A Mommybites reader asked:
My doctor mentioned that he may need to perform an episiotomy if he thinks I’m going to tear during labor. Is this procedure safe?
Recently, a student approached me with great concern about a comment her doctor had made during her 36 week visit. She was discussing her birth preferences and came to the subject of episiotomies. She expressed a strong desire to avoid this procedure unless medically necessary. She was a little surprised that her doctor said, “If I think you are going to tear, I am going to cut instead.”
My student was under the impression that episiotomies are not done very regularly and was curious about what I thought of the doctor’s comment. Many women may run up against this issue, so why not explore the pros, cons and general understanding of the usage of episiotomies.
What is an episiotomy?
An episiotomy is a surgical incision at the perineum (the region between the anus and the vagina). The intention of an episiotomy is to provide more space for the baby to pass through the vaginal opening. The cut of an episiotomy can be a midline cut – a cut straight down from the vaginal opening to the anus or, a mediolateral cut – an incision angling from the vaginal opening to the side, cutting more into the muscle rather than tendon. Nowadays, the mediolateral cut is primarily used over the midline cut to preserve the integrity of the pelvic floor.
How often are episiotomies performed?
The latest recommendations for ACOG (American College of Obstetricians and Gynecologist) were published in the April 2006 issue of Obstetrics & Gynecology. These guidelines were created to help practitioners in deciding when it is appropriate for an episiotomy. A practice bulletin from the ACOG states, “Although episiotomy is performed in approximately one third of vaginal births in the United States, prophylactic use of the procedure does not result in maternal or fetal benefit and should be restricted. Nonetheless, there is a place for episiotomy for maternal or fetal indications, such as avoiding severe maternal lacerations or facilitating or expediting difficult deliveries.” (1). The Lamaze Institute for Normal Birth states in their Care Practice Papers, “The episiotomy rate can be safely lowered to 10%, or even lower.”
What is the alternative to an episiotomy?
The alternative would be to tear naturally. Many care providers and medical studies are supporting the occurrence of a natural tear of the perineum over an intentional cut during childbirth. Part of the reasoning for this is data suggests that women who have an episiotomy do not have significantly improved labor, delivery, and recovery compared with those who do not have one (ACOG statement). Also, by foregoing a routine episiotomy, the mother has a chance to stretch the perineum during the course of second stage (the pushing phase) and may avoid any perineum damage altogether. With an episiotomy, the connective tissue, muscles and skin are cut and therefore the strength will permanently be compromised.
Are there any benefits to getting an episiotomy?
This is where some of the controversy starts. As with my student’s doctor, some believe it is better to have a straight controlled line of an incision instead of jagged line of a natural tear. Perhaps it is easier to repair a straight cut however, one argument against that is, once the incision is made, there is a higher chance for a deeper, longer tear. Imagine you are pulling at a piece of fabric. If you pull long and hard enough, there may be a bit of a ragged tear that starts, but it likely won’t tear to far. If you start to pull on the fabric with a small incision already present, the force of pulling will likely tear the fabric quicker and further. With that said, there are real medical reasons for needing an episiotomy including: extensive vaginal tearing appears likely, baby is in an abnormal position, baby needs a quick delivery which may include the need to use vacuum extraction or forceps.
What are the risks?
Some of the risks of an episiotomy include: extension to a third- or fourth-degree tear, subsequent pelvic floor dysfunction, anal sphincter dysfunction, painful sex, infection and fecal and urinary incontinence.
Is there a compromise?
You may be able to encourage your doctor to try applying warm compresses to the perineum which will help soften the skin and allow for the skin to stretch more easily before grabbing the scissors. I have seen many practitioners use this method as the baby is crowning. Also, remember to practice your kegels. Kegels can help create strength AND flexibility to the pelvic floor muscles. My student did report back that she spoke with her doctor again and explained she understood the risks versus the benefits of an episiotomy and would still prefer to avoid it if possible. I hope that she gets what she wants. Now armed with information, I hope you, too, can speak candidly with your care provider about episiotomies.
Sources
1. Practice Guideline Briefs – Am Fam Physician. 2006 Dec 1;74(11):1970-1976. ACOG Recommends That Physicians Restrict Episiotomy http://www.aafp.org/afp/2006/1201/p1970a.html
2.https://www.acog.org/About_ACOG/News_Room/News_Releases/2006/ACOG_Recommends_Restricted_Use_of_Episiotomies
3. Mayo clinic – Episiotomy: When it’s needed, when it’s not
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Debra Flashenberg, CD(DONA), LCCE, E-RYT 500 is the director of the Prenatal Yoga Center. She has spent most of her life performing and was introduced to yoga through a choreographer in 1997. After several years as a yoga student, she decided to continue her education and became certified as a Bikram Yoga instructor. After being witness to several “typical” hospital births, Debra felt it was important to move beyond the yoga room and be present in the birthing room. In 2006, Debra received her certification as a Lamaze® Certified Childbirth Educator. In September of 2007, Debra completed a Midwife Assistant Program with Ina May Gaskin, Pamela Hunt and many of the other Farm Midwives at The Farm Midwifery Center in Tennessee. Drawing on her experience as a prenatal yoga teacher, labor support doula and childbirth educator, Debra looks to establish safe and effective classes for pregnancy and beyond. She is the proud (and tired) mother of baby boy, Shay.
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