Suzan Lenz Interview

Could you briefly introduce yourself and tell us about your background as a midwife? Where do you work? How long have you been working with EPI-NO?

My name is Janina Köster, and I have been a practicing midwife since 2008. I completed my training from 2005 to 2008 at a large Level 1 hospital in Paderborn. After that, I worked in attending midwifery (Beleggeburtshilfe) from 2008 to 2015. Since 2015, I have been running my own midwifery practice in Olpe, focusing on prenatal care, postpartum care, childbirth preparation courses, and birth coaching. Additionally, I teach at vocational schools, for emergency paramedics, and in pediatric nursing care. I first heard about EPI-NO around 2013/2014, and I have been actively and intensively working with it for about three to four years.

How did EPI-NO become part of your clinical practice? What led your clinic to introduce EPI-NO? How has your use of EPI-NO evolved over the years?


I first learned about EPI-NO around 2013/2014, primarily through birthing center midwives who had already gathered very positive experience with it. About three to four years ago, expectant mothers in my practice began asking me about it more and more frequently. Their consistently positive feedback prompted me to examine the concept in greater detail. As a result, EPI-NO became an integral part of my preparation courses and birth coaching. In 2024, I proactively reached out to Ingo Giani to express my interest in conducting a practice-based study to place the topic on an even more evidence-based foundation.

Based on your experience, which pregnant women are most likely to benefit from EPI-NO? Do you recommend it for all first-time mothers? Are there particular groups who benefit the most?


First-time mothers benefit enormously from the training, as it allows them to become familiar with the sensation of pressure and stretching in the pelvic floor beforehand. Beyond that, I specifically recommend EPI-NO to two other key groups:

1 Multiparous women with previous major birth injuries: Women who experienced higher-grade injuries (such as 3rd or 4th-degree perineal tears or extensive episiotomies) during a previous birth and wish to gently prepare the scarred tissue while rebuilding trust in their body's capacity to stretch.

2 Women planning a vaginal birth after cesarean (VBAC): Expectant mothers with a history of C-section who are aiming for a vaginal birth this time and want to target their pelvic floor preparation.

• I generally recommend EPI-NO to all primiparae as well as women with tight tissue or scarring. The greatest benefit is seen where training helps women gain confidence in their body's flexibility and learn to consciously release tension under pressure.

How do you introduce EPI-NO to pregnant women? How do you explain its purpose and use? How often do you recommend they use it, for how long, and how do you advise them to progress during the weeks before birth? What questions or concerns do women most often have?


I usually introduce EPI-NO during childbirth preparation courses or during an individual consultation approximately 4 to 6 weeks before the due date. This is embedded within an overview of other supportive measures, such as eating dates, birth-prep acupuncture, and similar methods. I explain the device as a biofeedback trainer for gentle tissue stretching and body awareness.

◦ Recommendation: Start ideally between 36+0 and 37+0 weeks. I recommend using it twice daily for 10 to 15 minutes per session.

◦ Approach: Gradual, gentle progression without pain. The main objective is not reaching a maximum balloon diameter, but rather learning to consciously relax the pelvic floor under stretching pressure.

◦ Common Concerns: Women frequently ask whether the training could induce labor prematurely, cause pain, or overstretch ("loosen") the tissue. I reassure them by explaining that the pelvic floor is an elastic muscle and that the training safely enhances flexibility and body awareness in a controlled manner.

Looking back on your many years of experience, what have been your most important clinical observations? What differences have you noticed? Are there any experiences that have particularly influenced your approach?


The tissue is gently pre-stretched and becomes more supple. I like to explain it to women like this: Imagine you want to do the splits—without preparation, you might injure yourself or fail entirely. But with four weeks of advance preparation, it is a completely different story.
Women who train with EPI-NO enter the pushing stage with a completely different level of confidence and self-assurance. They are already familiar with the sensation of pressure, tense up less, and can actively work with the labor contractions. This often results in fewer birth injuries and a subjectively much more positive birth experience.

Your clinic has recently started documenting its long-term clinical experience through an observational study. What inspired this initiative? Why did you feel it was important to document your experience systematically? What questions are you hoping the study will help answer?


From daily practice and feedback from my clients, I knew about the positive effects, but it was essential to me to document these observations systematically and in a scientifically tangible way. Since I also teach at vocational schools and in specialized nursing education, evidence-based practice is very close to my heart. That is why I proactively approached Ingo Giani in 2024 to initiate a practice-based study. We aim to investigate how systematic training specifically impacts perineal injury rates, pain perception, and the sense of security women experience during birth, in order to provide fellow midwives with solid clinical data.

Have you encountered any challenges regarding the use of EPI-NO? What questions or concerns have colleagues or other healthcare professionals raised? How do you usually respond to these questions?


Many colleagues in Germany are not yet familiar with EPI-NO. When concerns were raised, they mostly stemmed from past reports of improper usage, often involving cheaper counterfeit products imported from abroad. Concerns primarily arise when the balloon is inserted completely incorrectly. Because the inner vagina is significantly more stretchable than the vaginal opening (introitus), incorrect placement or forced expulsion (similar to power-pushing) can indeed lead to injury.
I address these questions by providing education on correct anatomy and application: With proper professional instruction and correct placement, the training is entirely safe. As soon as colleagues see the actual outcomes and positive birthing experiences, the vast majority react very favorably.

Based on your experience, what advice would you give to midwives who are considering introducing EPI-NO in their own practice? Are there common misconceptions? Are there situations where you would not recommend EPI-NO? What do you think is the most important thing for colleagues to know?

◦ Advice & Practical Tip: View it not merely as a mechanical device, but as a psychological preparation tool for the woman's mindset. A key practical advantage is that women get the opportunity during pregnancy, within a safe environment, to practice the expulsion and delivery of the EPI-NO balloon in various birthing positions. This helps them tremendously when choosing their optimal birth position later on.

◦ Misconceptions: The prejudice that EPI-NO overstretches ("loosens") the tissue or renders professional midwifery care redundant.

◦ Contraindications: Do not use in cases of vaginal/genital infections, premature rupture of membranes, vaginal bleeding, placenta previa, or premature labor before 37+0 weeks.

◦ Key Takeaway: EPI-NO trains body perception. A woman who can feel her pelvic floor under pressure, consciously relax, and test delivering the balloon in different positions enters labor with immense empowerment and practical confidence.

Finally, if you could share one key message with Danish and Norwegian midwives about EPI-NO, what would it be?


EPI-NO is far more than just pelvic floor training, as it builds maternal confidence through gentle stretching and optimal preparation of the vaginal opening. In practice, we see a genuine reduction in both the rate and severity of birth injuries. From my side, it gets an absolute midwifery endorsement, as it gives women a practical tool to enter birth prepared, empowered, and with a positive mindset.