Episiotomy is the most common operation performed on women in Canada and the U.S. without their formal consent. In fact, it is performed in between 40 and 80 percent of all births. An episiotomy is a surgical incision into the area between the vagina and the rectum (the perineum) to enlarge the opening through which the baby will come. After the baby is born, the edges of the cut are approximated, frozen, and sewn back together.
Most doctors consider the episiotomy to be a minor surgical procedure of no importance, and perform it routinely out of habit, without being aware that its use has no scientific basis. In contrast, many women feel it is the most disabling part of childbirth.
The consent for episiotomy is actually covered by the general consent form covering all procedures connected with childbirth that is signed on hospital admission.
How The Routine Episiotomy Came Into Fashion
The episiotomy did not come into vogue until the early part of this century. At that time, it was devised to prevent the serious perineal tears that sometimes occurred during childbirth. In order to prevent these tears, the idea was to enlarge the vaginal opening with a straight surgical cut that could easily be repaired afterwards with the woman lying on her back with her feet in stirrups.
In 1871, it was Dr. William Goodell who questioned the obstetrician's persistent interference in the natural process. In an article in the American Journal Of the Medical Sciences, he asked the question: "Am I to believe that nature, after making such admirable provision, for the earlier stages of labour, bungles matters to such an extent at the end ..? (The) perineum was certainly not created to be torn, unless shored up by the hands of the physician."
In an article in the Canadian Family Physician Journal, Dr. Michael Klein, Professor of Family Medicine at the University of British Columbia discusses how in 1920 one prominent American obstetrician was largely responsible for selling the idea of the episiotomy to North American doctors. Dr. J.B. DeLee advocated episiotomy as part of his "preventative" forceps delivery, which he considered to be the ideal form of birth.
Dr. DeLee believed that woman's body was badly designed for birth. He compared the stress of delivery to a woman falling on a pitchfork and the effect on the baby to having one's head crushed in a door.
Dr. Klein quotes him as saying: "So frequent are the bad effects (of labour) that I often wonder whether nature did not deliberately intend women to be used up in the process of reproduction, in a matter analogous to that of the salmon, which dies after spawning."
By the 1950's the episiotomy had caught on and become standard obstetrical practice in the majority of deliveries, with or without forceps.
Surprisingly for such a "routine" procedure as the episiotomy came to be, until recently, there had been no scientific studies on whether it was effective in preventing damage either to the mother or infant. There have been a multitude of articles on which position of the episiotomy (midline or lateral) is superior or which suture materials or sewing techniques is optimal. Until 1984 there were no controlled studies comparing the results of normal vaginal delivery with and without an episiotomy.
During their training, few doctors have a chance to witness the incredible ability of a woman's body to stretch to accommodate the largest diameter of the baby's head. "Nature," one Toronto obstetrician told me, when asked about the alternatives to a large episiotomy, epidural and forceps, "would tear the women apart".
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