Episiotomy: what you need to know

What is an episiotomy?

An episiotomy is a surgical cut made into the perineum(area between the vagina and anus) to enlarge the opening before the birth of the baby’s head. It helps to ease the birth of the baby when the mother is having difficulty getting her baby out.

Although episiotomy is one of the most common surgical procedures carried out on women, the medical value of episiotomy is still open to debate.

History of episiotomy

Episiotomies in Europe

Episiotomies were first developed in Europe in the 18th century. An Irish doctor discussed the advantages of episiotomy in 1742 for women experiencing difficult births. Once local analgesia and suturing material became available, episiotomies became very popular in Europe.

Episiotomies in the United States of America

Episiotomy was introduced to the United States of America in 1851. In the 1920’s Dr Delee was the first person to advocate the practice of routine episiotomy with forceps delivery. Episiotomy then became a widespread practice throughout the world, with some authorities even advocating the use of routine (you get it even if you don’t need it) episiotomy for all first-time mothers. There are some obstetricians who still continue to hold this opinion today.

Recent studies show that episiotomies are often performed unnecessarily

As women become more informed about labour and birth and are more involved in the decisions regarding their care, the necessity for routine episiotomy is being questioned.

Recent studies show that episiotomies are often performed unnecessarily and therefore the indications for doing them are being reviewed. Studies show that routine episiotomy is not required for most births. There is also controversy over whether an episiotomy is preferable to a tear.

When is it necessary?

Many experts agree that the following are valid reasons for giving a woman an episiotomy. If the baby:

• Is in the breech position (bottom first instead of the usual head first position) and is born vaginally,
• Is premature and cannot tolerate prolonged pushing against a perineum,
• Is in distress and needs to be born quickly (an episiotomy can reduce the length of the second stage of labour by 5 to 15 minutes),
• Is very large (this is assessed by scan),
• Needs easing out by forceps (forceps are large curved tongs inserted into the vagina to assist delivery).

When is it not necessary?

Debatable reasons for doing an episiotomy are when the doctor or midwife feels that the perineum (the skin and tissues between the vagina and anus) is likely to tear as the baby’s head is born.

Studies have shown that when a tear occurs, it may be less painful and heal faster than an episiotomy, and not the other way around. Women with tears have also been found to resume sex sooner and with less pain than women who’ve had an episiotomy.

Episiotomies were thought to prevent some degree of relaxation or damage to the pelvic floor

Episiotomies were also thought to prevent some degree of relaxation or damage to the pelvic floor, with a further possible complication of a cystocele (a fistula or opening between the vagina and the urethra – causing incontinence), a rectocele (opening between the vagina and the rectum) and the possible prolapse of the uterus. Recent studies on pelvic floor relaxation show no correlation between poor perineal function and the presence or absence of episiotomy.

Exercise could help strengthen the pelvic floor after childbirth

One British study strongly suggested that exercise, not episiotomy, is the most common factor in restoring a woman’s normal pelvic floor strength after childbirth.

Some think that an episiotomy should only be used to relieve foetal or maternal distress

Numerous studies by Sleep, Roberts and Chalmers (1990) state that “the most common cause of perineal damage is episiotomy and episiotomy should only be used to relieve foetal or maternal distress, or to achieve adequate progress when it is the perineum that is responsible for the lack of progress”.

Ways to reduce the need for an episiotomy

During the birth of a baby, in which the mother is encouraged to ease the baby’s head out slowly, using a position which is aided by gravity, and the perineum is supported, it is possible to minimise tearing or the need for episiotomy and thus preserve the integrity of the pelvic floor.

Easing the baby's head out during the birth

Some doctors and midwives try to prevent the need for an episiotomy by easing the baby’s head out during the birth. Some women have tissues that naturally stretch more easily and are more likely to give birth without a tear or an episiotomy.

Give birth in a more upright position

Avoiding sustained pushing and giving birth on your back by being in a more upright position (for example, being raised on pillows into a semi-reclining position is much better than lying almost flat) allows gravity to help you give birth and helps the opening of the vagina to stretch more evenly.

Massaging the perineum

Massaging the perineum with natural oil (grape seed) for 6 weeks before your due date can improve the pliability of the skin and underlying tissues. This massage also helps women become familiar with their anatomy and accustomed to stretching sensations, which are common during the birth.

A warm, moist pad placed against the perineum

A warm, moist padplaced against the perineum during pushing increases the circulation to this area and provides support and comfort whilst these tissues stretch during birth.

Try avoid pushing using sustained breath holding

Try to avoid pushing using sustained breath holding, rather use gentler expulsive, spontaneous pushing, without excessive straining, to ease the baby down through the birth canal and out. By preventing excessive straining during pushing you can reduce the over stretching of the pelvic floor, as well as push your baby out more effectively.

Go to page 2 for information about how an episiotomy is performed