Excerpted from Birth as an American Rite of Passage

Episiotomy

(and some notes on forceps and Cesarean Section)

Description and Official Rationale

During labor, when the baby's head is exposed to a diameter of 3 to 4 centimeters, the attending physician will pick up a pair of sterile scissors and snip the stretching skin of the perineum downward toward the anus (median episiotomy) or downward and sideways (mediolateral episiotomy) to enlarge the vaginal opening and make it easier for the head to emerge. Most physicians sincerely believe that episiotomy shortens the pushing phase and thus reduces the chance the baby will suffer from oxygen deprivation, that it protects the fetal skull and brain from damage as it is "thrust against" the pelvic floor like a "battering ram," and prevents ragged perineal tears and "permanent relaxation of the pelvic floor with its possible sequelae of cystocoele, rectocele, and uterine prolapse" (Pritchard et al. 1985:339). Another reason given by many doctors in support of episiotomy is to maintain vaginal tightness for the enhanced pleasure of a sexual partner. According to several physicians I interviewed, so strong is the medical community's belief in the value of episiotomy that many obstetrical residents are not trained to deliver babies without performing one.

Physiological Effects

That episiotomy protects the fetus from damage is an unproven assumption revealing physicians' deep-seated belief that the fetus, their product, is in danger from malfunction of the mother's birthing machine. That birth without episiotomy will result in prolapse of the uterus, or in weakened support for the bladder from excessively stretched muscles has also never been proven (Cunningham et al. 1989:323; Harrison 1982:98; Thacker and Banta 1983). Moreover, should the woman desire enhanced sexual pleasure for herself or her partner from increased vaginal tightness, she can achieve the desired results by exercising the pelvic floor muscles after birth. States Harrison:

Think of the episiotomy this way: if you hold a piece of cloth at two corners and attempt to tear it by pulling at the two ends, it will rarely rip. However, if a small cut is made in the center, then pulling at the ends easily rips the cloth. Doing an episiotomy is analogous, and sometimes results in tears that extend into the rectum. Physicians argue that this "clean" tear is more easily repaired than the ragged one that occurs when a woman tears without the cut. My experience has been that the small tears that sometimes occur without episiotomy are easy to stitch and less bothersome to the woman. Episiotomies, once repaired, are often debilitating and are the source of much pain in the postpartum period. -Harrison 1982:97

One obstetrician I interviewed stated flatly, "I have never had a third or fourth degree extension [tear] through the sphincter or rectum unless I did an episiotomy." His observation is confirmed in a comparative study of home and hospital births (discussed in detail in Chapter 4), in which nine times more episiotomies were performed in the hospital births, accompanied by nine times as many severe (third and fourth degree) perineal tears. Another study of 241 first-time hospital-birthers showed that "the proportion of deep perineal lacerations was lowest (0.9%) in women without episiotomy who were not confined to the lithotomy position; it was greatest (27.9%) in women delivered in stirrups with an episiotomy....there was more than a twenty-fold increase in the rate of deep laceration when episiotomy was used," as well as a fourteen-fold increase in the rate of deep perineal lacerations when stirrups were used (Borgatta et al. 1989:295). In other words, the combination of episiotomy with the lithotomy position and stirrups works to offer women the highest possible chance that they will have deep perineal lacerations as they give birth.

Women's Responses

This was one of the single most-hated procedures by nearly all of the women in my study who experienced it, primarily because it took so long to heal, and thus made their first newborn month of motherhood far more painful and awkward than they felt it needed to be:

I hated having an episiotomy. I didn't think I needed it. It was three weeks before I could get around comfortably afterward, and I was miserable with it for all that time.
-Melinda Simpson

My sister tore, so I didn't mind having an episiotomy, if it made the doctor feel better. I figured that a nice smooth cut was not going to be any worse than whatever else might happen, and if it made him happy, I didn't really care all that much. But it was very uncomfortable for a long time after-- really messed up those special newborn days.
-Madeleine Oppenheimer

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Ritual Purposes

Episiotomies are performed on over 90% of first-time mothers delivering in major U.S. hospitals (Thacker and Banta 1983). (In the Netherlands, by way of contrast, they are performed in only 8% of births [Thacker and Banta 1983:165].) Besides its obvious function of hazing and ritual mutilation of the initiate, this procedure conveys to the initiate the value and importance of one of the most fundamental markers of our separation from nature--the straight line. The vagina constitutes the cross-cultural symbol par excellence of the natural, powerfully sexual, creative, and male-threatening aspects of women (long honored in myth as the vagina dentata, the vagina with teeth which threatens to consume or castrate the impotent male). Through episiotomies, physicians, as society's representatives, can deconstruct the vagina (and, by extension, its representations), then reconstruct it in accord with our cultural belief and value system. Episiotomies are performed in part because doctors are taught that straight cuts heal faster than jagged tears-- a teaching that is in accord with our Western belief in the superiority of culture over nature. The straight line does not exist in nature, and is therefore most useful in aiding us in our constant conceptual efforts to separate ourselves from nature.

The episiotomy is also conceptually useful to obstetrics. Since surgery constitutes the central core of Western medicine, the ultimate form of manipulation of the human body-machine, the legitimization of obstetrics necessitated the transformation of childbirth into a surgical procedure. Routinizing the episiotomy has proven to be an effective means of accomplishing this transformation--even "natural" births in the modern LDR or birthing suite can be transformed into surgical procedures by routine episiotomy.

On top of all that, the episiotomy reinforces and intensifies the messages of the other procedures about the importance of on-time production, the inherent defectiveness of the female birth machine, and the supremacy of the male over the female both in society and in the social production of the baby.

All of these messages are reinforced if the baby is pulled out with forceps. The application of forceps shows the mother beyond all doubt that her machine is indeed defective, and brings home the message that the lives of the mother and her baby are truly dependent on the institution and its technology. However, the use of forceps declined in many hospitals during the 1980s, as this procedure was rapidly being replaced by the Cesarean section, the operation that increasingly moved childbirth into the real O.R. The possibility of the routinization of delivery "from above" is the most extreme manifestation of the cultural attempt to use birth to demonstrate the superiority and control of Male over Female, Technology over Nature:

I found myself last night thinking about the day and the Cesarean I had done. Performing a Cesarean is the one time that truly gives you the feeling of delivering the baby. I remember having my hand in the uterus. Pressure was being applied by Dr. Joseph at the top of the uterus while my hand grasped the head of the baby and assisted it out through the incision. I felt a sense of excitement and of power and of personal accomplishment that is not present in a vaginal birth. This is the time the obstetrician truly delivers the baby; in a vaginal birth, it is the mother. (Harrison 1982:125)

Technically speaking, the Cesarean section should not even be considered here, as it is supposed to be a life-saving procedure, resorted to only when it becomes clear that vaginal birth is not an option. By this criterion, the Cesarean rate nationwide should be no more than 5%, as indeed it was before 1970. However, the Cesarean rate nationwide as of 1988 stood at 24.7% (National Bureau of Vital Statistics). In many large teaching hospitals, it reaches 50%; in 1991 in a non-teaching private hospital in Anycity it was 58%. A 1987 report from the National Center for Health Statistics concluded that at least half of the 934,000 Cesareans performed in the U.S. in 1987 were unnecessary, costing the public an extra $1 billion and uncalculated increases in maternal morbidity, with no discernible benefit to neonatal outcome. Private, for profit hospitals, and patients with the best-paying insurance plans had the highest rates, while state, local, and federal hospitals had the lowest.

An alarming example of just how far this trend could continue is provided by Brazil. A Brazilian childbirth educator residing in Rio de Janeiro recently informed me that the Cesarean rate in public teaching hospitals in Rio and Sao Paulo hovers around 65%, and in many private hospitals stands at 95%. Latin women in general are more strongly socialized to passively obey men than American women, while middle- and upper-class Latin women are often concerned to demonstrate their cultural distance from Indian and peasant women through highly cultural births and bottle- instead of breastfeeding. Additionally, as Carole Browner (personal communication) points out, Brazilian women place high value on scientific knowledge and control. Whatever the factors behind them, such Cesarean rates graphically demonstrate the potential inherent in the technocratic model for the complete technocratization of birth.

But in the American public mind, the ominously rising Cesarean rate-- which obviously has the potential to keep on going upward--has been uncomfortably highlighting the discontinuities between the technocratic model and true physiological necessity, and obstetricians have been under increasing public pressure to lower it. According to 1989 figures (the most recent available), public outcry, combined with medical acceptance of new research on the technocratic viability of the VBAC (vaginal birth after Cesarean) option, has apparently resulted in the stabilizing of the Cesarean rate:

The 25 years of rising Cesarean delivery rates in the U. S. may have finally run their course. In 1989 the rate of 23.8 Cesareans per 100 deliveries was not significantly different from 24.7 in 1988, 24.4 in 1987, or 24.1 in 1986.... The percentage of vaginal births after Cesarean section per 100 deliveries showed a remarkable rise between 1988 and 1989--from 12.6% in 1988 to 18.5% in 1989. Data are from the National Hospital Discharge Survey conducted bu the National Center for Health Statistics, Centers for Disease Control. (Taffel et al. 1991:1)

In ongoing interviews for a new study (Davis-Floyd 1992), I have recently become aware what may be the development of another counteractive trend besides the VBAC. It seems that some obstetricians, in an effort to lower their Cesarean rates, are revitalizing the epidural/episiotomy/forceps delivery (previously in decline). Three of my new interviewees who gave birth this summer (1991) in this manner proudly reported to me, "He cut a big episiotomy, and pulled the baby out with forceps, but I didn't have to have a Cesarean!"

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