To cut or tear: episiotomy during childbirth

by Troya Renee Yoder, MS

There are factors that may help you decide whether or not an episiotomy will be right for you.

When Katherine Higdon of Euless, Texas was pregnant, she was frightened by the idea of an episiotomy a surgical incision made between the vagina and anus to enlarge the vaginal opening during childbirth. But if it came down to a tear versus a cut, she hoped her doctor would opt for the episiotomy.

"I would have rather been cut than allowed to tear, which is more painful," she says.

Higdon's view that a clean cut is less painful than a tear reflects conventional wisdom that has persisted for decades. Ever since routine episiotomy became part of modern obstetrics in the 1920s, physicians have told women that episiotomy has several benefits, including preventing severe perineal tearing, maintaining pelvic floor functioning, reducing stretching of the vagina and thereby preventing sexual dysfunction, and shortening the second stage of labor, which reduces pressure on the baby's brain during delivery.

But some experts are saying that these reasons for episiotomy are not necessarily backed by scientific evidence.

by Troya Renee Yoder, MS

There are factors that may help you decide whether or not an episiotomy will be right for you.

When Katherine Higdon of Euless, Texas was pregnant, she was frightened by the idea of an episiotomy a surgical incision made between the vagina and anus to enlarge the vaginal opening during childbirth. But if it came down to a tear versus a cut, she hoped her doctor would opt for the episiotomy.

"I would have rather been cut than allowed to tear, which is more painful," she says.

Higdon's view that a clean cut is less painful than a tear reflects conventional wisdom that has persisted for decades. Ever since routine episiotomy became part of modern obstetrics in the 1920s, physicians have told women that episiotomy has several benefits, including preventing severe perineal tearing, maintaining pelvic floor functioning, reducing stretching of the vagina and thereby preventing sexual dysfunction, and shortening the second stage of labor, which reduces pressure on the baby's brain during delivery.

But some experts are saying that these reasons for episiotomy are not necessarily backed by scientific evidence.

When the first randomized controlled studies on episiotomies were initiated in North America in the early 1990s, the results challenged everything physicians believed about routine episiotomy.

"In fact, the research shows that episiotomies cause the very trauma they are supposed to prevent," says Dr. Michael Klein, MD, a professor of family practice and pediatrics at the University of British Columbia and head of the department of family practice at the Children's & Women's Centre of British Columbia, who led the research.

Klein and his colleagues at Children's & Women's Center in Vancouver as well as at McGill University and the University of Montreal studied several postpartum outcomes in women who had episiotomies versus women who did not.

They found that women who delivered over an intact perineum—eans no episiotomy and no tearing—e least perineal pain and the strongest pelvic floor musculature, and resumed sexual relations earlier than did women who did not deliver over an intact perineum. In addition, women with second-degree spontaneous tears (which involve the muscles of the perineum) experienced less perineal pain, less pain during sexual intercourse, and stronger pelvic floor function compared with women who had episiotomies. Women who had the more extensive third- and fourth-degree tears reported the most pain and fared the worst.

The researchers also found a strong relationship between episiotomies and severe perineal tearing. Of the 53 women studied who experienced third- or fourth-degree tears, 52 of them had undergone an episiotomy. That's not surprising if you think about it. Imagine how difficult it is to tear a piece of intact cloth, but make a little snip and it tears quite easily.

"When you do an episiotomy, [you have to expect that] under the pressure of the baby's head, the cut you've made will extend to tear and involve the rectum," says Klein.

Recent studies published this year in the British Medical Journal reported that women who had episiotomies had higher rates of anal incontinence during the first six months postpartum, even compared with women who had equivalent tears. In addition, episiotomy carries the same risks as other surgical procedures, including increased blood loss, poor wound healing, and infection.

Klein says that it boils down to beliefs. Physicians who routinely perform episiotomies generally have higher rates of all interventions, including use of forceps, vacuum, Cesarean section, induction and augmentation (the stimulation of labor after it has already begun).

"What it means to me," says Klein, "is that these physicians don't trust the birth process. They truly believe that women are unreliable incubators and babies need to be delivered at the earliest possible moment."

Your physician's attitude toward episiotomy can serve as a marker for his or her whole style of practice and view of birth, says Klein, and is a great entry point for women to open up discussions with their physicians.

While Klein and others feel that routine episiotomy should be abandoned, they support a highly selective use of episiotomy for specific fetal and maternal conditions.

The principle reason for doing an episiotomy should be for fetal reasons, says Klein. For example, an episiotomy may be necessary if a baby's heartbeat drops or there are other signs of fetal distress, which indicate that the baby needs to come out as soon as possible.

Klein's research has found that in a first birth, an episiotomy shortens labor by about nine minutes or three contractions. "And if that extra time is important for the well-being of the baby, then the episiotomy is legitimate," he says. But, according to Klein, this is only true in first births, because in subsequent births you gain almost no time at all.

There are also maternal indications that may warrant episiotomy. For example, women who are thoroughly exhausted and can't push or have had an especially dense epidural may require episiotomies. In fact, studies have associated epidurals as a risk factor for having an episiotomy.

Many doctors are trained to do an episiotomy any time they use forceps or vacuum. Klein, who often uses forceps and vacuum without episiotomy, says you can limit the trauma by not "packaging" the episiotomy along with forceps and vacuum. "There are times when you must use episiotomy, " he says, "but don't consider it a package. They are separate clinical issues."

Pat Sonnenstuhl, a Washington State certified nurse midwife, offers the following suggestions for women who wish to avoid an unnecessary episiotomy:

• Discuss with your health care provider his or her preference for doing or not doing episiotomies and choose a provider who doesn't choose to do them routinely. Since episiotomy is often a last-minute decision and it is difficult to predict who will need one, choose a provider who shares your belief in the female body and it's ability to give birth.
• Begin daily massage of the perineum (area between the vulva and the anus) around 34 weeks of your pregnancy to soften and smooth the perineal tissues, which improves the ability of your perineum to stretch during pushing.
• Experiment with different positions for giving birth, such as sitting, squatting or lying on your side.
• Work with your provider to learn controlled pushing to allow adequate time for the perineum to stretch and for slow, gentle delivery of the baby.