Women can learn how to stop pushing when requested to do so by the doctor through controlled breathing (a pant and blow-type of breath like blowing on hot soup in rapid short breaths). With good coaching the baby's head can gradually emerge from the mother while allowing plenty of time for the mother's tissues to gently stretch. After the head is out, the shoulders should be delivered with the same careful slowness.

Prevention Before Birth

Prenatal preparation is essential. General relaxation, as well as toning and relaxation of the pelvic floor muscles, (Kegels) and practice of second stage breathing patterns, are important skills to be learned ahead of time. However, these skills can also be learned right on the spot with the help of a good nurse or labour coach.

Some midwives advocate gently massaging the whole perineal area with olive oil or vitamin-E oil ten to 15 minutes a day for one to three months prior to the birth. This massage can also be done by the woman's partner. Although there is no evidence that it works, it will at the very least make a woman more aware of how to relax that area and promote intimacy between partners. Some midwives also massage the perineum with olive oil during second stage, so the tissues are moist, stretchy and relaxed, and the baby's head can slide out more easily. Again, this technique has not been studied, but the experience of midwives indicates that it may be useful.

There Is No Need For An Episiotomy In A Normal Birth

If asked, most doctors will tell you that they will only perform an episiotomy if necessary. But what they don't tell you is that in their experience, an episiotomy is almost always necessary. From their perspective, they are right. They have never seen any other kind of delivery. A more useful question to pose is what percent of their patients having their first or subsequent child receive episiotomies. They may tell you that women having their first babies usually need an episiotomy. This is not true. In fact in first births, there is usually more than enough time to stretch if adequate time is allowed for second stage pushing. Occasionally in subsequent births, the pushing stage may be rapid and difficult to control.

Obviously certain medical emergencies call for the use of an episiotomy such as when the baby's heart beat suddenly disappears during second pushing, or to facilitate the delivery of a premature or breech baby, and of course when forceps are used. In addition, an episiotomy may be required when the delivery of the baby's head is progressing at a rate or manner which will tear the perineum, or not allow for the normal gentle stretching to occur.

But for the vast majority of normal births there is no medical reason for the performance of a surgical incision of the perineum.

Arroll's Advice To Doctors

Dr. Bruce Arroll is a New Zealand obstetrician. He offers the following suggestions to doctors for low risk women during labour (Canadian Family Physician, Nov\84):

FIRST: Give every woman the chance to deliver without an episiotomy.

SECOND: Ask the woman if she has strong feelings about episiotomy. This may help in decision-making although there can be no guarantee an episiotomy won't be necessary.

THIRD: If you're performing episiotomies on more than ten percent of women having their first babies, your episiotomy rate may be too high.

FOURTH: If a tear starts before the largest diameter of the head is out, then an episiotomy may reduce further damage.

Dr. Arroll has called for a consensus conference on what is a medically acceptable episiotomy rate for doctors.

Tears Heal Quickly

Contrary to what the medical texts say, small tears, if they do occur, heal quickly and with little pain. In my experience with women who have had both, the tears healed faster and with less pain when compared to an episiotomy in a previous birth.