One item many women try to include in their birth plan is whether to have an episiotomy. This, however, is an option that is best left until the point of crowning, when the care provider can assess the perineal tissues and offer the best suggestion.

Episiotomy has been at the center of controversy for a number of years. The following appears on the website of the American College of Obstetricians and Gynecologists:

"There has been a significant reduction over the last two decades in the percentage of deliveries involving the use of episiotomy, according to a study in the March 2002 issue of Obstetrics & Gynecology. An episiotomy is a small cut made to widen the opening of a woman's vagina to ease delivery or prevent maternal lacerations.

"A review of over 34,000 vaginal deliveries at Thomas Jefferson University Hospital in Philadelphia between 1983 and 2000 found that the overall episiotomy rate fell from 69.6% of all vaginal births in 1983 to 19.4% in 2000.

"White women, whose episiotomy rate decreased from 79% to 32.1% during this time period, consistently underwent episiotomy more frequently than black women, whose episiotomy rates fell from 60.5% to 11.2%. While one study found that black women are less likely than white women to deliver with vaginal lacerations, the authors speculate that the racial disparity in episiotomy rates may be due in part to the non-scientific way in which some physicians determine who needs an episiotomy. They also note that the overall decline in episiotomy may reflect the impact of a growing body of literature strongly against routine episiotomy, and to improved patient education and participation in decision making during labor and delivery."

Conversely, Henci Goer, in her book Obstetric Myths vs Research Realities quotes Robbie Davis Floyd, a medical anthropologist:

Davis-Floyd also points out that episiotomy, the destruction and reconstruction of women's genitals, allows men to control the "powerfully sexual, creative, and male-threatening aspects of women." This is what lurks behind DeLee's emphasis on surgically restoring "virginal conditions." It also partially explains why most trials of episiotomy have been done in European countries where normal birth is conducted by female midwives, not in the U.S. or Canada, where birth is conducted (until recently) by male doctors: women are not subconsciously threatened by birth. Klein et al. attribute the greater success of a British "restricted" versus "liberal" use of episiotomy trial in achieving fewer episiotomies and more intact perineums to "the increased comfort of British midwives in attending births with the intention of preserving an intact perineum."

In short, routine episiotomy has a ritual function but serves no medical purpose. If any reader believes otherwise, I challenge him or her to find a credible study done in the past 15 years that supports those beliefs.

An editorial in the Lancet (January 22, 2000) demonstrated that perineal massage may help to prevent damage to the vagina and rectum during the birth process. Eighty-five percent of women delivering a baby vaginally tear the vaginal wall or rectum during delivery or have the care provider cut the vagina to prevent this tearing. This can cause painful intercourse, loss of control of urine or stool, and persistent pain in that area.

Five studies show that perineal massage helps to prevent tearing of the vagina during childbirth, particularly during the first childbirth. From the 35th week of pregnancy to the day of birth, a woman inserts a lubricated finger and stretches the vaginal opening for 10 minutes day. This procedure helped prevent tearing of the vagina and rectum primarily in women who were having their first childbirth. 80% said that they would repeat massage during future pregnancies, while more than 90% stated that they recommend it for other pregnant women.

Perineal massage involves gently stretching the tissues that surround the opening to the vagina. The perineum is the area of skin between the vagina and rectum.

Perineal massage may make tears or an episiotomy less likely; may reduce the stinging sensation during crowning, and familiarize laboring women with the stretching sensations of birth to enhance relaxation.

It is not within the scope of practice for doulas or labor support assistants to perform perineal massage. However, both expectant mothers and their partners can do perineal massage, as early as 34 weeks. It is usually done for 10 minutes each day. The following directions are for the expectant mother.

· Sit in a comfortable position. (A warm bath or warm compresses on the perineum for 10 minutes before massage may help with relaxation.)
· Put a water soluble lubricant (KY Jelly, olive oil, vegetable oil, Vit. E oil) on thumbs and perineum.
· Place thumb just inside of the vagina.
· Press downward towards the rectum and to the sides at the same time until a very slight burning, stinging, or tingling sensation is felt
· Hold the pressure for about 1 minute.
· Breathe deeply and slowly and try to consciously relax the muscles.
· Keep pressing down with the thumb and slowly and gently massage back and forth over the sides of the vagina in a 'U' movement for 3 minutes.
· Relax and repeat once.

Caution: Avoid pressure on the urethra (at the top of the vaginal opening), massage gently as vigorous massage could cause bruising or swelling, and do not massage if there is active vaginal infection or herpes lesions.