort, dyspareunia and postcoital bleeding. They presented 2-4 months following delivery with episiotomy. In these patients, the symptoms were associated with localised granulation tissue polyps, on the episiotomy site.'
Pain, Painful Intercourse , Narrowing of the Vagina and Disfigurement
According to Geburtshilfe Frauenheilkd. 1983 Oct;43(10):625-8, In 413 women following normal spontaneous delivery the short and long term complaints due to the episiotomy were studied. Every fifth woman found the cutting of the episiotomy painful. Episiotomies done by specialist's or chief residents were found to be less-painful. The suturing of the episiotomy was found to be painful by 4 of 10 women. The more experienced the surgeon the less was the pain. Only every tenth woman had no pain in the episiotomy immediately post-partum independent of the experience of the obstetrician. Medilateral episiotoma were twice as often very painful (21%) as median episiotomies (11%). Every fifth woman had pain in the perineum for more than one month. A third of these women had more pain with sexual intercourse than prior to delivery. Every tenth woman had infections in the episiotomy, half of these required treatment. Following medio-lateral episiotomy there were twice as many complication with the episiotomy than following median-episiotomy. Every fifth woman though that her vagina and perineum was disfigured by the episiotomy scar. This impression was independent of the type of episiotomy and of the experience of the obstetrician. More dyspareunia than prior to delivery was reported by twice as many primipara (20%) as multipara (11%). 18% of the women reported that the vaginal introitus appeared to be narrower than prior to the delivery.
Episiotomy and Haemorrhage
According to American Family Physician® > Vol. 75/No. 6 (March 15, 2007), 'Risk factors for postpartum hemorrhage include episiotomy...Strategies for minimizing the effects of postpartum hemorrhage include identifying and correcting anemia before delivery, being aware of the mother's beliefs about blood transfusions, and eliminating routine episiotomy.'
Performing an episiotomy can cut through blood vessels and cause the mother to bleed uncontrollably. I (Joanna Karpasea-Jones) recently saw a case on TV where a husband nearly lost his wife when she started haemorrhaging from an episiotomy wound.
Severe Infections And Death
According to Tacker and Banta, 1983, wound infections from episiotomy amounted to 3% of women studied.
Very severe, life threatening infections called Necrotizing Fascilitis and Clostridial Myonecrosis can occur after episiotomy and these can deform women, because they are flesh eating bacteria, or even kill.
Between 1969 and 1976 they caused a staggering 27% of maternal deaths in California, USA (Ewing, Smale and Eliot, 1979).
There were also nine other cases between 1977 and 1986 in which seven women died and another two required numerous surgeries to fix episiotomy complications.
All of the seven women who died had had normal labours with no complications - in effect, their episiotomies killed them. (Obstetric Myths VS Realities: A Guide To The Medical Literature', by Henci Goer, Greenwood Publishing Group).
"Outcomes with Episiotomy Can be Considered Worse"
Outcomes of Routine Episiotomy
A Systematic Review
Katherine Hartmann, MD, PhD; Meera Viswanathan, PhD; Rachel Palmieri, BS; Gerald Gartlehner, MD, MPH; John Thorp, Jr, MD; Kathleen N. Lohr, PhD
Context Episiotomy at the time of vaginal birth is common. Practice patterns vary widely, as do professional opinions about maternal risks and benefits associated with routine use.
Objective To systematically review the best evidence available about maternal outcomes of routine vs restrictive use of episiotomy.
Evidence Acquisition We searched MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Collaboration resources and performed a hand search for English-language articles from 1950 to 2004. We included randomized controlled trials of routine episiotomy or type of episiotomy that assessed outcomes in the first 3 postpartum months, along with trials and prospective studies that assessed longer-term outcomes. Twenty-six of 986 screened articles provided relevant data. We entered data into abstraction forms and conducted a second review for accuracy. Each article was also scored for research quality.
Evidence Synthesis Fair to good evidence from clinical trials suggests that immediate maternal outcomes of routine episiotomy, including severity of perineal laceration, pain, and pain medication use, are not better than those with restrictive use. Evidence is insufficient to provide guidance on choice of midline vs mediolateral episiotomy. Evidence regarding long-term sequelae is fair to poor. Incontinence and pelvic floor outcomes have not been followed up into the age range in which women are most likely to have sequelae. With this caveat, relevant studies are consistent in demonstrating no benefit from episiotomy for prevention of fecal and urinary incontinence or pelvic floor relaxation. Likewise, no evidence suggests that episiotomy reduces impaired sexual functionpain with intercourse was more common among women with episiotomy.
Conclusions Evidence does not support maternal benefits traditionally ascribed to routine episiotomy. In fact, outcomes with episiotomy can be considered worse since some proportion of women who would have had lesser injury instead had a surgical incision.
Source: JAMA. 2005;293:2141-2148
Episiotomy INCREASES the Risk of Tearing
OBJECTIVE: To explore the association between midline episiotomy and the risk of third- and fourth-degree lacerations during operative vaginal delivery with either vacuum extractor or forceps. METHODS: This retrospective cohort study analyzed all operative vaginal deliveries at a university hospital in 1989 and 1990. Univariate analysis of the relationships between perineal lacerations and obstetric variables was performed. Stratified analysis using the relevant variables was used to calculate relative risk (RR) estimates. RESULTS: Episiotomy, birth weight, and whether the index birth was the first vaginal birth were associated with third- and fourth-degree perineal lacerations. Stratified analysis demonstrated an RR of 2.4 with a 95% confidence interval of 1.7-3.5 for rectal injury with episiotomy, adjusting for parity and birth weight. CONCLUSION: Midline episiotomy is associated with an increased risk of third- and fourth-degree perineal lacerations in operative vaginal deliveries.
Source: Helwig, J. T., J. M. Thorp and W. A. Bowes. 1993. "Does midline episiotomy increase the risk of third- and fourth-degree lacerations in operative vaginal deliveries?" Obstetrics & Gynecology 82:276-9.
Female Circumcision and Episiotomy: Both Mutilation?
Many women worldwide undergo some form of female circumcision. The practice of female circumcision is more common in communities with high poverty levels and is usually undertaken by unqualified practitioners. The practice is deemed harmful by many health professionals because of the health problems associated with it. Episiotomy is a surgical procedure which is common in western cultures. It is strongly linked to an increased use of technology. The practice has been promoted by the medical and midwifery professions because it is perceived to be beneficial for the woman and her baby. However, a growing body of evidence suggests that the routine use of episiotomy is unlikely to confer any advantage on the woman and overuse of the procedure leads to short- and long-term morbidity. In this article, the two procedures are critiqued from a rational, scientific standpoint and the reasons for the enduring popularity of both procedures are explored.
Source: British Journal of Midwifery 9(3): 137 - 142 (Mar 2001) - http://www.intermid.co.uk/cgi-bin/go.pl/library/abstract.html?uid=7997
Episiotomy: a form of genital mutilation
In his Sketches from The Lancet (April 24, p 1453)1 Peter Kandela describes how over 130 years ago The Lancet played a part in turning support away from one form of female genital mutilation in the UKclitoridectomy. Hopefully, you can play a part in turning support away from another form of female genital mutilation which is widespread in the UK todayepisiotomy.
After their review of scientific evidence, Thacker and Banta2 concluded that an episiotomy rate over 20% cannot be justified. On the basis of this and other evidence, WHO published the recommendation: The systematic use of episiotomy is not justified. The protection of the perineum through alternative methods should be evaluated and adopted.3 More recent research presents further evidence against frequent use of episiotomy.4
All this evidence shows that, compared with a natural tear, episiotomy results in more bleeding, more pain, more permanent vaginal deformity, more temporary, and longlasting difficulty with sexual intercourse. Further, the main benefits claimed by proponents of episiotomyprevention of third-degree tears, prevention of long-term damage to the pelvic floor, and protection of the baby from the adverse consequences of an extended second stage of labourare not supported by the evidence.
Despite the evidence, widespread use of episiotomy continues. In US hospitals rates for primiparous women in excess of 80% are commonplace.4 Episiotomy rates for all births in Eastern Europe are essentially 100%.5 On the other hand, the national episiotomy rate for the Netherlands is 8%, and the rate for planned out-of-hospital births (home or birth centre) managed by midwives in the USA is between 4% and 20%.5
Closing the gap between the evidence for and against episiotomy and the practice of episiotomy is as difficult and painful as closing the episiotomy wound. Can The Lancet once more help turn support away from female genital mutilation, in this case its modern formepisiotomy?
Source: The Lancet, Volume 353, Issue 9168, Pages 1977 - 1978, 5 June 1999 - http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2805%2977197-X/fulltext
Midline versus mediolateral episiotomy: We Still Don't Know How Beneficial the Procedure Is
The first systematic review of this procedure was published in 1983.4 The evidence at that timethree studies with control groups and no randomised controlled trialsconcluded that little research has been done to test the benefit of the procedure, and no published study could be considered adequate in its design and execution to determine whether hypothesized benefits do in fact result. The authors noted that the purported benefits of episiotomy, including prevention of third degree laceration, damage to the pelvic floor, and fetal injury (both mechanical and hypoxic), were plausible but unproved. However, they found that the risks of episiotomy, including the extension of the incision, unsatisfactory anatomical results, blood loss, pain, oedema, and infection, were serious.
A subsequent systematic review of the literature in 1995 found that episiotomies prevent anterior perineal lacerations (which result in minimal morbidity) but confer none of the other maternal or fetal benefits that are traditionally ascribed.5 The author argued that the incision substantially increased maternal blood loss, the average depth of posterior perineal injury, the risk of damage to the anal sphincter, the risk of improper healing of the perineal wound, and the amount of postpartum pain.
One of the greatest concerns is difficult to address in a randomised controlled trial: what is the relation, if any, between episiotomy and pelvic floor disorders later in life, especially urinary stress incontinence and relaxation of the pelvic floor? Although some obstetricians contend that episiotomy may help prevent these outcomes, there remains a need for epidemiological studies to examine this belief.
Source: BMJ. 2000 June 17; 320(7250): 16151616 - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1127405/
VAN UK's Comment: Note here it says the benefit to the neonate is UNPROVEN, i.e. they don't even have any evidence that it helps the baby!
Pain Relief And Healing If You've Already Had Episiotomy
If it's too late to refuse an episiotomy and you're looking at this page because you've already had one and are in pain, here are a few tips to help you:
If you're in severe pain, you're not going mad, it really does happen to a lot of women - the medical profession just don't tell you.
For severe pain, you can ask the hospital for laser treatment to help you heal. Some hospitals do this as standard. My sister also had an episiotomy with her first child and she was given laser treatment afterwards. She felt okay and was up and walking and doing housework within a few days. I did not have laser treatment as it wasn't offered at my hospital and I was in severe, debilitating pain for two weeks and continuing less severe pain for two years. It has now been nearly 13 years since and I still have on and off pain from the scar. My sister doesn't. While this is anecdotal, it is worth knowing. Lots of ladies do have laser treatment to help them heal from episiotomy.
INSIST on stronger pain medication if you are in severe pain. I was given codeine eventually, which is a morphine based drug. Do not suffer in silence and DON'T take no for an answer, or accept paracetamol which won't do anything for severe pain.
If you are breast feeding, codeine is contra-indicated. However, you may be able to pump off the first part of the milk, which has the highest concentration of drug, before feeding your baby, or take it at the beginning of your baby's longest nap, such as before bedtime, so that it has a chance to extrete before he next feeds. If you are planning on doing something like this, do it in consultation with your doctor so as not to put your baby at risk.
You can also ask if there is an alternative stronger drug which may be suitable for use in breast feeding.
Natural Self-Help Measures
There are also other things you can do to help ease pain. These methods helped me:
1. Take Arnica 200 homeopathy. I used to be skeptical many years ago, until I accidently trapped my finger in a cupboard and ripped off my finger nail. I dragged around in pain for days and conventional meds did not help. Then I took Arnica and the pain was gone in half an hour.
2. Aconite homeopathy may also help you heal faster and get over any feelings of shock or violation.
3. Cold gel pads can be soothing and are available from various natural health outlets online (I won't advertise companies on here but if you're interested in this, email me and I can tell you where to purchase).
4. Warm baths. In the initial few days after birth, the bath was the only place I found relief.
5. When using the toilet you can pour a jug of warm water over yourself at the same time, as this eases the sting, or even go in the bath tub - it sounds horrible but if it works, who cares?
6. Some ladies have used TENS machines to ease their episiotomy pain. I haven't, so I can't say if it works, but it certainly did for labour, so you might wish to try that.
If anyone knows any tips that I haven't included here, email me and let me know, then I can add them on.
If you are sick of birth rape, being strapped down to a bed, having fingers forced into your genitals, being knifed in your most intimate area, TAKE BACK YOUR POWER, Have a Home Birth!!
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