Avoiding Episiotomy Complications

 Question from N. E.:       I gave birth to my daughter in February at home with a certified nurse
midwife. The midwife made me believe an episiotomy was necessary due to a
long labor and fatigue. It was devastating to have to go through this after
many months of preparing for a normal birth for both my baby and my body.
Unfortunately, the CNM didn’t assess or repair my perineum or my rectal
muscles correctly. I had to have another surgical procedure to have my body
put back together.

I want to heal as completely as possible with minimal scar tissue in hopes
of having future homebirths without being cut. Is the herbal supplement
gotu kola safe to take while breastfeeding? My research has shown that this
herb is great for skin regeneration. However, half the information I have
found states that it is safe for anyone to take, and the other half states
not to take if you are breastfeeding.

Crowning head art

Crowning head art


The OB/GYN who performed my repair surgery said I will always have to have
an episiotomy with all future births. I don’t want to believe this is true.
How many midwives out there can tell me if they have had clients who have
had a similar situation, or have had clients who have had a fourth degree
episiotomy and have gone on to have births without having major tears?

Your letter brings up several issues that I would like to reply to.
First, the use of herbs. I am not familiar with the herb you are inquiring
about but my own policy with herbs, medications, and vitamin products is
“If in doubt (especially for pregnancy/lactation), don’t take it.”

Second, it sounds like you have doubts that your episiotomy was really
necessary and really repaired correctly. I urge you to write to the CNM and
express your feelings to her. Is it possible to meet with her and talk?
Episiotomies are rare in midwifery cases but there are a small number that
are done and the situation you had is a tough one for the practitioner
(long labour, pushing contractions fading out, baby on an unyielding
perineum for too long, etc.) Obviously, it was horrible for you but, having
been in that situation myself, I would not be judgmental of the midwife
based on what you have said. Doing an episiotomy in a homebirth situation
is a last resort because the suturing after is difficult and exhausting to
an already exhausted midwife.


I encourage clients to speak directly to the practitioner involved because
they might open up some improvement in that person’s practise that could
make a difference in the care given to another woman. Complaining is
usually best done directly to someone who can take action about the problem.

Third, remember that obstetricians love to knock midwives at every
opportunity and that is probably our karmic comeupness because (guess
what!) midwives like to knock obstetricians just as much. So, the clients
end up in an endless morass of professional turf battles. It sounds to me
like the obstetrician is very negative about your chances of having a birth
with an intact perineum perhaps because he/she wants to make a point with
you about midwifery care being inferior. Most midwives can tell you about
lots of cases like yours where episiotomies were cut by physicians in hospital, repaired, the repair
fell apart, re-repaired and the woman gave birth just fine after all that.
One of the reasons that so much surgery has been performed on the female
genitalia in N. America is that healthy young women recover and heal from
this abuse amazingly well. If you have healed to the extent that you do not
have fecal incontinence and you are able to have comfortable sex, I would
be very optimistic about your second birth having a great outcome.

Starting to see a bit of the crowning head

Starting to see a bit of the crowning head

One word of caution to your future midwife: it’s always nice to be the
midwife in the second birth because everything goes quicker and stretches
easier than the first time. There is a great sense of accomplishment to see
a woman who has had a tough birth the first time just breeze through the
second one. Don’t be disparaging of the first midwife because the woman may
have had a cesarean the first time without her. There is a very good karmic
reward for those midwives who give proper credit to the woman who was there
for the long, hard first birth. This is something learned through maturity
and experience. The roles will be reversed in your future and you will
appreciate those midwives who do the same for you.

Fourth, the actions you can take to have healthy, stretchy tissues right
now are:
-Eat a healthy diet and doing lots of kegels to take blood supply to your
-Keep up good communication with your partner on what he can do to help you
have pleasurable sex.
-When you give birth next time, do lots of talking with your midwife about
your fears and needs for reassurance during the pushing stage. Your midwife
will guide you by letting you know that it’s normal to feel like the baby’s
head is too big, it’s normal to feel like it’s coming out through your bum,
it’s normal to feel a lot of burning sensation, etc. She will encourage you
to reach down and support your own tissues and will help you pant the
baby’s head out rather than give a hard push at the end. She will also use
warm oils or immersion in a water tub to help everything be slippery and
-Taking prenatal yoga and toning classes would be helpful for you, too.

My personal experience is that I had an episiotomy (lots of stitches) with
my first baby, a one inch tear (not stitched) with my second and no tear
with the third. Of course, the no tear birth was my favourite way to go.
You are wise to be taking actions to achieve this goal.
-Gloria Lemay


Reprinted from Midwifery Today E-News (Vol 2 Issue 20 May 19, 2000)



Kudos to Gloria Lemay for her response to the young woman’s concerns about
her episiotomy and what she can do to prepare for her next birth. Gloria’s
words were balanced, kind and fair, and full of wisdom and good advice. This is
the sort of approach we should all model when trying to make sense of a
troubling story. Too often we take sides or jump to conclusions, when we
can’t see all sides of the stories. I loved her words about being the
midwife for a difficult first birth, and how easy it is to look (and feel?)
like a heroine when the mother gives birth the second time. She has taught
me a lot.


Thank you, Gloria, and Midwifery Today for sharing her spirit with all of us.
And I completely agree with her about a woman’s ability to give birth over
an intact perineum after a traumatic experience. I have seen this to be
true over and over again. A good diet, a positive attitude, and a patient
midwife can do the trick!
-Penni Harmon, CNM

Penny Harmon, CNM

Penny Harmon, CNM


As a labor and delivery nurse, I have personally seen women who have had
previous 4th degree lacerations come in and deliver a baby over an intact
perineum. And not a 5 lb baby–some have been 8 and 9 lbs. It really
depends on a patient birth attendant (whether doctor, CNM or CPM) and the
birthing woman listening and working with the birth attendant. With
perineal support and slow, steady pushing, it can and does happen.
-Michelle Smith, R.N.


Reprinted from Midwifery Today E-News (Vol 2 Issue 21 May 26, 2000)

Midwife’s Guide to an Intact Perineum

by Gloria Lemay


An intact perineum is the goal of every birthing woman. We love to have whole, healthy female genitalia. Many people consider the health of the vagina/perineum to be a matter of chance, luck or being at the mercy of the circumstances of the forces that prevail at the time of the birth.


Folklore abounds about doing perineal massage prenatally. No other species of mammal does this. Advising a woman to do perineal massage in pregnancy implies a lack of confidence that her tissues have been designed perfectly to give birth to her infant.


The intact perineum begins long before the day of the birth. Sharing what the feeling of a baby’s head stretching the tissues will be like and warning the mother about the pitfalls in pushing will go a long way to having a smooth passage for both baby and mother.


The woman will be open and receptive to conversations in prenatal visits about the realities of the birth process. Here, in point form, is the information I convey for the second stage (pushing):


1. When you begin to feel like pushing it will be a bowel-movement-like feeling in your bum. We will not rush this part. You will tune in to your body and do the least bearing down possible. This will allow your body to suffuse hormones to your perineum and make it very stretchy by the time the baby’s head is stretching it.


2. The feeling in your bum will increase until it feels like you are splitting in two and it’s more than you can stand. This is normal and no one has ever split in two, so you won’t be the first. Because you have been educated that this is normal, you will relax and find this an interesting and weird experience. You may have the thought, “Gloria told me it would be like this and she was so right. I guess this has been going on since the beginning of humankind.”

"Red (or purple) Line that extends upwards between the bum cheeks"

“Red (or purple) Line that extends upwards between the bum cheeks”


3. The next distinct feeling is a burning, pins-and-needles feeling at the opening of the vagina. Many women describe this as a “ring of fire” all around the vaginal opening. It is instinctive to slap your hand down on the now-bulging vulva and try to control where the baby’s head is starting to emerge. This instinct should be followed. It seems to really help to have your own hands there. Sometimes women like to have very hot face cloths applied to their perineum at this point. If you like the feeling of this, say so, and if you don’t, say so. We will do whatever you feel like.


4. Most women like pushing more than dilating. When you’re pushing, you feel like you’re getting somewhere and that there really is a goal for your efforts.


5. This is a time of great concentration and focus for you. Extraneous conversation will not be allowed in the room. Everyone will be silent and respectful in between sensations while you regather your focus. Once you begin feeling the ring of fire, there is no need for hurry. You will be guided to push as you feel like until the baby is crowning (the biggest part of the back top of the head is visible). All that will be touching your tissues is the hot face cloth and your own hands. It is important for the practitioner to keep their hands off because the blood-filled tissues can be easily bruised and weakened by poking, external fingers. This can lead to tearing. We will use a plastic mirror and a flashlight to see what’s happening so we can guide you. We won’t touch you or the baby.


6. This point of full crowning is very intense and requires extreme focus on the burning—it is a safe, healthy feeling but unlike anything you have felt before. You may hear a devil woman inside your head who will say to you, “All you have to do is give one almighty push here and it will all be over—who cares if you tear . . . just give it hell and get that forehead off your butt!” This devil woman is not your friend. Thank her for sharing and then have your higher self say, “Just hang in there. It’s OK. Panting and rising above the pushing urge will help me stay together, and I will have less discomfort in the long run.” Your practitioner will be giving only positive commands at this point, and she will be keeping them as simple as possible to maintain your focus. Typically the birth attendant’s instructions are “Okay, Linda, easy . . . easy . . . easy . . . pant . . . pant with me . . . Hah . . . Hah . . . Hah . . . Hah . . . Hah . . . Hah. Good, that one’s over. You’re stretching beautifully; there’s lots of space for your baby. This baby’s the perfect size to come through.”


7. You will be offered plain water with a bendable straw throughout this phase because hydration seems to be important when pushing, and you can take the water or leave it, as you wish.


8. Once the head is fully born, you will feel a great sense of relief. You will keep focused for the next sensation, which will bring the baby’s shoulders out, and the baby’s whole body will quickly emerge after that with very little effort on your part. The baby will go up onto your bare skin immediately, and it is the most ecstatic feeling in the world to have that slippery, crawling, amazing little baby with you on the outside of your body. Your perineum may feel somewhat hot and tender in the first hour after birth, and believe it or not, the remedy that helps the most is to apply very hot, wet face cloths. This is in keeping with the Chinese medicine theory that cold should never be applied to new mothers or babies. Women report that they feel instantly more comfortable when heat is applied, and any swelling diminishes rapidly.


9. When you push your placenta out, the feeling will be like that of a large, soft tampon just plopping out. It is a good feeling to complete the entire process of birth with the emergence of the placenta.


When a new mother has an intact perineum, she recuperates faster and easier from birth. I like to twist a diagonally folded bath towel into a very tight roll and coil that into a ring for the woman to sit on when breastfeeding. Lovemaking can resume whenever the couple is ready; it feels good to use a little olive or almond oil as a lubricant the first few times.


Originally published in Midwifery Today Magazine.