Tuesday, April 01, 2008

Are episiotomies necessary?

We were taking a class in suturing yesterday. It was taught by a pharmaceutical rep who obviously never had to sew a human being back together. First we had to watch a video that was made about 20 years ago. The guy was talking about digits and adjacent fingers and approximating. Total mish-mosh. Then the dude stopped the video and we each received a spool of suture and a pig's foot. We had to create an incision on the pig's foot. Then with our needle driver and pickups with teeth, each of us attempted to place stitches using the square-knot technique. I was so frustrated I wanted to pick up that pig's foot and throw it through the window. I hope you guys don't ever need me to give you stitches!

My inner perfectionist wanted nice, neat rows of stitches. What I got instead was loose, floating stitches. Despite that the wound edges were well approximated! Aha! My inner DiVa emerges. I overheard someone saying something about episiotomies being un-necessary. Huh...? This person has never worked in labor and delivery. She is someone that I happen to know pretty well, we are almost friends. She has had one child with which she had an episiotomy, and based on that experience and a clinical rotation in L&D that lasted maybe four weeks her professional opinion is that an episiotomy is un-necessary? Let me retort. Episiotomies ARE necessary in certain circumstances.

Now, if a lady is having her first baby and has been pushing for all of five minutes and the physician says, "Let's cut an episiotomy." I would say a resounding NO. Give her a chance. Pushing is truly an art. You have to be able to coordinate your breathing and get into the perfect position. A little perineal massage with mineral oil or surgi-lube would also help. I have had an episiotomy, and I know how bad it hurts. I was not given a chance to prove myself in the pushing department. In that case, an episiotomy is more for the convenience of the physician than anyone else.

On the flipside, if Mom has been pushing: 1. for an hour or more, and the physician has assessed the perineum and it is obvious that there is no room for baby to rotate, descend and emerge OR 2. Baby is in distress, is in the perineum at a very low station, we need to get the baby out NOW and a c-section can be avoided OR 3. Mom is not going to stretch, has already started to tear a little and we are trying to run damage control 4. We are having a forceps/vacuum delivery where a tear is inevitable...I know I am leaving out some situations, but these cases an episiotomy is TOTALLY necessary.

People who say ignorant things like that about episiotomies, (people with no experience in L&D), get on my nerves because they are talking to my patients and misinforming them about childbirth, epidurals, IV pain medication and other things that they are unqualified to speak on, and I have to try to calm them and re-educate them to have an open mind about the whole delivery process. If you don't know what you're talking about don't say anything. You are NOT helping. Do you know how hard it is to fix a perineal tear? I have seen doctors pouring over a ladies crotch trying to make sure that a Mom can poop and pee out of two different holes. It takes HOURS to repair a torn ass. HOURS. Besides that, it is far easier to repair a deliberate cut than jagged edges. After I told that lady my opinion of episiotomies and challenged her knowledge base, she didn't want to talk anymore. How funny! What do you think?


DiVa...