Episiotomies
FGM at Home

This page recognizes the many ways the genital integrity of females is compromised in our society. Statistics show that women who are cut are more likely to allow their babies to be cut. FGM has many forms: Sunna (amputation of the clitoral hood, also called the prepuce); clitoridectomy (amputation of the clitoris itself); infibulation (amputation of the inner labia and clitoris and some of the outer labia and stitching the vagina almost shut); most episiotomies (cutting the perineum to enlarge the vagina during birth--especially when birth is attempted in positions that do not use gravity and don't allow full vaginal and pelvic opening); many hysterectomies (the operation  that cuts out a woman's uterus and often her overies-- so-named because it supposedly removed a woman's hysteria, an operation that is life-saving when needed but done done far too often according to many authorities). Such unnecessary operations on minors has been illegal since 1996 according to North Dakota and Federal law.

Episiotomies May Raise, Not Lower, Incontinence Risk
Speaking out on Unacknowledged FGM 
Episiotomy: Ritual Genital Mutilation in Western Obstetrics.
Journal of Family Practice, Neonatal circumcision: associated factors [including episiotomy].
Email from a Woman Who Was Cut.

>http://www.abcnews.go.com/sections/living/DailyNews/episiotomy000107.html

To Cut or Not to Cut
Episiotomies May Raise, Not Lower, Incontinence Risk

By Shawna Vogel
ABCNEWS.com
B O S T O N, Jan. 7  — A minor surgical procedure often performed on women just before childbirth may cause trouble rather than preventing it, according to new research.
     A new study in the British Medical Journal suggests that women who receive episiotomies, a procedure to enlarge the opening from which the baby emerges, run a higher risk of losing their bowel control, which the procedure is supposed to help prevent.

More Harm than Good?
Experts say this research adds to the ongoing debate over whether this often routine procedure — performed on nearly one-third of the three-million-plus U.S. women who give birth each year — does a woman more harm than good.
     Episiotomy involves a quick cut of the perineum, which is between the vagina and rectum, as a mother is pushing out her baby. It was once thought to protect a woman from damage to the anal sphincter. Such damage is believed to be the main cause of the anal incontinence — loss of bowel control — that affects up to 10 percent of women who have given birth.
    

But in the past decade, evidence has mounted that episiotomy may be inflicting the damage. “One of the questions with these studies,” says Amanda Clark, chief of the division of urogynecology and reconstructive pelvic surgery at Oregon Health Sciences University, “has been, is it episiotomy that causes the problem or is it the forceps and the larger babies” — two aspects of birth that often go hand in hand with the procedure.
     To study the issue, Lisa Signorello and her colleagues at Harvard Medical School asked 626 women who delivered their first infant vaginally to report any anal incontinence they experienced in the months after giving birth. They were divided into three almost-equal groups: women who received episiotomies, women whose perineums tore “naturally” during delivery, and women who had remained intact.

Higher Risk After Episiotomies
“About 10 percent of women with episiotomies were experiencing fecal incontinence three months after giving birth,” Signorello writes. “Women in the “tear” group and the intact group had less than half that risk.” Women in all the groups reported less incontinence at six months, but it was still two times more common for the episiotomy recipients than for the other two groups.
     Signorello found that the extra risk for bowel problems had nothing to do with the mother’s age, the baby’s weight, labor length, use of forceps or vacuum extractor, or other complications of labor.
     “This would argue against routine use of episiotomy to protect the pelvic floor during birth,” Clark says.
     Ben Sachs, chief of OB/GYN at Boston’s Beth Israel Deaconess Medical Center and co-director of the Harvard Center of Excellence in Women’s Health, isn’t ready to agree. He says the study would have been more meaningful if the researchers had looked at more patients.
     He also pointed out that the women in the episiotomy group were generally older than those in the other groups. “And the condition of the perineum is going to be somewhat reflective of age,” he said.

Not Recommended Routinely
Nevertheless, he says, “I personally think that there is no evidence that routine episiotomy does any good.”
     He and Clark point out, however, that there may still be circumstances in which episiotomy is recommended — in cases in which the child’s health is threatened, for example, Clark says it can shorten delivery time by up to half an hour.

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An FGM Activist Speaks Out on an FGM Unacknowledged

[Comments by Pat]:

I have been collecting research about American ritualized sexual mutilation for over 20 years. Episiotomy is America's most common surgery and most common form of FGM. There is NO medical research showing value for episiotomy. Instead, it causes the severe tearing we have been led to believe that it will prevent. The website mentioned below is similar to CIRP. It is a collection of research studies and current writings about episiotomy.

I couldn't bring myself to have a homebirth the first time because of all the surgeries I had when I was a teenager. I feared that my body might fail again. (I have recently discovered that all of these surgeries were unnecessary.) When I was a childbirth teacher I worked with several women who were adult survivors of childhood sexual abuse and two whose mothers had died during their childhood. All of these women were particularly vulnerable to excessive intervention and surgery during birth, no matter how physically healthy they were. Toward the end of my teaching, I could accurately predict who would end up cut. I was increasingly unable to help these moms make changes in their care that would make them safer. Instead, I found that my classes were helping some women feel safe when they should not. They wielded their birth plans like magic talismans, but guess what? Scissors still cut paper. I don't teach anymore.

The OB at my first birth had agreed not to do an episiotomy. He cut me anyway. The cut extended into a third degree tear, a complication associated almost exclusively with episiotomy. When the doctor saw what was happening, he tried unsuccessfully to stop the tear by cutting a mediolateral episiotomy (see website for definitions). I was in severe pain for a long time. I noted in a journal that I kept that six weeks later I was still not able to sit for long. At my six week appointment, this doctor claimed that my perineum was "abnormally strong" which required him to cut me without my consent. He derided me for not resuming intercourse, and suggested that I was frigid. Another doctor I consulted at that time was not able to insert two fingers to examine me. He advised reconstructive surgery or gradual stretching. It was two years before I no longer bled with intercourse.

I have permanent sexual damage. I am not alone. See Sheila Kitzinger's "Episiotomy" and "Some Women's Experience of Episiotomy" for similar stories.

Research shows that birth attendant skill is the key factor in avoiding perineal harm during birth. However, attendant skill is not a factor in preventing severe harm caused by extended episiotomy. There is no way to predict who will have a catastrophic tear or to prevent one once an episiotomy has created the opportunity. The only way to avoid this harm is to not allow anyone with cutting implements near you while giving birth.

Plain and simple:
Hire a birth attendant who is not a surgeon for starters. Birth tubs are great because they provide a physical barrier. Don't give birth in a place that makes money from cutting up women.

I knew how harmful episiotomy was before I gave birth. I had files of studies proving harm. (One study of maternal deaths showed that 20% occurred in otherwise healthy women who death resulted from an infected episiotomy.) I had even written about it. I thought that I had done what I needed to protect myself. Van is right! I am proud that I was able to protect my son, but will always regret that I didn't protect myself.

Episiotomy, cesarean section, and circumcision didn't become common in this country until birth was moved to hospitals. Read "The Five Standards of Safe Childbirth" by David Stewart (of NAPSAC) for research proving the superior safety of homebirth for most women. There are lots more eloquent books with this viewpoint, but this one and Henci Goer's "Obstetric Myth versus Research Reality" document the research.

Empowering women to give birth without mutilation will empower them to protect their babies, also according to research! Read the conclusions of the abstract of "Neonatal circumcision: associated factors and length of hospital stay" at the bottom of this page. This study is available on >CIRP.

Every woman who has a cesarean section or an episiotomy experiences sexual harm, not just those who have extensions. I will send one more message on this topic, a study showing that clitoral tissue is far more extensive than previously thought. It appears that almost any surgery in the genital area will cut into clitoral nerve endings.

The uterus is a sex organ, too. Uterine muscles contract during orgasm. Some women who have had cesareans complain of inability to have orgasms or loss of intensity, but no one has ever studied sexual function after cesarean section. There is research available documenting this loss of sexual pleasure after hysterectomy.

I'll close what has become my essay with a revision of yesterday's letter:

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Imagine that you are an expectant mom, happy and excited to be in labor. Now imagine that a person (just as likely to be a woman as a man) takes your clothes, straps you to a bed, sticks a needle in your arm and your lower back--warning you not to move--and drugs you. Now imagine this person cutting your baby out with a knife--either through your uterus or your perineum. Your baby is taken away while you are sewn back together, and is probably given a bottle, even if this is against your wishes. You are left weakened and unable to care for your baby without assistance. Do you scream for help and call the police? Nope. You thank this person gratefully and pay her/him a great deal of money. Not surprisingly, you are more likely to be in the US than in any other country.

It doesn't have to be like this! Go to:

Episiotomy: Ritual Genital Mutilation in Western Obstetrics
 >http://www.changesurfer.com/Hlth/episiotomy.html 

Introduction

The practice of routinely cutting the perineum during hospital deliveries in the United States, episiotomy, has been shown to be the principal risk factor for severe tearing during delivery, which is the injury that it is supposed to prevent. Nonetheless American obstetricians continue to overuse this procedure ten times more often than is called for. Episiotomy is also a major risk factor for infection, loss of sexual pleasure, and incontinence. Women who have been subjected to episiotomies take longer to heal from delivery, even compared to women who have equivalent tears.

  Given the completely unscientific, ritual approach obstetricians have to this practice, it illuminates the Western outrage over ritual genital mutilation of girls and women in East Africa, which also has many painful and disabling sequelae. Just as we reach out in solidarity with African feminists to stop genital mutilation in Africa, we need to stop the iatrogenic, unscientific practice of episiotomy in American obstetrics.

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A sample study:

Woolley RJ. Benefits and risks of episiotomy:
A review of the English-language literature since 1980.
Part I and II. Obstet Gynecol Survey 1995; 50:806-820.

Conclusion: The English-language literature published since 1980 on the benefits and risks of episiotomy can be summarized as follows: Episiotomies prevent anterior perineal lacerations (which carry minimal morbidity), but fail to accomplish any of the other maternal or fetal benefits traditionally ascribed, including prevention of perineal damage and its sequelae, prevention of pelvic floor relaxation and its sequelae, and protection of the newborn from either intracranial hemorrhage or intrapartum asphyxia. In the process of affording this one small advantage, the incision substantially increases maternal blood loss, the average depth of posterior perineal injury, the risk of anal sphincter damage and its attendant long-term morbidity (at least for midline episiotomy), the risk of improper perineal wound healing, and the amount of pain in the first several postpartum days.

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JOURNAL OF FAMILY PRACTICE,
Volume 41 Number 4, Oct 1995: Page 370-376.

Neonatal circumcision: associated factors [including episiotomy] and length of hospital stay

Authors: Mansfield, Christopher J.; Hueston, William J.; Rudy, Mary

Full Text COPYRIGHT Appleton & Lange 1995

Background. Controversy exists regarding the efficacy of routine neonatal circumcision of male infants. Little is known about parental or provider characteristics or the use of medical resources associated with this procedure.

Methods. Records of 3703 male infants born during 1990 and 1991 at four US sites were analyzed to discern associations between circumcision and the above factors. Analyses were limited to healthy infants.

Results. Eighty-five percent of the infants in the study population were circumcised. White and African-American male infants were much more likely to be circumcised than those of other races (odds ratios [Ors], 7.3 and 7.1, respectively, P<.001). Compared with self-pay patients, those covered by private insurance were 2.5 times more likely to be circumcised (P<.001). Logistic regression showed that rates for obstetricians and family physicians were not significantly different. Increased odds of circumcision were found if the mother received an episiotomy (OR=1.9, P<.001) or cesarean section (OR=2.1, P<.001).

Circumcised infants stayed in the hospital an average of one fourth of a day longer than did those who were not circumcised (mean difference, 0.26 days; 95% confidence interval, 0.16 to 0.36).

Conclusions. Mother's insurance status and race as well as surgical interventions during delivery are related to circumcision. Associations with episiotomy and cesarean section suggest physician and/or parental preference for interventional approaches to health care. Generalizing the difference in hospital length of stay to the United States suggests an annual cost between $234 million and $527 million beyond charges for the procedure itself. words. Circumcision; infant, newborn; male; socioeconomic factors; cesarean section; episiotomy; specialties, medical, length of stay; hospital costs. (J Fam Pract 1995; 41:370-376)

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Email from a Woman Who Was Cut

Hello.  My name is CJ and I would like to learn more about
the "Genital Integrity Law" and some history about how it came to be. I am not a minor as this law seems to be directed towards, but I am a woman that had requested, verbally and in written form, NOT to have an episiotomy
performed during the birth of my last child.  To make a long story short, the procedure was performed anyway.  In my case, the episiotomy was inappropriately and improperly performed and has left me with permanent disfigurement and pain.  

Then to make matters worse my OB/GYN (not the one that did the episiotomy but the one that should have been there for the delivery) tried covering up the incompetence starting with my first postnatal visit.  In the state of Michigan where I live it took me nearly 3 years to find a competent doctor that was even willing to acknowledge I had a real physical problem. I have had to have corrective surgery in an attempt to correct the damage done.  
 
I cannot accept the fact that doctors and hospitals continue to treat people like this and get away with it. Any information would help. Things need to Change.
 
Thank You,
C J 

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http://www.chicagotribune.com/features/women/chi-0204030287apr03.story [link no longer works]

April 3, 2002 Ob-gyns finding that the kindest cut is nature's By Connie Lauerman Chicago Tribune staff reporter Published April 3, 2002 After routinely performing episiotomies in delivery rooms for the better part of the last century, ob-gyns are putting the knives aside and letting nature take its course instead....

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"One of the most common surgical procedures performed in the United States -- an incision many pregnant women receive to reduce the risk of tissue tears during delivery -- has no benefits and actually causes more complications, according to the most comprehensive analysis to evaluate the practice."      http://www.changesurfer.com/Hlth/episiotomy.html

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Ian Graham has published a sociohistorical analysis of episiotomy called Episiotomy -- Challenging Obstetric Intervention (1997: Blackwell Science).