Ep 299: How to Protect Your Power and Avoid an Unnecessary Episiotomy

Nicole Rankins (00:00.192)

Apesiotomy is not routine anymore, but it hasn't gone away. And if it's done without your consent or done because your doctor's in a hurry, that is a problem. So let's talk about it. Because when you understand what apesiotomy really is, when it's actually needed and how to protect yourself from one that isn't needed, that's when you step into your power.

Nicole Rankins (00:31.822)

Welcome to the Birth with Power podcast, where knowledge is power and power transforms birth. I'm Dr. Nicole Callaway-Rankins, mom of two and practicing board certified OB-GYN with over 20 years of experience and nearly 2,000 births attended. I've seen firsthand how the hospital system can leave women feeling unheard and uncertain, but that doesn't have to be your story. Here, you'll get the knowledge, support and strategies to take charge of your birth experience.

so you can walk into the hospital feeling calm, confident, and empowered. Note, this podcast is for educational purposes only and it's not a substitute for medical advice. See the full disclaimer at drnaclomaragans.com forward slash disclaimer. Now let's get to it.

Hello there, welcome to another episode of the podcast. This is episode number 299, whether this is your first time listening or you've been here before, I am so glad you are spending some time with me today. In this episode, I am breaking down episiotomy, a topic I first covered back in 2020, but I want to circle back to it because I wanna come out harder with my thoughts on consent,

power, how doctors habits can shape your birth and things you can do to protect yourself. So whether this is brand new for you or something you've heard horror stories about, stay with me because I'm giving you the real deal on what episiotomy is, why it used to be done so often, why we now know better and know that routine episiotomy causes more harm than good.

You're going to learn about when a PC otomy might actually be needed. That is rare, but it is real. And then how to ask your doctor the right questions and decode their answers. Plus things to watch out and listen for in labor. So nothing is done to you without your consent. This episode is all about preparing you for potential interventions without fear.

Nicole Rankins (02:44.62)

so you can respond from a place of confidence and not confusion. Let's get into it. So let's start off with what exactly is an episiotomy. An episiotomy is a surgical cut. We do it with scissors and it's made in the perineum. The perineum is the area between your vaginal opening and your anus and it's done right as the baby's head is being born.

The reason that episiotomy is done is that it will enlarge the vaginal opening. And when the vaginal opening is larger, the baby will come out faster because there's just more space. So the baby comes out sooner. There are two types of episiotomy. One is a midline episiotomy. That is when the cut is made straight downwards towards the rectum. So,

Think about like six o'clock on a clock face. If you think of the vaginal opening like a clock, a midline episiotomy will be a cut down towards six o'clock. A medial lateral episiotomy is an angle cut to the side. So that's gonna be more like four or five o'clock or seven or eight o'clock. Now the medial lateral episiotomy approach is preferred if an episiotomy is necessary.

because it's less likely to extend into the rectum. And that makes sense with that midline one and you're cutting straight down towards the rectum, that's more likely to spread into the rectum. But either way, an episiotomy is a significant intervention. episiotomy used to be done routinely. And let me tell you why. So in the 1970s, more than 60 % of vaginal births involved in episiotomy, doctors who will

who were primarily male, I will say at the time, believed that episiotomy would actually prevent worse tears, that episiotomy would protect the pelvic floor, that an episiotomy would be easier to repair because the edges would be more like a smooth cut than the rough edges of a natural tear. They believed that an episiotomy would reduce incontinence and that it would even help

Nicole Rankins (05:00.088)

prevent shoulder dystocia. However, when these claims have actually been studied, not a single one of them has held up. A major Cochrane review from 2017 showed that episiotomy doesn't reduce pain, doesn't improve healing, doesn't protect against future issues like incontinence. In fact, routine episiotomy often causes more

complications and not fewer. So let's talk about some of those risks of doing an episiotomy. An episiotomy can increase your chances of having a severe tear. And by severe tear, I mean a third or fourth degree tear. A third degree tear is one that goes into the anal sphincter. The anal sphincter is the group of muscles around the rectum that allow you to control

when you pass gas or have a bowel movement. So they are responsible for gas and fecal incontinence. Or that fourth degree tear goes through the anal sphincter muscles and then through the rectum. That is the most severe type of perineal tear. Apesiotomy can also increase your chances of infection. It can increase your chances of having higher blood loss. It can increase your chances of having scar tissue or pain with sex afterwards.

you can have a higher chance of re tearing in the same spot during future births. And then there's actually a higher chance of asymmetry or a narrowed vaginal opening due to poor healing. So while episiotomy was theoretically thought to be easier to repair in the moment, it actually often proved to be harder to heal from in the long run. So where'd

things stand now in terms of episiotomy. I'm glad to say that we have made a lot of progress. The most recent US data around 2018 or so shows that episiotomy has performed in under 8 % of vaginal births, lower in some places. It's very low at the hospital where I work. That is down from 12 % in 2012. And then again, more than 60 % back in the seventies. That of course is encouraging, but

Nicole Rankins (07:26.05)

Here's the thing, and it's important, I want you to know this, averages can actually be a little bit deceiving because one hospital may have an overall very low episiotomy rate, but the individual doctors in that hospital can vary wildly. I worked at a hospital before where you might have one OB.

that has a 1 % episiotomy rate. And then there were two or three others that had episiotomy rates in like the 60%. That was the same hospital, same labor and delivery, but completely different approaches. So the biggest takeaway and what I want you to hear from this is that the strongest predictor of whether or not you will get an episiotomy is your

Doctor. I'm gonna say that again. The strongest predictor of whether or not you get an episiotomy is your doctor. It's not your baby size. It's not your birth preferences. It's not your insurance. It is the person who is catching your baby and the habits that they bring it to that room, period, full stop. If that doctor is used to doing episiotomies, then they do episiotomies.

This is something that I have seen honestly much more with doctors who've been out in practice for a while because when they trained, episiotomies were a lot more common and they just haven't updated their practice. I will say that with doctors in more recent years, definitely in the last 10 to 15 years, we don't get trained on episiotomies or newer doctors don't get trained on doing episiotomies routinely. So it's not going to be as common. But again, the strongest predictor

of whether or not you'll get an episiotomy is your doctor and how frequently they do them. Now I do want to be clear, and it's important for you to know that sometimes an episiotomy is actually necessary and it may be helpful. And there are two situations where an episiotomy is appropriate and can be helpful. One is if a baby is in distress and needs to be delivered quickly. So that's when the heart rate is very low,

Nicole Rankins (09:43.638)

and it's been low for a little bit, baby is showing obvious signs of distress to the heart rate, baby needs to be born, then an episiotomy is going to help that baby be born quicker. That is the instance in the rare times that I've done an episiotomy in the last few years, it's because the baby's been in distress. The second one is if there is a shoulder dystocia. A shoulder dystocia is a true obstetric emergency where the shoulder gets stuck under the pubic bone.

And sometimes we may need more room to get our hand inside your vagina to perform maneuvers to help move the baby and free the shoulder from up under that pubic bone. Okay. So if there's a shoulder dystocia, we may need to do an episiotomy in order to just make more space in order to move the baby. Now, even in those emergency type situations, you 1,000 bazillion

gazillion percent still deserve to be told what is happening and why. I've heard people say like, it was an emergency. I didn't have time to explain what was going on. That is not true. It takes seconds to say your baby is showing signs of distress. I need to make a small cut in your vagina in order to create more space so that your baby can be born quickly. Is that okay? That short explanation.

builds trust and it protects your autonomy. I have done this and every single time I have done this, the woman said yes, because I'm looking her in the eye and I'm like, your baby's in distress and I'm very clear about what's going on and the urgency of the situation. They understood what was happening. So it takes just a few seconds. Those few seconds are not gonna negatively impact your baby. We can always, always, always get.

Consent is non-negotiable. I need you to know this. Apesiotomy should never, ever, ever be done without your explicit consent, ever. There's no situation where it needs to be done without consent. And if an episiotomy is done without your consent, it could absolutely be considered assault. In 2020, there was a California woman who successfully sued her OB

Nicole Rankins (12:09.012)

After he performed actually multiple episiotomies, the video is awful on her without consent. She had clearly said no multiple times and he cut anyway. A jury awarded her $1 million in damages. That verdict obviously sent a message, but it should never have happened in the first place. Your body is not up for negotiation.

And no matter how experienced your doctor is or how quickly things are moving, you still deserve to be asked. If you are not asked, then you can certainly report it. Now let's talk about how to protect yourself. You want to start in prenatal visits by asking these two questions. One is how often do you perform episiotomies? Make them give you a number, not a vague answer. And definitely don't say,

do you do a lot of episiotomies? Because of course the answer to that question is going to be no, I don't do a lot of episiotomies. Like who's going to say yes. So you want to say how often do you perform episiotomy? So they give you an actual number. If someone asked me this question, I would say I rarely do episiotomies and I cannot remember the last time I did an episiotomy. That is the God's honest truth. It's probably been, I know it's been well over a year.

since I've done an episiotomy. And when I did it, it was because the baby was under stress. So I would explain all of that. And then the second question you ask is how do you help patients avoid tearing or the need for an episiotomy? And you want to hear things like, we use warm compresses, we do perineal massage, we use olive oil to help with lubrication while you're pushing.

And the biggest one is going to be patience. Patience is one of the most underrated skills in obstetrics. So really just using patience while the head crowns. The body is meant to stretch. The skin is meant to stretch. We just have to be patient and allow it to do so. So patience is absolutely key. And if the answers to these questions are dismissive or they're unclear,

Nicole Rankins (14:23.734)

red flag, red flag, red flag. And if they say, you know, only when necessary, but can't explain what that means, also red flag. So pay attention to those answers and how they respond. Now you may find yourself in a situation where you're with someone who you're not familiar with during labor, more more practices, have the doctor who's on call. You may get a hospitalist like me who you may not have met before.

So I want you to listen out for some things during labor, some phrases to be alert for. If you hear someone say, you know what, I'm just going to make a little room for the baby to come out or I'm just helping the baby out or I'm just going to make a little snip to ease things along. If you hear that, stop and ask, are you about to do an episiotomy? Okay. Say that very clearly. Are you about to do an episiotomy?

And if you are not in a place to ask because you're in the throes of labor, then be sure that your partner or a family member, if you have a doula, knows that it's time to stop and speak up for you. All right. This is not about confrontation. This is about protecting your autonomy and your right to know what is happening in your body. So if you hear those phrases again, I'm going make a little bit of room. I'm just going to snip, do a little snip here just to help the baby out.

stop and clearly ask, are you about to do an episiotomy? And if you don't want it, then say, I don't want it. Or you can say, what are alternative options? There is almost always time to wait. Okay. Now I don't want to be all doom and gloom. I do want you to know that if you do end up having an episiotomy, the vast majority of people heal well and without any problems, it will require stitches.

in order to repair those dissolve on their own and you may feel some soreness and some swelling. We typically do ice or sits baths, also pay medications to help with the discomfort, but most women will heal very well. However, if you experience anything like pain with intercourse or numbness or scar tissue, then speak up.

Nicole Rankins (16:42.562)

Those things are actually treatable. Pelvic physical therapy can be very helpful with that. So don't suffer thinking that, this is just a part of birth. If you have any issues healing after birth, actually whether it's an episiotomy or not, then do seek help. And the sooner you seek help, the better in order to get you functioning and back more like yourself. So just to recap, here's what I want you to take with you from this episode.

Routine episiotomy is outdated, unnecessary in most cases, and thankfully very rarely done. The biggest risk factor for having an episiotomy is whether or not your doctor does a lot of episiotomies, period. There are risks to having an episiotomy or side effects like serious tears and healing issues. Those true emergencies are really rare where episiotomy needs to be done quickly. And even then, you...

absolutely deserve consent. It's 30 seconds or less of consent. It can always happen. Do ask those two questions in advance so you're more well informed. How many episiotomies do you do and what do you do to protect against episiotomies or tears? Be alert to that vague language or that euphemistic language. I'm just going to make a little snip during labor. That is a red flag because remember you have options and you

always have a voice about what is happening in your own body. So that's it for this episode. If you found it helpful, share it with a friend. Every pregnant woman deserves to feel informed and empower. I would love it if you would subscribe to the podcast so you never miss an episode. And if you like this show, leave me a five star review if you feel like it's a five star podcast.

Leave me that five star review and Apple podcast. helps the show to grow. It's really important to help the show grow actually. And it helps more moms to be, to find birth with power and they can step into birth with confidence just like you. If you want to connect with me outside of this podcast, message me and follow me on Instagram at drnicholerankins. My DMS are wide open. I love to hear what you think about this show. Now do me one more favor and come on back next week.

Nicole Rankins (18:56.054)

And remember to trust your power and take charge of your birth.