Articles and Topics
Episiotomy
As a baby is born vaginally, a mother’s skin stretches around her baby’s head and body. If the delivery is allowed to proceed slowly, care is taken to support the perineum (the skin between the vagina and anus), and if the mother’s skin is adequately pliable, it is possible for the perineum to remain intact as it stretches around the baby. If the baby is large or facing forward, if the delivery occurs rapidly or requires forceps, or if the mother’s skin is tight, tears may occur in the tissues around the vaginal opening. An episiotomy is a surgical cut in the perineum to widen the passageway for a vaginal birth. It is done after numbing the skin with a local anesthetic, either as a straight cut from the back of the vagina towards the anus (median episiotomy) or as an incision angled slightly to one side (a mediolateral episiotomy).

Episiotomies are the most common surgical procedure done in this country, and have traditionally been promoted as having numerous benefits. It was first proposed that episiotomies were protective for newborns, lessening head trauma from the birth itself. It was also thought that episiotomies reduced perineal trauma and would heal better than spontaneous lacerations. Episiotomies were thought to prevent long-term maternal problems resulting from prolonged stretching of the pelvic tissues during childbirth such as loss of urinary control (called incontinence) and loosening of vaginal and rectal tissue (called pelvic relaxation). It was hoped that performing an episiotomy would shorten the pushing phase of labor and prevent some of these conditions. Other proposed advantages included lessening the pain following delivery and enabling faster deliveries in situations where fetal distress was noted.

Recent research has challenged these assumptions, suggesting that many of the proposed advantages of episiotomy may not be valid. Studies reveal that episiotomies may actually increase the amount of damage to the perineum, by making it easier for skin to tear. Episiotomies have been linked to a higher rate of deep lacerations including 3rd degree extensions—tears that include the anal sphincter—and 4th degree extensions—tears that extend into the rectum itself. There is a higher rate of maternal blood loss with episiotomies, and a greater chance of infection and ongoing discomfort. So far, studies have not shown that episiotomies decrease the long-term rates of pelvic floor relaxation or urinary incontinence, or that episiotomies lower chances for newborn birth trauma. Only one type of tear is seen more frequently in women who do not have episiotomies: tears of the anterior perineum. These tears involve the labia and the skin around the opening of the urethra.

Rates of episiotomy today vary with characteristics of the mother, her baby, and her birth attendant. For example, first-time mothers are more likely to receive episiotomies than women who have previously delivered, and women with large babies are more likely to tear. Ethnic differences may affect the need for episiotomies; Asian women tend to have less pliable skin than Caucasian women, and African-Americans may have more pliable skin.

Birth attendants with lower rates of episiotomy have been trained in techniques that minimize tears, such as flexing the newborn head, using lubricant to massage the maternal skin, and using hands-on techniques to support and protect the perineum during the delivery. They also must be patient and tolerant of a slow birth process rather than eager to speed up the last phases of delivery.

Two self-help techniques are advocated by birthing instructors to minimize the need for episiotomies: Kegel exercises and perineal massage. With Kegel exercises, women are taught to contract and strengthen the muscles of the pelvic floor. For perineal massage, women or their partners use oil to massage and stretch the vaginal opening several minutes each day during the last six weeks of pregnancy. These techniques have not been adequately studied to determine whether they indeed lower the rates of episiotomy. However, they are unlikely to be harmful and many women swear by them.

The routine use of episiotomy no longer seems justified and episiotomy rates have been decreasing. In the U.S., it is estimated that episiotomy rates fell from 65% in 1979 to 39% in 1997. Currently, many doctors and midwives feel that episiotomies should be performed only for specific indications and rates around 20% are advocated. It is entirely reasonable to discuss episiotomy with your health care provider. You can ask how frequently and under which conditions episiotomies are necessary, and whether he/she uses methods to lower the chances for this procedure.

Laura E. Stachel M.D. Obstetrician & Gynecologist