Making the Cut- Episiotomy in Modern Obstetrics


 

By Georgia Ragonetti-Zebell, MD

What’s all the fuss about an episiotomy?

Episiotomy has been in the news quite a bit lately. There is the woman suing her obstetrician for assault for a “forced episiotomy.” Another woman recently won a $50 million lawsuit against her obstetrician for complications that arose after her second delivery (with another provider) which she claims were caused by the episiotomy performed during her first delivery.  ACOG also recently published a Practice Bulletin on the “Prevention and management of obstetric lacerations” that addresses episiotomy use.  Wow. That’s quite a lot of debate (and money) over one small cut.

What is an episiotomy?

In case you haven’t been obsessed with the debate, an episiotomy is an incision (made with scissors) in the vaginal tissue during a vaginal delivery. It was first reported in the 1850s, and widely popularized by Dr. Delee in the 1920s, along with forceps deliveries. It was reported to have several benefits- easier delivery, easier repair, less damage to the pelvic floor leading to less incontinence.  

Baby slides out, I don’t pee myself…sounds great! Sign me up!

Not so fast. Dr. Delee practiced in the days before evidence based medicine and randomized controlled trials. What he said went.  And, as the number of deliveries in the hospital rather than home increased, so did the number of episiotomies. But years passed and evidence based medicine began to question the  standing practices of modern obstetrics. And benefit has not been proven with routine use of episiotomy.

Research on the routine use of episiotomy shows that restricted use leads to fewer tears and possibly fewer anal sphincter tears, depending on how the incision is performed. When it comes to incontinence, studies show that the biggest risk factor is severe damage to the pelvic floor, or the muscles that surround the urethra, vagina and anus. The biggest risk factor for severe damage? You guessed it- episiotomy. Specifically a median episiotomy, meaning one cut in the middle instead of to the side. In fact, women who did not have an episiotomy were found to have better muscle control. Episiotomy does not appear to protect the pelvic floor and may lead to more severe tears.

All of that sounds bad. Never cut me. Never. Ever.

Wait, wait, wait. The studies that show no benefit to episiotomy are looking at routine use, meaning episiotomy for every delivery versus restricted use, meaning only when there is a reason. What are the reasons, you ask? There are two main reasons to cut an episiotomy. One, to get the baby out more quickly. If there is a concern about the baby during the time that momma is pushing, sometimes a small cut will allow the baby to be born immediately. Or baby’s shoulders are stuck, and an episiotomy can make more room to help deliver baby. This, like a cesarean, is protecting the baby at the expense of the mother. It may cause there to be a larger tear, or an extension, but may decrease or prevent neurologic problems with baby, if the baby needed to be delivered quickly. Sometimes, momma is exhausted. She has been pushing for hours, and the only thing holding baby in is a little band of vaginal tissue that is slowly, slowly stretching. A small cut can speed up delivery. Sometimes, a tear has already begun, and is heading directly for the sphincter. A mediolateral episiotomy, or cut to the side away from the sphincter, can direct any tears away from the (very important) anal sphincter. Mediolateral episiotomies do appear to prevent anal sphincter injuries, but may also lead to more perineal pain and painful intercourse. Although research is limited, these are commonly given reasons for an episiotomy.

My doctor wants to cut an episiotomy. What should I do?

A conversation about episiotomy is best had in the office, long before the pushing phase. Ask your doctor how often she cuts an episiotomy. What situations would she recommend an episiotomy? What type of episiotomy does she typically use and why? You both can discuss your comfort levels and come to an agreement ahead of time in the ideal situation. But, sometimes your doctor isn’t there, or you haven’t had a chance to bring it up yet. What happens “in the moment”? The length of the discussion between you and your doctor will likely depend on the urgency of the situation. If there is time, Aask your doctor why she wants to cut an episiotomy and what the alternatives are. Does she have concerns for the baby? Is a tear very likely? What would happen if she didn’t perform an episiotomy? In this discussion, you and your doctor can decide together what the best plan is for you and your baby.

Ok, I’d like to avoid an episiotomy, unless absolutely necessary. What about…{gulp}…tears?

I remember after my first delivery (and tear), my mother was surprised I hadn’t had an episiotomy.  “They let you…tear?” The thought of your nether regions ripping apart is definitely one of the greatest fears of mommas to be. However, having felt all of my deliveries, I will say that the thought of tearing was worse than the actual tear. There was definitely an intense burning sensation, the “ring of fire” you may have heard about (sorry, Johnny Cash). But, quite frankly, it looks worse that it feels. And thankfully, there are a few things that can help prevent severe tearing. Perineal massage, either during pregnancy or during pushing, can decrease the rate of severe tears. It does not, however, reduce all types of tears. Manual support by your doctor may or may not help. Many doctors have their little tricks to reduce tears, but due the variety of methods used, these haven’t been well studied. One thing that does seem to help is warm compresses. Again, this reduces severe tears, but not the overall number of tears. Research on birthing positions and delayed pushing is mixed, and these may or not help.

 

Since the days of Dr. DeLee, episiotomy rates have dropped to about 12%. Which is good considering it was once routine procedure. I suspect the rate will continue to drop as the “routine users” retire.  I honestly don’t know any that use them routinely, and current training emphasizes restricted use. Thankfully, episiotomies are rarely necessary, and “tearing” often sounds worse than it is.

 

Georgia Ragonetti-Zebell, MD is an OB/GYN practicing in Upstate South Carolina, and is mommy to four (yes, FOUR) boys. She is a graduate of the Women’s Health Pathway at Drexel University College of Medicine in Philadelphia, Pennsylvania and completed her residency in Obstetrics and Gynecology with the Greenville Health System in Greenville, South Carolina. She has a special interest in natural childbirth, breastfeeding, and alternative methods in labor and delivery. She enjoys yoga, crochet, and reading, but spends most of her free time cleaning up poop while trying not to step on Legos.


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