Episiotomy: CUT IT OUT!

Surgical scissors for episiotomy

The E word can make a grown woman cross her legs and cringe in revulsion. Pregnant women are often terrified of it. And with good reason. We’re talking about episiotomy.

An episiotomy is a surgical cut to the delicate tissues between the vaginal opening and the anus. They are performed during childbirth when more space is needed to safely deliver a baby.

There was a time when obstetricians would perform episiotomies routinely.

After all, babies are big and vaginas seem quite small. The reality, though, is that the tissues that make up the vagina and vaginal opening are normally quite elastic. They are designed by nature to slowly stretch to allow for birth, and then come back to their natural size soon after.

Episiotomy leads to painful recovery from birth and in some cases, may damage the integrity of the pelvic floor muscles. In some instances, more severe tears mat occur if the length of the cut is too small. Some people experience sexual dysfunction after having an episiotomy.

Repairs from episiotomies have a tendency to heal more slowly than the repairs of naturally occurring tears.

None of this is good news for the birthing person.

Since we know all of that, why do people cut the perineum anyway?

Anyone still performing routine episiotomy on their patients was likely taught to do so in medical school. And, some habits are just very hard to break when you have practiced a certain way for your entire career.

But, routine episiotomy is becoming less and less common.

In the US the number of episiotomies performed in 2012 was down to 12% of all vaginal deliveries, though there are hospitals with especially high rates of routine incisions and as well as those with very low rates.

ACOG (American College of Obstetricians and Gynecologists) issued a practice bullet in 2006 encouraging the discontinuation of routine episiotomy.

The Society of Obstetricians and Gynaecologists of Canada (SOGC) is actively trying to reduce the number of episiotomies performed. They created an initiative in 2017 called “Choosing Wisely Canada” whose first recommendation is “Do not use routine episiotomy in spontaneous vaginal births.”

There are some specific situations when episiotomy is called for.

Many assisted deliveries involving forceps or vacuum benefit from this incision to allow for accurate placement of instruments. Some babies experiencing distress may benefit from an episiotomy to speed up delivery. Rarely a perineum may not stretch as expected and need an incision to allow for the birth.

Local anesthesia is almost always used when an episiotomy is performed. If the baby is crowning local anesthesia may not be used. Luckily the stretching tissues mask any further sensation caused by an incision.

So, what’s a doula to do?

When a client expresses worry about this, the doula can encourage their client to talk to their doctor and midwife.

They can ask about episiotomy rates.

The client can also ask their OB or midwife to share what circumstances most often require them to perform an episiotomy.

A doula can also help their client understand the importance of communicating their desires directly to their care provider.

The client who is recovering from an episiotomy can often benefit from some extra postpartum support. Doulas can help their clients rest by providing postpartum and Infant care doula support.

In the end, there is no evidence to support the routine use of episiotomies. With continued refusal by birthing people and pressure from the medical community overall, eventually all providers will “cut out” unnecessary incisions.

Leanne Palmerston, Owner, Hamilton Family Doulas