Episiotomy

What is an episiotomy?

An episiotomy is a surgical cut to widen the vaginal opening during delivery. Doctors sometimes make an incision in the perineum -- the area between the vagina and the anus -- to help the baby come out. Your doctor will likely numb the area with a local anesthetic before making the cut and suture the incision after the baby is born.

When is an episiotomy necessary?

The original argument for performing episiotomies was that cutting the vaginal opening would prevent the skin from tearing and prevent damage to the pelvis. However, recent research has largely disproved that on both counts. Studies show women who don't have episiotomies recover faster, require fewer stitches, and are ready to have sex sooner than women who have them.

In fact, routine episiotomies may do more harm than good. A review of 26 studies of episiotomies published in the Journal of the American Medical Association showed that they are linked with a higher risk of injury, more trouble healing, and more pain. Episiotomies also did not help with incontinence, pelvic floor strength, or sexual function. Women who had the procedure waited longer to resume sex after childbirth and experienced more pain with intercourse after birth that women who did not have it.

Even more surprising, studies show that severe tears -- known as third- or fourth-degree lacerations (ones that are close to or through the rectum) -- are actually more common with an episiotomy. For example, when doctors at several Canadian hospitals reviewed outcomes in women who had episiotomies versus women who did not, they found that 52 of the 53 women studied who experienced third- or fourth-degree tears had undergone an episiotomy. The researchers concluded that an episiotomy can actually make a severe tear more likely, just as making a snip in a piece of cloth makes it easier to tear.

There are two kinds of episiotomies, midline and mediolateral, differentiated by the direction in which the surgical cut is made. Midline episiotomies are associated with more severe tears than mediolateral ones.

Should I have an episiotomy?

The American Congress of Obstetricians and Gynecologists recommends against the routine or liberal use of episiotomies, but has approved its use in restricted cases, such as difficult deliveries when a baby is "stuck" or shows signs of stress. It's an individual call for your doctor or midwife, but many doctors will consider performing an episiotomy if one or more of the following applies:

  • Your baby's heart rate slows and the doctor believes he needs to be delivered right away. This may make necessary room to make it easier to deliver the baby quickly.
  • If the need for a speedy delivery requires your doctor to use forceps or vacuum extraction to help your baby out. Performing an episiotomy makes it easier to reach the baby in these situations.
  • If you experience a prolonged second stage of labor.

Some practitioners will also perform an episiotomy when a baby's head has been delivered but his shoulders are trapped. This is an emergency known as shoulder dystocia. However, recent studies show that even in these emergency situations, doctors can often safely avoid an episiotomy. In addition, researchers concluded that performing an episiotomy in most cases is highly unlikely to reduce the chances that a baby will be injured during delivery.

How can I avoid an episiotomy?

Talk with your health care provider about his or her preference for doing or not doing episiotomies. This will give you a better idea about whether you should choose another provider who doesn't do them routinely. Also ask your doctor to advise you about controlled pushing to allow adequate time for the perineum to stretch and for a slow, gentle delivery.

Studies show that doctors are changing their attitudes toward episiotomies and that they are less common than they were in the past. In fact, a 2009 study found that episiotomy rates in the U.S. declined from 60.9 percent of all vaginal deliveries in 1979 to 24.5 percent in 2004. However, doctors' opinions on the procedure may be influenced by where they practice. A six-year study by the American Congress of Obstetrics and Gynecology (ACOG) found that 17.7 percent of doctors who practiced at hospitals and universities performed episiotomies, compared with 67.1 percent for private practice physicians. Reassure your doctor that you practice your Kegel exercises to strengthen your pelvic floor muscles in preparation for labor and delivery.

References

Frankman, EA, et al. Episiotomy in the United States: Has anything changed? American Journal of Obstetrics and Gynecology. February 25, 2009.

University of Michigan Medical School. Anatomy Tables: Perineum and External Genitalia.

Riskin-Mashiah, S. et al. Risk factors for severe perineal tear: can we do better? American Journal of Perinatology. 2002 July; 19(5):225-34.

St. John Health. To Cut or Tear, Episiotomy During Childbirth http://www.stjohn.org/HealthInfoLib/HGArticle.aspx?ArticleID=14692

Hartmann, K. et al. Outcomes of Routine Episiotomy. Journal of the American Medical Association. May 2005; 293:2141-2148.

Burrows, L.J. et al. Predictors of Third- and Fourth-Degree Perineal Lacerations. Journal of Pelvic Medicine and Surgery. January/February 2004; 10(1):15-17. http://www.jpelvicsurgery.com/pt/re/spv/abstract.

Leeman L. et al. Repair of Obstetric Perineal Lacerations. American Family Physician. October 2003. http://www.aafp.org/afp/20031015/1585.html

Johns Hopkins Medicine. Episiotomies Do Not Prevent Shoulder Injury to Infants Stuck in Birth Canal. October 2004. http://www.hopkinsmedicine.org/Press_releases/2004/10_04a_04.html

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