English Version | Lado B: Mutilated Dreams

11 Mar 2022
By Pureza Fleming

Given the motto “better to cut than to tear”, the episiotomy (or surgical enlargement of the vagina to enable childbirth) has been the cause for much debate and scrutiny. Is this incisive practice a necessary evil? Or is it more of a lesser evil and, beyond that, totally unnecessary?

Given the motto “better to cut than to tear”, the episiotomy (or surgical enlargement of the vagina to enable childbirth) has been the cause for much debate and scrutiny. Is this incisive practice a necessary evil? Or is it more of a lesser evil and, beyond that, totally unnecessary? 

Having a child: this is, for many women, the dream of a lifetime. Much like any other dream and wish, it has its catch (or catches). Having a baby implies going through a big season, throughout which your body doubles, sometimes triples, its size, characterized by a series of storms in the middle that are everything but lyrical. Despite it all, labor remains the most feared of moments during pregnancy: no matter how much one wants to have a child, nobody smiles – not light-heartedly – when faced with the thought of having a creature weighing the equivalent to a few bags of rice come out of “there”. That is also why, around that time, when everything anybody going through labor needs is calm and support, the idea of an episiotomy – or surgical enlargement of the back of the vagina through an incision on the perineum to make the vaginal delivery easier – doesn’t sound that appealing. Laura Ramos checked in at the Hospital (non-disclosed) on the 22nd of December 2016, around 11h30, in labor and 36 weeks gestation. Her son, Vasco, was born at 15h30, but during the four hours period before his birth, instead of being welcomed by the hospital and supported by the medical staff, she shares how she felt “humiliated, disrespected and physically and psychologically assaulted” in her rights. 

In a staunch review posted on the Portuguese Association for the Rights of Women in Pregnancy and Childbirth, and addressed as well to the Health Regulatory Entity, Order of Doctors, Order of Nurses and, in the form of an open letter or petition (signed by all the women who have felt objects of obstetric violence), to the Health Ministry, she reports, among many other subjects, the following: “It all started when I was met at the emergency room by a doctor who, before saying anything else, such as ‘Good morning’, or introducing himself, distantly ordered me to get undressed so he could proceed to perform the vaginal check.” The description continues until the time of labor, and that is when the moment of the unwanted episiotomy arrives: “Later on, because she was preparing to do an episiotomy without asking for my consent and I refused, there was an altercation between me and the Doctor who had just arrived, clearly moody and whose energy had already contaminated the spirit of the entire team. The Doctor insisted on the episiotomy, and I refused, once again: ‘I don’t want the episiotomy! No, I don’t want it!’ To what she replied: ‘And I don’t want screaming!’ Before my astonishment, she tried to excuse herself by saying it was counterproductive for me and the baby if I yelled. I even went as far to say, ‘but what is this, I’m in labor, it’s normal that I scream!’ The Doctor answered: ‘Depends on the point of view’”. Laura Ramos continues: “Well, if the point of view of an obstetrician is not to hear screaming, perhaps she should consider another line of work, since the probability of a silent delivery is quite minimal.”

According to a study based on an online inquiry directed to women who had children during the first year of the pandemic, Portugal continues to have elevated rates compared to other European countries when it comes to cases of obstetric violent procedures, such as the case of routine episiotomies. In our country, women have been subjected to more non-recommended hospital practices by the World Health Organization than the average of the other 11 countries belonging to the organization in the European region. There were responses from 21.027 women from various European countries, 1685 of which were Portuguese, representing a fifth of the study sample. The cut in the woman’s perineum to create space for the baby to go through during labor, or episiotomy, is associated with a more painful recovery, difficulties in resuming one’s sex life, urinary or even fecal incontinence, among others. Under the motto “better to cut than to tear”, women are often cut without their consent – as it was the case for Laura Ramos. “Lately, there have been a lot of conversations about ‘obstetric violence’, with various extreme standings especially in social media. The truth is that the theme has already created protests and reform bills. The term ‘obstetric violence’ is regrettable to describe the practices of healthcare professionals when assisting pregnancies, labor, and post-partum [a time where physical and psychological changes also occur]. Having been firstly used in Venezuela within the context of unauthorized sterilizations, its generalization, in the Portuguese context, is at least inadequate.” These are the words of Irina Ramilo who, rapidly, clarifies the question of resorting (or not) to an episiotomy: “The routine resort to episiotomies has decreased based on the mounting evidence for its increased complications. Therefore, its practice is realized in an individual and selective way. It is considered by some professionals when the clinical circumstances put the mother at high risk of laceration of the third or fourth degree of the perineum, alterations of the heartbeat, and suspicion of fetal distress that justify the acceleration of the natural delivery.” She also specifies that the WHO recommends that the percentage of episiotomies is 10%, thus contributing to the reduction of grave obstetric lacerations in selected cases. And she adds that, in a meta-analysis of 12 studies comparing the use of selective episiotomies and episiotomies in women who were expecting a non-assisted vaginal delivery, the selective episiotomy provoked up to 30% less trauma in the perineum or vaginal area. The conclusion? There were no differences between the groups in terms of pain in the perineum on the third day post-partum, pain during intercourse in the long term, or urinary incontinence or genital prolapse. 

Who decides, then? The future mother or the healthcare professional? “The decision to perform the episiotomy depends a lot on the opinion of the doctor who delivers the baby. It is a clinical judgment call, it requires experience and knowledge, based on the clinical scenario of each delivery. There are no specific situations in which the episiotomy is essential. From a standpoint, a doctor will know what is best for their patient, however what has been happening is that episiotomies have already been compared to female genital mutilation. What seems to be the result from all this discussion is a lack of trust in the obstetrician-nurse midwife-mother-couple”. Irina Ramilo explains. And she continues: “The base must always be communication from the healthcare professional to the person who is pregnant, just like any other thing in human nature. All doubts, consents, expectations should be discussed in consult and in the preparation leading up to the delivery. It is acceptable that a pregnant person or couple arrive at the delivery room with some anxiety, fearful and afraid, but never mistrusting the medical staff that is welcoming them.” She underlines that any type of violence must be sanctioned and condemned, whether physical or psychological: “although she considers ‘obstetric violence’ to be nonconsensual, she assumes some healthcare professionals are deliberately doing their job very poorly (with the intent of hurting the patient in the delivery room). The limits of what can be identified as an act of violence across all medical interventions during pregnancy, delivery and post-partum are not clear.” Irina Ramilo reminds us that although giving birth remains an organic process, sometimes violent, in a woman’s life, along with all the transformations that come with it. Thus, there are many ways to be born and all of them are consequences not just of a person’s anatomy, fetal position, labor, and mother-fetus well-being: “You can’t allow a woman to feel guilty or like a failure just because the labor process was not exactly like they imagined”, she adds. The truth is that “many procedures and interventions that are deemed unnecessary or as a form of violence have been scientifically determined as useful in certain situations, therefore are rightfully applied.” 

And what happens when an episiotomy doesn’t go according to plan? “Although the mid-lateral episiotomy doesn’t prevent severe lacerations, its incision is, in practice, easier to repair when compared to the majority of other second-degree spontaneous and irregular lacerations”, she explains. Despite everything, “there is still a shortage of data that demonstrate better results in the long run with the episiotomy.” Giving birth, in all its dimensions, from its physical to the psychological stages, obviously not disregarding the emotional, makes it paramount that there is a good relationship between the mother and her doctor. And, as in all relationships, one that starts with trust. In the opinion of Irina Ramilo, “the solution is not to ‘demonize’ healthcare. The Portuguese medical staff is dedicated, competent and committed to following women in this monumental part of their lives. They must do their job based on scientific evidence whose primary and ultimate goal is the preservation of life and health of both the mothers and their babies. Even though obstetrician care in Portugal is excellent (as both our infant and maternal mortality rates prove it), we should come together and fight for the improvement of quality in the response of maternity hospitals, modernizing infrastructures, adequate ratios of availability of medical staff, updating techniques, limiting excessive procedures, but above all, fight for more transparency in the registration and practices of each institution. This transparency is what will allow the characterization of current practices in different institutions, allowing for the identification and sanctioning of abusive behaviors. On the other hand, educating families with scientific detail, because the easy consultation of contents (especially on social media) doesn’t always contribute to real knowledge of what goes on during labor and post-partum.” The content in which these complaints occur is also not less relevant: “Even under exceptional measurements motivated by the pandemic, the medical staff is still overwhelmed. In these adverse circumstances of course, the radicalized and alarming discourses are the ones that take place. Which are not always from and to women, exposing the resurgence of professional groups of questionable education who have a clear agenda and for whom the mistrust in healthcare professionals gives them more than enough room to do some damage.” As in everything, there is another side of the coin. And, fundamentally, there is something that should be underlined: the patients’ trust, in this case, of pregnant women giving birth, in the healthcare staff, is paramount; but it can’t exist without respect, empathy and patience towards the women who are preparing to go through one of the most peculiar and vulnerable instances of their lives: giving birth.

Translated form the original on The Body Issue, from Vogue Portugal, published March 2022.Full stories and credits on the print issue.

Pureza Fleming By Pureza Fleming

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