Why Doctors No Longer Recommend Episiotomies

Calling labor painful is an understatement at best, and it's not uncommon that the delivering mother experiences tears in the vagina as the baby is emerging. In the past, doctors often helped the process along with an episiotomy, an incision in the perineum (the tissue between the vagina and the anus) that widened the vaginal opening so it was easier for the baby to come out.

An episiotomy was used to prevent vaginal tears and performed only during the final stages of labor. It was thought that if a woman was going to tear, it could be much more severe and difficult to suture back together than if the doctor made a calculated incision. However, this approach assumed a woman would tear during childbirth, and not all women do. But when an episiotomy was performed, the woman then had to heal from the additional physical trauma anyway. This is one of the many reasons doctors no longer rely on, or recommend, episiotomies, except in rare cases.

"Although an episiotomy is considered minor surgery, a cut is a cut and should be made after careful consideration," stated Hira Shaheen, M.D., an OB-GYN consultant in NYC. "It has far-reaching impacts...and we should try to conserve the perineum as much as we can and should weigh the pros and cons."

When is an episiotomy needed?

While doctors no longer routinely perform episiotomies, there are certain circumstances when the procedure is still needed and used to prevent more severe damage.

"There is no methodology to predict if a woman will require this procedure until the fetal head crowns, at which point the health provider determines need," said Kecia Gaither, M.D., MPH, FACOG, who is double board-certified in OB-GYN and maternal-fetal medicine, and the director of perinatal services at NYC Health + Hospitals/Lincoln in the Bronx.

Gaither noted there are a couple of situations in which an episiotomy is used, including when the baby needs to be delivered as quickly as possible and when there is the need for operative vaginal delivery using forceps or a vacuum. According to the Mayo Clinic, an episiotomy may also be needed if the baby's shoulder is stuck behind the mother's pelvic bone.

Shaheen added that normal births often do not require episiotomy unless there is an indication, such as a large-sized baby or first birth. She also pointed out that it is illegal to perform an episiotomy without taking informed consent from the patient. However, if emergencies arise during birth, such as the cases listed above, an episiotomy can be performed without consent to save the baby and prevent the mother from being harmed.

The end goal, whether an episiotomy is performed or not, is to deliver the baby as safely as possible and minimize the trauma to the mother. Sometimes, an episiotomy is the only way to make that happen.

How episiotomies work

Clench your legs if you need to, because explaining how episiotomies work is no walk in the park. First, if your doctor determines you need an episiotomy, your anesthesia will either need to still be effective or you'll receive a local anesthetic to numb the area. You should not feel the incision whatsoever.

There are two different types of episiotomy incisions:

• A midline (median) incision is a vertical incision between the vaginal opening and anus and is easier to repair. However, there is a higher risk of a tear extending farther into the anal area with this type of incision.

• A mediolateral incision is performed at an angle and offers the best protection against an extended tear into the anal area, but is harder to repair and can be more painful. According to Gaither, this type of episiotomy works best for women whose perineum is short, but it's the least often utilized type of episiotomy.

The risks of episiotomies

There are many risks associated with an episiotomy. Additionally, science has shown that episiotomies don't always prevent tearing, and can actually increase the chance of tearing.

"[An episiotomy] was a routine procedure until 2006 when the American College of Obstetrics and Gynaecology recommended against it," Shaheen said. "It limited episiotomy to selective conditions when it was absolutely necessary. The reasoning behind [using] it was that it is better to have an organized cut that you can stitch than the natural tear that is difficult to handle. In some parts of the world, this reasoning is still used to justify an episiotomy. But with excessive use of episiotomy, problems like pain, wound infection and perineal problems in the next birth started increasing and made us question the practice."

Shaheen pointed to a study published in 1984 which showed 21 percent of women gave birth without any complication to their perineum when not given a routine episiotomy, while 25 percent had only a first-degree tear, which resolves much faster than an episiotomy.

A few of the complications resulting from an episiotomy include bleeding, tearing in the rectal tissues/anal sphincter muscles (which can result in fecal incontinence), infection, hematoma, swelling, painful sex, pelvic floor dysfunction and improper wound healing, Gaither said.

If an episiotomy is not necessary for the safety of the baby or the mother, a doctor will try to avoid inflicting this additional pain and trauma.

Preventive measures for vaginal tearing

Though episiotomies aren't routinely performed anymore, several other methods are available to help protect against vaginal tearing during childbirth, and you can do many of them at home throughout your pregnancy.

Perineal massage

"There is an age-old method of perinatal massage which aims to stretch the perineum tissue, with the hopes of [preventing] the need for an episiotomy," Gaither explained.

Perineal massage involves using oil on the perineum, placing thumbs in the vagina and firmly massaging upward in a u-shape motion. This is done daily during the third trimester of pregnancy. It is important for the area and your hands to be clean, and that no vaginal or vulvar infections, such as herpes, are present.

"There is no guarantee that this daily procedure will result in a vaginal birth without the assistance of an episiotomy," Gaither cautioned.

Keep the perineum warm

Something as simple as placing a warm washcloth on the perineum area can help prevent tearing. When the tissue and muscles are warm, they are more likely to stretch a little bit more than when they are cold, just like other muscles in your body that you warm up before a workout.

Find a better birthing position

Women tend to give birth while on their back, maybe propped up a bit and with their legs pulled toward their chest. However, other positions are better for preventing vaginal tearing. One position is being on all fours, letting gravity do most of the work. Another position is upright, either propped almost all the way up or in a near-standing position.

The less you have to push to get the baby out, the less likely you are to tear. Of course, you'll want to speak to your healthcare professional to make sure these are viable options for you.