Episiotomy: You want to cut me WHERE?!!

What is an episiotomy?

An episiotomy is an incision made in the perineum to enlarge the vaginal outlet.  A midline episiotomy begins at the center of the perineum and extends straight down towards the anus.  A mediolateral episiotomy is cut at a 45 degree angle, which points downward to the right or left of the perineum (1).

(Just in case you’re wondering what your perineum is, it’s the area between the vagina and anus.)

When is an episiotomy necessary?

Back in the day, episiotomies were given routinely to women just before birth to help speed up the pushing phase.  This is an outdated practice that has, in many cases, proven no benefit.  Today, the use of episiotomies is restricted only to situations where it is medically necessary, such as:

• Baby is in distress and needs to be born quickly.  Episiotomies have been found to shorten the time to birth by five to fifteen minutes (2).
• Forceps are necessary to help baby descend in an assisted delivery.  An episiotomy is done before a forceps delivery so that the tool can fit into the birth canal.

Factors that are associated with a higher rate of episiotomies include (1):

• Being a 1st time mom
• Larger-than-average baby
• Baby is in the occiput-poster position
• Shoulder dystocia

What are the risks of an episiotomy?

An episiotomy makes it more likely that a woman will suffer deep perineal tears.  Major perineal trauma — a 4th degree tear that extends to the muscles of the anus — is significantly more likely to happen with a midline episiotomy.  Also, episiotomies make it more likely that repeat trauma to the perineum will occur in future births.

Episiotomies are associated with additional complications such as blood loss and infection.  They cause perineal discomfort that can last for weeks past birth, as well as painful sex.

Does an episiotomy hurt?

If you are planning a natural birth, you are probably eager to know if episiotomies hurt.  Surprisingly, many women say that they didn’t feel pain when the incision was initially made.  As baby’s head descends into the birth canal, the muscles of the perineum stretch and thin out.  Muscle that was once 5 cm thick becomes less than 1 cm thick.  This thinning results in a decrease of blood flow to the area, which results in a natural anesthesia.

However, it would be grossly inaccurate to say that episiotomies don’t hurt.  There is significant discomfort associated with the incision in the days and weeks following the birth.  Perineal swelling and tenderness can make walking, sitting, and using the bathroom painful experiences (4).   Additionally, the stitches can tug when moving and cause an unrelenting itch while healing.  (Learn how to care for perineal tears and incisions.)

Can I avoid an episiotomy?

Here are some general tips to help reduce your chance of an episiotomy:

• Interview your doctor or midwife and choose a healthcare provider that has a low episiotomy rate (less than 20%)
• Attempt perineal massage during pregnancy
• Use natural pushing (spontaneous bearing down) during labor rather than directed pushing
• Avoid the lithotomy position (flat on your back) during pushing
• Prepare yourself with tools for a natural birth — natural birth yields a lower rate of forceps delivery

Episiotomy vs Tearing

Most women are going to experience some minor lacerations on the perineum during pushing.  When they occur naturally, it is known as “tearing.”  When compared to a routine episiotomy, tearing has been found to be less painful.  It is also less traumatic to the perineal tissue.  Tears also heal better than episiotomy lacerations (5).

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References:

(1)  Ladewig, P.A., London, M.L., Davidson, M.R.  (2006).  Contemporary Maternal-Newborn Nursing Care, 6th edition.  Pearson Prentice Hall.  Upper Saddle River, NJ.

(2)  Simkin, P., Whalley, J., Keppler, A.  (2010).  Pregnancy Childbirth and the Newborn.  4th Edition.  Meadowbrook Press.  New York.

(3)  Varney, H., Kriebs, J.M., & Gregor, C.L. (2004).  Varney’s Midwifery.  (4th ed.).  Boston:  Jones and Bartlett Publishers.

(4)  Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A.  Listening to MothersSM III: Pregnancy and Birth.  New York: Childbirth Connection, May 2013.

(5)  Carroli, G., & Mignini, L. (2009).  Episiotomy for vaginal birth.  Cochrane Database of Systematic Reviews, Issue 1.  Art No: CD000081.