Episiotomy—A Birmingham Obstetrician’s View

Episiotomy—the small surgical incision made to enlarge the vaginal opening shortly before a baby is delivered—was not a commonly accepted birth procedure until the twentieth century.  But by mid-century, over half of vaginal deliveries included an episiotomy. The idea was that making a small incision would reduce the risk of a large spontaneous tear in the tissues surrounding the vagina (the perineum), as the infant’s head delivered.

As physicians, we want to offer our patients only medical interventions that—based on solid evidence—actually benefit them. By the 1980s, we began to realize that the medical benefits of routine episiotomy were uncertain.  According to recent data, less than 12% of women delivering vaginally now have an episiotomy. We do not consider episiotomy a routine part of childbirth.

So why not stop performing episiotomies altogether? A number of childbirth groups have taken this position with aggressive media coverage. Unfortunately, quality medical studies do not support this conclusion either.

Worse yet for expectant parents trying to understand the issue, groups who advise “never” sometimes misunderstand or misquote current medical guidelines. From NPR for example (July 2016), “Episiotomy…has been officially discouraged for at least a decade by the leading association of obstetrician-gynecologists in the United States.”  The actual guideline from the American College of Obstetricians and Gynecologists (ACOG), states: “Restrictive episiotomy use is recommended over routine episiotomy.” In other words, it discourages performing an episiotomy as a matter of routine, without regard to whether the delivery can be managed without one. Publicizing an “episiotomy controversy” may get headlines, but, for most obstetricians, this has not been controversial for decades. I haven’t surveyed my colleagues at Brookwood, but I doubt that any of us has performed routine episiotomies for many years.

Media reports often quote episiotomy rates (the percent of a doctor or hospital’s patients that delivery with an episiotomy). These statistics would be more helpful to parents if they included information—not only about episiotomy rates—but also about the percent of patients who experienced significant spontaneous tears.

As you can imagine, many factors determine whether your baby’s delivery is likely to cause the perineum to tear. The infant’s weight, head size, and position, the number of previous deliveries, the rapidness of labor, emergencies requiring an immediate delivery, and many other factors all play a role. Each birth is a unique event, an individual combination of these many factors. For this reason, reliable research about which specific factor increases or decreases the risk of a tear is very difficult to obtain.

The answer is important because serious tearing can cause great discomfort during a mother’s post-partum recovery, as well as long-term complications. When birth tears between the vagina and rectum penetrate the muscle of the rectum partially or completely (3rd and 4th degree tears), a woman is more likely to have problems with urinary or fecal incontinence (leaking of urine or stool) later.

So, while we cannot say that episiotomy prevents these complications, we also are not able to say that an episiotomy is never the safer option. None of your physicians at Sparks & Favor routinely performs an episiotomy during delivery. Yet we all recommend it to a patient if—in our years of clinical experience—we feel it may be the safer option for her individual situation. We may also recommend an episiotomy to expedite the delivery if the baby is experiencing distress.  The American College of Obstetrics and Gynecology provides the following guidance on the subject: “Larger trials are needed to address uncertainties in the existing medical literature and to better define a list of indications for episiotomy…the decision to perform an episiotomy should be based on clinical considerations.”

We hope you will discuss with your primary physician any concerns you have about episiotomy and include your preferences in your birth plan. We encourage the application of warm compresses to the perineum, the use of lubricants, and/or perineal massage during the pushing stage of labor, all to help stretch the skin and avoid episiotomy. Some research suggests that these measures may reduce the risk of 3rd and 4th degree tears.

We share your desire that your baby enter the world gently, and above all, safely.