Reply turned post, a VBAC reality check

I am a huge fan of RH Reality Check. However, I was recently a little troubled by a post about choosing elective cesarean over attempted VBAC (vaginal delivery after cesarean). I am a little, OK way behind on my blog reader. The original article, I’ve Made My Birthing Choice, and It May Surprise You was published in September, but I just got around to reading it tonight. I had a gut reaction similar to the reaction I have to many blog entries I have read defending a common, mainstream choice that is disguised as an underdog, against the system, authority challenging choice. But, I was more troubled by the many medical inaccuracies in the piece.

So, I wrote a reply. One I am upset to see has a bunch of html fail in it. I guess RH Reality Check doesn’t support hyperlinks. So, here is the prettier version:

I want to support you and your decision to have a repeat elective cesarean instead of a VBAC attempt, and your choice is indeed valid.

I have to join in the chorus challenging some of your points, however. On the one hand, I am hesitant, since I cringe at the thought of how judgmental people are towards pregnant women and their choices. However, there are a few reasons why I am choosing to do so. First of all, I think you have some statements in your article that are medically inaccurate. And, this isn’t a personal blog. This is presented as journalism / advocacy. Journalism on medical topics needs to be held to a higher standard.

Secondly, you are defending a choice, elective repeat cesarean, that is really not in need of defense – it is presented as the most reasonable choice, and in many cases only choice, for the vast majority of women in the U.S. The power balance is dramatically tilted against women being able to choose VBAC. How is it surprising that it was your choice? Of course it’s valid – it’s almost guaranteed!

Let’s start with some of the inaccuracies.

I am in medical school and just completed a research fellowship on labor interventions. I think the exercise you did in your childbirthing class was atrocious. We do not need to choose between a healthy baby and evidence based, women centered medicine. Avoiding non-evidence based interventions that have worse outcomes for the mother and baby makes it more likely that we can have healthy babies. They should not be presented as competing priorities.

For example, we can have a healthy baby AND not have an episiotomy. Episiotomies should be avoided at all costs, according to substantial research. They do not make babies more healthy. There is not one situation in which they save a baby’s life. It is even recommended that they be avoided for operative vaginal delivery (when an intervention such as vacuum extraction is needed) – they lead to more maternal and neonatal morbidity. I consider episiotomy use to be a litmus test for an obstetrical health care practitioner.

As other people have pointed out, non medically indicated inductions, especially those in a first time mother, carry more than double the risk of cesarean. In fact, some hospitals are now banning elective inductions on first time moms as a quality assurance measure. Rixa has a good synopsis of links on this topic at Stand and Deliver. The Bishop’s score is an important indicator of whether an induction is likely to be successful, as opposed to a several day long ordeal that ends with a cascade of interventions, leading to an emergency / iatrogenic cesarean. If there is a compelling medical indication that one would get a cesarean for anyway, that is one thing. But, in our society, many women are told to get induced before their baby gets to big, or because the baby is looking a little small, or because the obstetrician is going on vacation, or the calendar year is changing, or because they have a certain amount of time off from work and they really want to plan their maternity leave. These psychosocial factors for induction are all indeed valid, and birth is not the only medical decision in which psychosocial factors are weighed, but they do sometimes increase the risk of not having as healthy a baby or as healthy a mom. More than an episiotomy would.

Or an epidural. Epidurals are associated with maternal fever, especially longer lasting epidurals, such as those associated with inductions. If a mom’s membranes break, or more likely, are artificially ruptured during active management of labor or an induction, and she subsequently develops a fever, many practitioners will consider that to be an indication for cesarean section.

Group B Strep is present in up to 40% of healthy women – a cesarean is not the recommended intervention for prevention of transmission of group B strep to a baby. The current standard of care is to administer antibiotics during labor.

As for the VBAC vs. elective repeat cesarean issue – it is obviously a highly personal choice, and one I am happy you were able to make without apparent pressure from your hospital system or your chosen practitioner. Please don’t present VBAC as higher risk, however. The larger risks of an emergency situation are very, very uncommon in a VBAC. In fact, they are identical to the risk of perinatal mortality in a primary vaginal delivery. There is a definite imbalance of risks to the mother (increased risk of hemorrhage, need for transfusion, and infection, as illustrated by your anecdotal experience) with a cesarean, and increased risk of neonatal trauma or morbidity with a VBAC. But, these risks are vanishingly small. One set of risks is not large and uncontrolled and scary, compared to one set being small and manageable and acceptable.

Anyway, I wish you a safe and uneventful birth, regardless of your chosen method of delivery. I am always happy when this site steps out of the zone of reproductive choice just being about preventing birth. And, you were very brave to put your personal decision our there. Just, please remember that when you are writing for a site such as RH Reality Check, a little reality checking may be in order.

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35 Comments

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35 responses to “Reply turned post, a VBAC reality check

  1. VW

    Great response!

    Quick question: can you ask not to have an episiotomy for an instrumental delivery? When I had forceps for my daughter’s birth, they presented it as a package deal with an episiotomy and I accepted it as such. Given the problems I had with an infection and a wonky scar that required revision months later, I’d like to know (not that I’d actually agree to an instrumental delivery again -it was most likely a huge factor in my daughter’s shoulder dystocia that put her in the NICU).

    • MomTFH

      You can ask, certainly. But, it really depends on your practitioner. Many practitioners don’t appreciate being told not to perform a procedure. I would discuss it pre-delivery, and bring in supporting literature if necessary. If a practitioner gets really upset by this, i would consider that to be a serious red flag.

      Remember that, especially with forceps, you may tear without an episiotomy. However, research indicates less trauma, less postpartum pain and faster healing without the episiotomy, even with a tear.

    • Helen

      It’s my understanding that forceps deliveries generally do require episiotomies. My forceps delivery was unusual: the OB brought the baby down to near-crowning with forceps and then took the forceps out; delivery was spontaneous thereafter. I had a ton of surface splitting, but no tears through the muscle. I don’t think this is a technique that’s commonly used these days. I forget whether it has a name; will check.

      • MomTFH

        I thought they did too, but the study I link to says otherwise. I suppose your experience does, too. I think many physicians just assume that an episiotomy is necessary. Now, I have never used forceps. I have seen forceps, but never seen them used.

        I am definitely planning on getting trained to use them, but, as far as I know, it is much more preferable to try vacuum extraction if possible.

        • VW

          I asked about the vacuum too, but the baby’s head had a caput so they told me it wasn’t an option.

          I get the sense that c-sections are used more frequently in the US when forceps are the only other option. I’m in NZ and many of my American friends were surprised I had forceps because they thought it was only used in third world countries nowadays.

          At the time, I was very focused on avoiding the c-section, but it turns out (hindsight is 20/20) that with the shoulder dystocia and its aftermath that followed the forceps, I might have been better off with the c-section. HBACs are no problem here in NZ, but b/c of the severity of the shoulder dystocia, I’ve pretty much risked myself out of the home birth option for my next birth.

  2. Olivia

    Awesome comment. I hate seeing medical inaccuracies go unchecked. And your point about choosing a 2nd c-section is bang on. It’s the most common “choice” in our country, so it’s hardly surprising. Simply because advocates for VBAC (or non-medicated childbirth, or homebirth etc.) are being heard more in the media, does not make the alternative, more statistically prevelant method the “underdog”.

  3. Christie B

    There were a couple of points in your reply that really articulated for me some things that made me uncomfortable when reading the initial post. I agree that the childbirth “education” exercise was unconscionable. What if there were cards in the stack like “not being punched in the face by nursing staff/OB” or “not being raped by wild dogs”? Sure, most people are going to rank “healthy baby” higher – so what? Are there that many people walking out thinking, “Whoa – apparently I care about having a healthy baby – who knew?”
    It’s also interesting to me how inductions seem to be key in destroying women’s confidence in their bodies’ potential to birth and really making labor seem terrible – painful, restricting, scary, prolonged, and ultimately futile. I wonder if insurance companies could play a role in clamping down on inductions that aren’t medically indicated – it could possibly go a long way toward lowering c-sections rates both initial and “elective” repeats.

  4. I don’t know. You know I’m a big admirer of yours, but I think that she is being unfairly jumped on from a few directions. RH Reality Check is not 100% Medical Journalism All the Time. In particular, Robin Marty’s coverage of her personal struggle with miscarriage and fertility, and her decision about VBAC, has been more of a personal column in which she blogs about these reproductive experiences in real time.

    Sometimes I think that other people’s writing can be a Rorschach test – some people see her as putting forth a bunch of medical inaccuracies that other women won’t be able to see past in making their decisions. I see a column that is not really about the actual medical evidence at all, but her working through her research and feeling on some unexpected gut level like a repeat cesarean is the set of risks she’s willing to deal with under the circumstances (including her past experience). I think that the standard of care for GBS+ probably matters less in her calculus than the experience of having her baby in NICU.

    It is possible that the element of “surprise” is not in that choosing a repeat cesarean is such an anti-establishment renegade choice, but that she went into this thinking that *of course* she was going to have a VBAC. Particularly someone who writes for RH Reality Check where most of the people who write about birth (myself included) are VBAC advocates.

    So maybe it’s also possible that the visceral clutch and urge to take down are misplaced, and might also explain why women might feel defensive when they don’t choose VBAC.

    • MomTFH

      I understand and respect your point of view on this. I read your comment on her post and I was happy that she was getting some sympathetic reactions to her personal decision, which she deserves.

      I have to disagree with you, though, about the post being merely a personal reflection of a mom who has gone through a previous birth with some complications. RH Reality Check is an advocacy site, under the greater umbrella of women’s health journalism. Her post included language in more than one place discussing her decision in the framework of reproductive choice and method of delivery advocacy. If this post was on her personal blog, I would have refrained from critical comment.

      As for the GBS issue specifically, I think my point that up to 40% of women can be GBS positive was more important than the standard of care on preventing transmission. There is a very, very good chance that someone reading that post will screen positive. Less than 1 in 1000 women with a positive GBS screen will pass on the infection to the infant if they are treated with intrapartum antibiotics.

      More importantly, advocating cesarean as a response to normal vaginal flora perpetuates the perception that the vagina is a scary, dirty threat to the safety of the newborn. And, a cesarean delivery, especially before 39 weeks, as hers is scheduled to be, is more likely to land her child in NICU with respiratory distress than a vaginal delivery with GBS.

      I would compare it to someone saying: I support the right of others to choose to terminate, but my mother died of breast cancer, and I just don’t want to increase my risk anymore, on RH Reality Check. Personal, valid choice based on a negative family experience, but medically inaccurate and perpetuating myths that decrease women’s informed choice.

      There is indeed a delicate balance when discussing personal choices in reproduction and birth. I also disagree that her decision is not typical of the feminist counterculture. I find that the birth advocacy community and feminist community, especially the pro-choice advocacy community, do not overlap as much as some might think. I have been told in person by a fellow midwifery student and on this blog that being pro-midwifery and being pro-choice are contradictory, incompatible positions. I have seen this defensive underdog positioning often in this context- defending many mainstream choices: epidurals, not initiating breastfeeding, elective primary cesarean, changing one’s name to one’s husband’s, etc. Again, all valid choices, and I am not one to revoke feminist status or to engage in mommy wars. But, it rubs me the wrong way to see these choices as somehow challenging to the mainstream.

  5. Yehudit

    “There is not one situation in which they save a baby’s life.”

    The midwifery mentors I most respect have a good proverb: “never say never.” I work in an environment where routine episiotomy has been erradicated. Episiotomy is still done on occasion however because

    a) Forceps. Ventouse and forceps and not interchangeable – there are definitely situations in which the latter is prefereable to the former (caput is one of them) and a forceps without a mediolateral episiotomy risks a midline tear, possibly 3rd or 4th degree. If a mediolateral epis extends, it will not be into the anal sphincter. In the US, I understand that midline epis is standard, so the benefits may be correspondingly smaller.

    b) In case of a prolonged fetal bradycardia without recovery where the head is on the perenium but not crowning. In this case, episiotomy is the obvious response to expedite delivery, and the failure to do one would likely result in an acidotic compromised baby.

    c) theoretically, to allow access for internal maneouvres in case of shoulder dystocia (though if you have space to cut an epis, you probably have space for the maeouvres). But it’s useful to have the option, because if you need to use internal maneouvres, you might just find that an epis is the thing that helps save the baby’s life.

    I am glad that I have been trained in how to cut an episiotomy, including the indications for doing so, even if I have the good fortune never to have to use that knowledge.

    • MomTFH

      A. According to the study I have linked to twice, once in my original post and once in the comments, episiotomy for operative delivery, including forceps, increases trauma to the mother and the neonate. Episiotomy increases the risk of extended tears, not decreases.

      B. In the case of fetal bradycardia on the perineum, it is not the thin soft tissue of the perineum that is keeping the baby from crowning. Making a cut in the perineum will not facilitate expulsion of the fetus in any situation I have seen this in. Vacuum aspiration might, or other maneuvers, but see the above mentioned study about episiotomy increasing morbidity for the mother AND neonate when operative delivery is indicated.

      C. Same thing for shoulder dystocias. I have seen shoulder dystocias maneuvers performed without episiotomy numerous times. There is nothing in shoulder dystocia protocols about episiotomy.

      Evidence contradicts all of these so called indications. The perineum will tear with better outcomes if it is ever a minor barrier. It is not a significant barrier that, when intact, will threaten a baby’s life. If there was some sort of mutilation procedure done, that is a different story.

  6. Yehudit

    The study you cite is completely unhelpful in terms of telling us whether or not episiotomy is beneficial when doing forceps. It is not an RCT, so chock full of confounding variables. I invite you to read the full text! In particular, just 21% of the women in the cohort did not have an episiotomy. Since this was a prospective cohort study (not an RCT) these 21% of women were actively selected by the obstetrician as most favourable for instrumental delivery without episiotomy – it’s a pretty enormous confounding variable.

    On B) – I hope you never have a situation in your practice where the fetal heartrate is down for many minutes and the perineum neither stretches nor tears. Because episiotomy in that situation is the far quicker, and arguably less invasive, than an instumental delivery. And if you practice in community then you won’t have the option of an instrumental delivery anyway.

    • MomTFH

      A) Show me an RCT that says episiotomy is better for forceps. It doesn’t exist. This study is the best we have so far on the subject.

      B) I don’t understand this comment. If I practice is what community I won’t have the option for instrumental delivery? I am going to be an obstetrician. Do you mean at a community hospital? I think instrumental deliveries happen there. I am not a practicing obstetrician yet, and I am not sure what I will do when I am faced with a fetal heart rate that is down with the fetal head on the perineum. I find it hard to believe that the soft, thin tissue of the perineum is strong enough to be an effective barrier against delivery. I will judge each case individually and obviously choose any interventions based on what will provide the best outcomes in that individual circumstance.

      • Yehudit

        I meant, midwives who practice in community settings (home birth/birth centre) don’t generally have the option of the instrumental delivery (forceps ‘lift out’ or kiwi ventouse) to expedite delivery, even if there was time to do one

        • MomTFH

          I am going to be an obstetrician. So, I will not be practicing under those limitations. That is one of the many reasons I decided to be an ob, not a midwife. If you meant the universal “you”, again, you are going way beyond the scope of this original post. I wasn’t discussing midwives with limited scopes of practice in extremely rare emergencies. Which is still a questionable application.

  7. Yehudit

    There certainly is something in shoulder dystocia protocols about episiotomy. It is the “E” of the HELPERR mneumonic “Evaluate for Episiotomy” and it means that you should do exactly that – evaluate. Plenty of times it won’t be needed, but “never say never” are wise words, and again – you might one day find yourself in a situation where Gaskin, McRoberts and suprapubic pressure have failed, and where you can’t get access to remove the posterior arm or other internal manouevres without cutting an episiotomy. (Of course, the chances are that you can’t get access to cut an episiotomy in that scenario too). A desparate situation indeed.

    I find the dogma that an episiotomy should NEVER be cut in any situation a little worrying.

    • MomTFH

      Here is a good reference for you to read on the subject.

      Am J Obstet Gynecol. 2004 Sep;191(3):911-6.
      Episiotomy versus fetal manipulation in managing severe shoulder dystocia: a comparison of outcomes.
      Gurewitsch ED, Donithan M, Stallings SP, Moore PL, Agarwal S, Allen LM, Allen RH.

      Department of Gynecology and Obstetrics, Johns Hopkins University, School of Medicine, Baltimore, Md 21287, USA. egurewi@jhmi.edu
      Comment in:

      Am J Obstet Gynecol. 2005 Oct;193(4):1582-3; author reply 1583-4.
      Abstract
      OBJECTIVE: In severe shoulder dystocia, when initial maneuvers fail, either episiotomy or fetal manipulation (Rubin, Woods’ screw, or posterior arm release) is recommended. We sought to compare maternal and neonatal outcomes between severe shoulder dystocia deliveries managed with episiotomy versus fetal manipulation.

      STUDY DESIGN: We identified severe shoulder dystocia deliveries from three databases: all shoulder dystocia deliveries (1993-2003 and 1994-1997) from two teaching institutions and litigated cases of shoulder dystocia-associated permanent brachial plexus palsy from multiple U.S. institutions. Pair-wise comparisons were made among three groups of deliveries: those managed by fetal manipulation without episiotomy (fetal manipulation-only), those managed by episiotomy without fetal manipulation (episiotomy-only), and those managed with both (episiotomy + fetal manipulation). Rates of brachial plexus palsy, neonatal depression, and anal sphincter trauma were compared among groups using chi 2 , with significance at P < .05.

      RESULTS: Among episiotomy-only, 13 of 22 (59.1%) sustained brachial plexus palsy, compared with 20 of 57 (35.1%) among fetal manipulation-only (P = .05). Twenty-eight of 48 (58.3%) in episiotomy + fetal manipulation had brachial plexus palsy, which did not differ from episiotomy-only (P = .95) but was higher than fetal manipulation-only (P = .02), suggesting that the addition of episiotomy conferred no benefit in averting neonatal injury. Anal sphincter trauma was significantly more common among episiotomy-only and episiotomy + fetal manipulation, compared with fetal manipulation-only.

      CONCLUSION: In severe shoulder dystocia, if fetal manipulation can be performed without episiotomy, severe perineal trauma can be averted without incurring greater risk of brachial plexus palsy.

      Not worrisome to me. Never is a strong word, but when study after study shows that it makes outcomes worse, I don't know why anyone should consider it.

      That is the difference between anecdotal medicine and evidence based medicine. I will also never give a woman thalidomide for morning sickness. I will never do a twilight sleep delivery with a high forceps extraction. We can learn from our mistakes and advance obstetrics without defending practices that have been shown to be destructive.

  8. Yehudit

    Again, with the offbeam study. I’m talking about episiotomy as an adjunct to make internal maneouvres possible, not episiotomy versus internal maneouvres (which seems to be the main focus of the study). Obviously, shoulder dystocia is not a soft tissue problem, so episiotomy alone is not a solution (I’m surprised anyone would expect it to be, and it speaks volumes for the quality of the article that this is their main comparison). However, episiotomy can be necessary to facilitate internal maneouvres. And the study appears to agree with my take on this – check out the wording of the conclusion:

    “In severe shoulder dystocia, *if* fetal manipulation can be performed without episiotomy, severe perineal trauma can be averted without incurring greater risk of brachial plexus palsy.” The “if” implying that there may be scenarios in which fetal manipulation cannot be performed without episiotomy. I would entirely concur. That is why the E of HELPERR is “Evaluate for Episiotomy” (i.e. assess whether internal maneouvres are required and whether they can be done without episiotomy) and not simply “Episiotomy, cut one”.

    • MomTFH

      Look, this post is not about episiotomy, and I am choosing to not continue this back and forth about episiotomy.

      Thank you for your defense of episiotomy. I disagree about its usefulness, and until you show me a higher quality study showing that it actually improved outcomes, I am going to rely on the available data. Obstetrics data will always be limited by confounders and ethical considerations, and we have to use the data we have available, which I believe strongly discourages episiotomy.

      I have heard your point about how useful you think it is, and please feel free to continue supporting its use. Please refrain from any more off topic comments on this particular post on VBAC. Thanks.

  9. doctorjen

    I have to agree with Yehudit on this one – and my episiotomy rate in practice approaches zero – I haven’t done one in 2 years. We do know that episiotomy shortens 2nd stage in primiparous mothers especially. Most of the time, this is of no benefit to anyone – crowning for 5 minutes or so is not harmful. Rarely, though, with severe bradycardia that won’t resolve with position changes, especially in a fetus you suspect to already be compromised, those 5 ish minutes matter. In that case, shortening the second stage is not a terrible idea. I’m not talking about the baby who did great the whole labor and has a terminal bradycardia for a few minutes, likely from rapid descent and head compression, those babies can often tolerate a little longer, but those babies who are already doing poorly, and then have persistent bradycardia and need to be delivered as soon as possible.

    Also, the study you linked for shoulder dystocia is difficult to evaluate because of it’s retrospective nature. I saw a recent similar study on vertical vs horizontal incision for emergency cesarean in the true crash situation. Babies born via vertical incision had worse outcomes despite faster interval from incision to delivery – however, this may well be confounded by the physician choosing a vertical incision for those babies they suspected to be the most compromised. Same with physicians choosing to use episiotomy AND maneuvers, and those babies having the worse outcomes. It would make intuitive sense that some babies were so stuck that the docs tried everything and still couldn’t get the baby out in time to prevent a bad outcome. Shoulder dystocia is of course not a true soft tissue disease – but if you’ve tried everything and are struggling to get the baby out when baby may already be compromised, and you need extra room to get your maneuvers done, episiotomy might be reasonable. I agree with the HELPERR mnenomic, though, from ALSO – Evaluate for Episiotomy, not automatically perform one.

    I think “never say never” is a pretty good practice motto for many areas. Especially before you’ve had to single-handedly manage a bunch of complicated births. I believe wholeheartedly that for the grand majority of normal and complicated births, scissors have no place near the girlie bits – but on those rare occasions when the baby’s life is in danger and it may be possible to shorten the second stage, I will consider it.

    I have less opinion on operative delivery – I don’t do forceps and don’t use episiotomy for vacuum, finding it not necessary (and don’t have an increased risk of tears with a vacuum.) I’ve seen forceps done without episiotomy successfully on occasion.

    • MomTFH

      Thanks for your input. As I have said, I am not a practicing obstetrician yet. If I ever find myself in a situation in which I think the perineum is the only thing between me and a healthy baby, I am sure I will use one. I just don’t think it is defensible in the context of the original post, in which it was used as an alternative to having a healthy baby in a childbirthing class. I also don’t think the almost 40% rate of episiotomy in the US reflects extremely conservative usage. I am glad you haven’t felt the need to use one in the past two years, and I hope you continue to have noncomplicated deliveries.

  10. Yehudit

    Thanks for understanding, doctorjen. “Never say never” is not some kind of universal “defence of episiotomy”.

    • MomTFH

      I also don’t think it is an appropriate response to the context of the original post. Episiotomy is overwhelmingly overapplied, not underapplied. I understand that “never” is a strong term, but I think you can agree that it rarely, if ever, improves outcomes, and in many cases seems to make outcomes worse. If a doctor who practices obstetrics can say she hasn’t done one in over two years, isn’t that pretty much never per year, x 2?

      I don’t think, especially considering the context of the discussion of episiotomy in the original post, which was weighing avoiding episiotomy against having a healthy baby in a regular childbirth class, this extended argument is appropriate.

      • Yehudit

        In the course of making your (very valid) points about pitting healthy babies against interventions, you made a completely unqualified absolute statement “There is not one situation in which they [episiotomies] save a baby’s life.”

        I hoped to correct this dogmatic viewpoint, but you have dug your heels in. Now, when you are a practising obstetrician, there may perhaps be no siutation in which an episiotomy will save a baby’s life. In the event of the non-recovering brady you will simply (!) apply your ventouse or forceps (without doing an episiotomy) and in the event of the severe shoulder dystocia with lack of access you will simply (!) do the zavanelli manouvre and go for section. No episiotomy required.

        But in a world where vaginal births are attended by midwives rather than obstetricians, there are certainly situations where episiotomy might save a baby’s life. I was trying to open your eyes to that – I don’t see what is inappropriate with challenging dogma wherever it hails from.

        • MomTFH

          Again, I am asking you politely to stop derailing the original post. I never even used the word “never”. I am not dogmatic – I am accurately reflecting the best evidence we have on the subject. There is not one situation in which evidence supports episiotomy as the difference between life and death for a baby. As the primary choice of interventions. Got it? That is what I meant, and if you can’t understand that, I am sorry.

          I find episiotomy to be sadly overapplied, and think if even the physician who comes on here to sort of agree with you says she hasn’t needed one in two years, we can agree that I wasn’t being needlessly dogmatic. If I haven’t had a drink in two years, I wouldn’t say I sometimes need a drink.

          I think it was pretty clear I was not discussing the rarest of rare situations in my original post. I wasn’t discussing homebirth midwives. I was discussing a conventional childbirth class taught to women seeking hospital births being told that they need to choose between having an episiotomy and having a healthy baby, as if these are commonly competing priorities.

          Did you read the original post? Do you really think my dogmatic stance against episiotomy was the most important take away message? Do you think this dogmatic stance against episiotomy is what is plaguing conventional VBAC rates in the US?

          Holy derail. Please stop. I get it. There can possibly be a rare situation in which a midwife is in a remote location and ALL ELSE HAS FAILED. Notice you dropped the other justifications. There is no way she could force a tear with her attempts because that perineum would be just too damn tough. Got it. I obviously grossly misspoke and ruined the whole post. Thanks for clearing that up. Sigh.

          Any other posts that simply repeat your previous points that have been stated ad nauseum will be deleted. If I do a original post on how an episiotomy should never ever be done, even if it is the best judgment of the practitioner and there are limitations on the practitioner, please feel free to bring up these points.

  11. Yehudit

    Typical obstetric arrogance! Nothing to learn from your midwifery colleagues….

    I stand by the forceps thing too, just so you know.

    • MomTFH

      I am the dogmatic one? I am the one digging in my heels? I have typical obstetric arrogance?

      Do you read my blog? Did you read the original post?

      Telling a future obstetrician that she is arrogant, or isn’t learning from midwives enough because she isn’t supportive enough of the use of episiotomy would be laughable if it didn’t involve your insulting me on my blog and irretrievably derailing a post. You have been asked politely to stop several times.

      I will delete any more comments from you on this post. Be proud – this has only happened once before, and it was Dr. Amy.

  12. Yehudit

    You used the words “There is not one situation in which they [episiotomies] save a baby’s life.”

    not one situation = never.

    • MomTFH

      They don’t. At best, they may facilitate other maneuvers that can save a baby’s life in extremely rare circumstances. Also, there is no peer reviewed evidence to back up their life saving qualities. You may criticize the quality of my evidence (with generic confounding arguments that apply to nearly all obstetrics studies) but you have yet to provide more than a mnemonic to support your claim of episiotomies saving lives.

      I asked you to stop repeating the same arguments several times politely.

  13. B

    MTH, you just need to be a bit more open-minded on this issue. You claimed by reading a couple of studies and without enough of your own experience as an ob, that episiotomy isn’t necessary in any case. You have two experienced people (Yehudit and drjen) with low episiotomy rates describing for you that there are some useful cases. No one seems to be in disagreement that epsiotomy is drastically over-used out there by many ob’s and midwives. There is no need to dig your heels in but be open minded that a close to zero episiotomy rate is possible, but that some rare cases could benefit from it.

    • I don’t see the point of the continued back and forth on this, especially considering the context of the original post. I have made it clear that episiotomy can, in very rare circumstances, expedite other necessary procedures. Even Dr. Jen said that she hasn’t done one in two years.

      The evidence is strongly discouraging of the practice. I never said no practitioner can ever make that judgment call in an emergency. It is not a first line treatment, and in the original post, it was presented as some sort of path to a healthy baby in a childbirthing class. Considering the reality of about a 40% episiotomy rate, and the way I have seen it frequently applied in many non-emergency situations, I am not understanding this continued argument. It doesn’t need more defense.

  14. Susan Peterson

    I really think it is better to let people say their say and let the argument go where it may, so long as people are adducing arguments and not slinging insults. And here, I believe, they were adducing arguments.

    From someone who has been cut both above and below, and lived to deliver several large babies over an intact if scarred perineum, and also to enjoy sex and be continent of B&B! And who was enjoying the interchange of opinions here until you became so very exasperated with it.

    Susan Peterson

    • MomTFH

      I am happy with your anecdotal success with your episiotomy. However, clinical evidence suggests that painful recovery, painful sex, extended tears and bowel incontinence are more common following episiotomy than vaginal delivery without episiotomy. Not guaranteed, as shown by your case, just more common.

      I am also happy to read now that you were enjoying the interchanged that occurred on here over two months ago, before I decided to end it. But, as the moderator of the comments on my own blog, it is up to me to decide when a conversation has exceeded my standards. You may disagree, but when a commenter calls me arrogant, I consider it to be an insult. I also disagree that continuing to repeat the same point endlessly, then resorting to insults, is an adducing argument.

  15. Wow that was odd. I just wrote an really long comment but
    after I clicked submit my comment didn’t appear. Grrrr… well I’m not writing all
    that over again. Anyhow, just wanted to say wonderful blog!

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