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As with so many things about birth, prevention is better than cure-so how can you ensure that you have the least possible chance of having to have an episiotomy?

• Decide well in advance that you will not have an episiotomy except for one of the very specific medical reasons that you have been able to discuss well ahead of time at an ante-natal visit, or if your experienced midwife is fairly certain that you will have a bad tear if you do not have one. Get the staff to write it in on your notes, and ensure that your husband or partner understands your feelings precisely. Then it will be understood that the midwife or obstetrician will have to justify the episiotomy to you before doing it. This should dramatically reduce the likelihood that you will have one as a matter of routine. Of course, ideally you should choose a unit where episiotomies are done rarely and only for good medical reasons, but such units are rare.

• Practice pelvic-floor muscle and perineal stretching exercises during pregnancy.

• If you arrange in advance to labour in an upright position of some kind, and to keep changing position as you feel best, it will probably reduce the likelihood of your needing an episiotomy.

• If you do end up on your back because it is deemed obstetrically necessary, ask the midwives to hold your legs so that your knees are only a foot or so apart, not widely apart as in lithotomy stirrups. This will reduce the stretching of the perineal tissues and so reduce the likelihood that an episiotomy will need to be done.

• It is worth learning perineal massage, even from quite early on in pregnancy. In this the woman lies flat on her back on the floor or on a bed with the soles of her feet flat together. Her husband or partner then uses his fingers, well lubricated with vegetable oil or baby oil, to massage the whole of the lower vulva and the area between the vagina and the anus. It is this area that stretches so much during the birth of the baby, and a supple, relaxed perineum is far less likely to tear or to need an episiotomy than is an unprepared one. This form of massage can easily develop into sexual foreplay as the man inserts his fingers into the vagina until, towards the end of pregnancy, the woman will be able to take four fingers quite easily. Don’t forget that from quite early on in pregnancy a woman’s vagina becomes more relaxed and will, by twelve or fourteen weeks, be able to take two or three fingers easily. Using sweeping movements around the lower vagina, the man can often feel the deep pelvic muscles relaxing as pregnancy progresses, and the woman will learn to relax her perineum and sense the stretching of her perineal tissues in a controlled, loving setting before the real thing takes place in the labour ward.

The idea early on is to stretch the woman’s vulval opening to the point where she complains of tingling or pins and needles, or simply says it’s enough. The man then holds his fingers in this position for some time until the stretching sensation passes. Over subsequent sessions the couple can gradually increase the amount of vaginal stretching until the woman can easily take four fingers. Any woman who has had this kind of perineal preparation is unlikely to need an episiotomy, especially if she gives birth in an upright position. When it comes to experiencing the strange bursting sensations as the baby’s head stretches her vulva during the last stage of labour she will not be alarmed or think she is going to burst open (as many unprepared women fear) because she will have experienced similar (though less intense) sensations.

Some American midwives use perineal massage as the baby’s head comes down the birth canal, massaging the tight, whitened and thinned areas of the vaginal opening with oil as the baby’s head emerges. They also massage the pelvic muscles to relax them via the vaginal walls. Such midwives rarely use episiotomies however big the baby.

• It can also be a useful preparation for the birth to master pelvic exercises, and they can be of considerable value after the birth of the baby too, to both you and your partner. Here are three ways of exercising your deep pelvic muscles. Do any or all of them, several times a day, perhaps while driving the car or watching TV.

Start off by sitting on the lavatory and, while passing urine, stop in mid-flow. Start and stop; learn to control the stream at will. The muscles you are using are the deep pelvic ones that you will need to be aware of, both during the birth and afterwards when you are getting back to normal. Once you have conquered this to your satisfaction, start on the exercises proper.

1. Tighten and relax your pelvic muscles, holding them in a tightly contracted position for several seconds and then relaxing them. Try to increase the length of time you can hold the muscles contracted.

2. Tighten and relax the muscles quickly, in a sort of fluttering way, gradually increasing your control.

3. Pull up your entire pelvic area as if your vagina were a pump drawing up water and then force the ‘water’ out of the ‘pump’. This exercise uses some abdominal as well as pelvic muscles.

If you put a finger or two inside your vagina (or get your partner to do so) you can gauge how well you are progressing with your muscle control. Early on it may well feel flabby and rather weak, but after a few weeks the muscles will be so powerful that they will feel as if they could squeeze your fingers off.

These exercises are also very useful post-natally to get your pelvic muscles back to strength after being stretched by the baby coming down the birth canal.

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