It’s a fortunate truth that highly trained practitioners, aided by modern equipment and advanced techniques, have made childbirth a relatively risk-free occurrence.
However, when viewed objectively, a vaginal delivery is still an intrinsically drastic event. Powerful anatomical and biological processes are launched into irreversible motion, and they must be managed in a timely manner. Emerging babies set and follow their own schedules.
In coping with the unstoppable nature of childbirth, earlier obstetric physicians sometimes adopted practices that seemed sensible at the time. Then, without much further examination, these practices became the accepted standards of care.
Some of those grandfathered features of obstetric practice, which have been considered standard birth management techniques for centuries, are now undergoing much-needed scrutiny. One such practice is the routine use of an episiotomy to facilitate a child’s exit from its mother’s womb.
What is an episiotomy?
The area between a woman’s vagina and her anus is called the perineum. During delivery, the perineum comes under severe pressure, as the inexorable contractions of labor force the baby’s head through the vaginal opening.
Until quite recently, it was routine practice for the attending obstetrician to use a surgical incision to enlarge the mother’s vagina. Thereby simultaneously easing and hastening the baby’s entrance into the wider world.
Two types of surgical cuts are used for an episiotomy
- A midline episiotomy slices along a line that extends the vaginal midline toward the anus.
- The other, called a mediolateral incision, makes a diagonal cut at the base of the vagina. The mediolateral cut is harder to repair, but it tends to avoid incursions into the anal sphincter during labor.
What is the history of episiotomy?
In the 1700s, using a scalpel to enlarge a woman’s vagina during childbirth was deemed useful for “difficult deliveries” – when a woman couldn’t push out her baby, even though it was properly positioned in her birth canal.
The practice persisted for centuries. As of 1979, over 60% of the women giving birth in the United States routinely received episiotomies.
First-time mothers were especially likely to receive an episiotomy because their deliveries were automatically deemed to be more difficult. An episiotomy was still considered to be within the prevailing standard of care.
Pain during the surgery wasn’t a concern, because either an epidural or local anesthetic would eliminate sensation.
Upon re-examination, it now appears that the chief beneficiary of the routine episiotomy may often have been the convenience of the healthcare provider. It’s a fact that episiotomies do shorten delivery time.
What arguments were used to justify routine episiotomies?
About 80% of women do experience some perineal tears with a vaginal birth. But “tears” is a broadly inclusive term. Most natural tears during birth are shallow injuries to perineal tissue that don’t require stitches. These tears typically heal on their own and cause no further issues.
Proponents of routine episiotomies held that a cut administered by a surgeon would be both more precise and easier to repair than inadvertent lacerations. So the residual harm from an episiotomy would be more limited than from natural tears, the argument went.
But we know now that routine episiotomies actually increase the rate of severe lacerations. An episiotomy invites a larger tear to occur than would have happened naturally. That’s because an episiotomy incision provides a starting point for a further, more severe, laceration.
It was also thought (wrongly) that episiotomies protect the muscles that support the pelvic floor.
What harm do episiotomies cause?
Studies indicate that women who receive episiotomies are four times more likely to suffer lacerations into their anal sphincter than women whose doctors don’t cut them during childbirth.
When an incision of the perineum during childbirth accidentally extends into the anal sphincter, it can be a postpartum disaster. Stool softeners may not prevent bowel movements from being very painful for months, and fecal incontinence is also possible. Sexual activity can also be negatively affected.
Do any institutions still offer episiotomies routinely?
The answer is an unfortunately resounding yes. In 2006, the American College of Obstetricians and Gynecologists (ACOG) issued a practice bulletin that strongly recommends sparing use of episiotomies. But it appears that old habits die hard.
In 2019, a USA Today investigation examined data from 533 hospitals. The researchers found that dozens of hospitals, spread over eight states, were running episiotomy rates of 20% or higher.
These episiotomy rates were being incurred despite the 2006 practice bulletin from ACOG. Furthermore, a leading hospital safety group found that episiotomies should occur in no more than 5% of vaginal deliveries.
Are episiotomies ever appropriate?
Yes. In fact, there are occasions when an episiotomy is practically mandated:
- Sometimes, a baby’s shoulder will be immovably lodged (this is called shoulder dystocia).
- The baby’s heart rate may be so accelerated that immediate removal is necessary.
- A breech delivery can be so complicated that forceps are required.
These situations can present a choice between an episiotomy and a cesarean delivery. Given the equality of all other factors, an episiotomy is almost always the preferred choice.
How can I avoid an unnecessary episiotomy?
First, have a candid discussion with your healthcare provider. Find out if an episiotomy is planned for your delivery. If so, find out why. If the answer is along the lines of “well, that’s just how we do it,” strongly consider finding another healthcare provider.
There are some measures that can help reduce the severity of perineal tears:
- Practice perineal massage for 6 to 8 weeks before your due date.
- Do Kegel exercises throughout your pregnancy.
Talk with your OB/GYN about preventing perineal tears by:
- Placing a warm compress on your perineum during labor to soften the skin in the area and enhance its stretchability.
- Using a standing or squatting posture while pushing the baby out.
- Having someone apply gentle counter pressure to your perineum as the baby’s head emerges so that an over-hasty exit doesn’t cause an unnecessary tear.
About Dr. Aliabadi
As one of the nation’s leading OB/GYN’s, Dr. Thaïs Aliabadi offers the very best in obstetrics and gynecology, including telehealth appointments. Together with her warm professional team, Dr. Aliabadi supports women through all phases of life. She creates a special one-on-one relationship between patient and doctor.
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