An eight pound baby in the hospital is expected to have caused lacerations—if not a c-section. Midwives don't have this attitude, and they don't come to expect this in their practice. Why?
Because position and pushing matter: how the woman positions herself, and how she pushes during delivery. All of the women we saw had to labor and deliver on their backs, and were "coached" (or hollered at) to bear down regardless of whether she had the instinctive urge to push. Women are put on their backs, regardless of what position their body tells them to be in, and despite the fact that we know that the sacroiliac joints can't open up in this position. Supine delivery increases the likelihood of a difficult labor, shoulder dystocia, and a forceps or vacuum extraction. And women are yelled at to push despite the fact that we know there's an actual reflex that prompts the woman to push when the fetus is descending properly and smoothly. All I could think was that if the women we saw could labor in whatever position they liked (read: obstetricians and nurses weren't afraid to get down and catch babies in whatever position they're coming, like midwives do), and they could push when they want to push (with eased guidance from a tearing-conscious practitioner, rather than a shouting person who's worried about lawsuits), we would not have seen so many tears.
It's not a small deal. One of my patients had to be sewn up for an hour (for a six pounder). I wrote in my journal about another patient's horrible tearing:
The nurses were so busy today. One shouted that she needed a Foley urine catheter taken out and would a student like to learn to do it. I finally volunteered, not to learn but because I already know how to from my job. It turned out the patient who needed the Foley out was the poor young lady who another student had yesterday - she had described an episiotomy and horrible tearing - what the teacher said they unofficially call a 'vaginal C-section'. We had asked how big the baby was, and it was only six pounds. The nurses are like "The poor girl's never going to sit the same again." So I go into the room, tell her what I'm going to do, that it's fast and pretty painless, that it can be done without really uncovering anything, and then I wash my hands and put on gloves. When I come back to the bedside, the girl is SOBBING. Completely crying and shaking. She was so afraid it was going to hurt, because of how she had already been hurt. I was so upset after that. They completely butchered this girl, as far as I feel. It's her first birth. She'll spend her whole life remembering this.Of course, my wife is telling me it doesn't matter—I could prove that forcing women on their backs for labor and delivery actually kills people, and doctors still wouldn't stop doing it. You need to be on your back for the EFM, and for the safety of your baby (read: the convenience of the staff).
On the other hand, the epidural patients can't get out of bed, and have no urge to push—and now that I think of it all my patients with tears had epidurals.