Episiotomy: What Is It and Why Is It Done?

An episiotomy is a surgical incision into the perineal tissue during the second stage of delivery. It was originally developed by doctors to “prevent perineal trauma, improve pelvic floor functioning, enhance sexual functioning, and prevent the pelvic floor from relaxation” ¹. Williams Obstetrics (the text by which all OB’s learn) states the purported benefits for episiotomy: “It substitutes a straight, neat surgical incision for a ragged laceration that otherwise frequently results and is easier to repair and heals better than a tear” ². Lacerations (whether a spontaneous tear, an episiotomy or an extension of an episiotomy) are categorized in degrees: first degree is skin only, second degree is skin and muscle (fascia), third degree goes from skin and fascia into the external rectal sphincter (partial) and fourth degree goes completely through the rectal sphincter and into the rectal mucosa. But women have been voicing that episiotomies aren’t giving them the benefits cited above and are reporting more than the purported risks of episiotomies: excessive blood loss, hematoma formation (localized collection of blood) and potentially fatal infections ². In addition, women are often not given a choice as to whether or not it’s performed on them.

Women Report

“No one asked (about cutting an epis) - but then, no one did in those days (’76). It was a routine part of the delivery, and I had no other expectation. Pain level afterward was probably typical - unpleasant, but not unmanageable. I used Dermoplast spray and warm water irrigation during urination. And a pillow to sit on. I did have a difficulty recovering though. Intercourse caused an irritation at the fourchette. At a later checkup, I mentioned this to the doctor, and he said a healed flap of skin was being stretched and irritated. That matched my perception; it felt like a small rupture each time. He numbed the area and did a tiny incision which was then allowed to heal open. However, there has continued to be minor pain at that spot on a somewhat regular basis ever since - now 23 years.”

*Kathy, Childbirth educator from California

“I have had two children and two episiotomies. In neither birth was there an emergency to get the baby out quickly. I think that my FP just did them with every birth. With my first I pushed for 1 hour and 15 minutes. He cut an epi just so that I would not tear (his words) and probably because I was pretty drugged up with an epidural and nubain and had a hard time staying awake between ctx. I know I was exhausted. I was induced 14 days post dates with pitocin. My son was only 7 pounds 10 ounces. My stitches were not sewn right if you ask me. My doc let the Intern do the stitch work. I felt sewed too tight. The stitches were uncomfortable always feeling like they were pulling apart. The knot in the cord was too big and took a very long time to dissolve causing a little infection at the site. Sex was painful and I could not bear to wear a tampon. My second was born 12 days early. I had SROM at 11pm and delivered at 5:52am. While pushing the intern turned to the doc and said, “she’s going to tear”, he (same doc with first baby) picked up the scissors and cut. He did not tell me, or ask me. That bothers me still to this day. I pushed for 7 minutes with that baby; I have the whole thing on video. This time I was stitched up properly. No long term problems afterwards. I am currently expecting our third baby. I have chosen to deliver at a Birth Center with CNM’s. I have been putting vitamin E oil on my episiotomy scars and plan to do perineal massage. The CNM’s use olive oil during crowning and delivery. I intend to use a birth chair or birth stool to deliver and to avoid a tear or episiotomy. BTW, with the first two children I was in a traditional hospital birthing bed, semi-lithotomy and in stirrups for the delivery.”

*Jodie M, Doula, Indianapolis, IN

A Brief History

Several major studies have been done on episiotomies. In 1983, Banta and Thacker presented their hallmark review of the literature; they found no evidence that episiotomies yielded the benefits cited by Williams Obstetrics. They concluded that “the widespread use of episiotomy does not withstand scientific scrutiny” ² and that “little research has been done to test for benefit of the procedure, and no published study can be considered adequate in its design and execution to determine whether hypothesized benefits do in fact result.” ⁶. As a result, the procedure came under scrutiny. In 1987, Nancy Fleming, CNM, Ph.D. studied perineal outcomes for her doctoral dissertation at the University of Illinois. She concluded from her study that “the naturally occurring laceration appears to be at least as good as an episiotomy statistically, and better than one clinically when compared in the areas of sexual function, perineal pain, time of healing and change in perineal muscle function ” ². She found at least 12 studies documenting a higher risk of severe laceration (an extension) after an episiotomy than with spontaneous lacerations. As a result, she, like many other midwives, performs only “medically indicated” episiotomies those needed to respond to declining fetal status or a prolonged second stage where the perineum resists the emergence of the baby’s head.

Other Health Care Provider’s Views

Some other midwives and health care practitioners responded to an Internet list query about episiotomies:

“My partner and I have only done 2 episiotomies on our homebirth clients. I have never seen a 4th degree tear and only a few 3rd degrees. We attend first-time moms and plenty of huge babies. I don’t believe in cutting normal, healthy moms with normal healthy babies. If a mother has something wrong with her perineum, such as an old repair that was sewn too extensively, or if a baby is in distress and needs to get out NOW, then I would see epis as medically necessary. “

*Reita, Midwife, North Carolina

“The public hospital I work at has the lowest episiotomy rate in our state - around 6%. (Our forceps rate is about 8% and our epidural rate is also about 8%). We do 2,500 births a year - which is the 5th largest unit in the state. We have 3 obs, 10 GPS doing deliveries, plus several midwifery programs. We don’t have an excessive rate of bad 2 or 3 degree tears. In fact often the nasty ones are the tears extended from the episiotomies. I see all the women who have bad tears and all epis - for perineal care advice (keeping in mind our primips stay in 4-5 days and our multips for 2-3 days). Those who I see that continue to be in considerable pain we arrange for home visits to be done by a Women’s Health physio (and any other service required) - for up to 6 weeks - this is all free. Often they only need a few extra days of treatment and they’re good. Apart from ice for the perineum, we also use ultrasound (therapeutic, not diagnostic) and some of the women report an immediate improvement. From my hospital situation I’d stick with the “don’t cut it” philosophy. By the way, (we) have some doctors who are very good at doing vac extract and forceps without needing to do an epis.”
*Allison Hilbig, Physiotherapist, Australia

” Personally, I only cut an epis for severe fetal distress. I might cut one for a rigid perineum if there was obviously no other way the baby would come out, but I haven’t seen it yet in my practice.”

*Alicia, Midwife in Oregon

Medical Facts

In 1990, Shiono, Klenbanff and Carey concluded from their study of more than 24,000 childbearing women that women who had midline episiotomies were more than 50 times likely to suffer severe lacerations (extensions) than women who did not undergo episiotomy ⁶. In 1995 Dr. Michael Klein and others performed a randomized controlled trial of episiotomy to examine whether physicians’ beliefs concerning episiotomy are related to their use of procedures and the associated outcomes. They found that women who are attended by physicians who viewed episiotomy very unfavorably were more likely than women attended by the other physicians to have an intact perineum, experience less perineal trauma and be more satisfied with their birth experience ⁴.

Always Ask For the Statistics

One local doula reported:

“My friend, Sondra (the one that just found out she was pregnant) asked her OB/GYN what his episiotomy rate was. I explained to her it would be a good indication of what kind of care he provided for his patients, etc. They told her his episiotomy rate is 99%!!!!!!!!!!! I thought I was going to fall of my chair. Especially because I took her to this appointment and I was sitting right there when they told her that and then went into all the really lame reasons why his rates are so high. It took all I had to keep my mouth shut. But I talked to her about it after we left (of-course).” *Marni, Doula in California

“I wish all our hospitals shared the epis stats (those of her hospital, reported above) but alas that is not the case. One of our big hospitals has a rate more round 30% (although some of the midwives estimate it may be more like 50% for primips). Certainly the stats over here are that private patients have higher intervention levels than public patients. It shows you need to choose carefully. The difference with our hospital is that it is largely a midwife-run unit. We don’t have an obstetric professor calling the shots. Women come in under their own doctor (mostly GPs) with most of the labour managed by the hospital midwives. Our women can birth anyway they like. <snip> As for perineal prep - massage etc. … The literature seems to be inconclusive about its benefits and we (the physiotherapist assoc.) have now taken the stand of NOT recommending it because some women were getting so zealous with their massage that they were arriving in labour already with tears from their massage! Some were over-stretching their bodies. What women really need is to understand their bodies and what sensations feel like in that “don’t talk about region”. I know some private midwives are doing internals on their women to orient them to their bodies. Perhaps couples should be encouraged to be a little more exploratory - gentle touching within the vagina and moving out against the vaginal walls, placing fingers back against the anal region with some slight pressure - perhaps even using a book to help identify what is what in the body (this is all what these midwives are doing in educating their clients.) Perhaps a little controversial - I don’t know. If massage is done it should really only be done gently and to help the woman relax while feeling pressure and touching in her vagina. I wonder what the difference is between women doing it themselves and those whose husbands do it for them.”

*Allison Hilbig, Physiotherapist, Australia

How Educators and Doulas Can Help

So, what can a woman do? How can doulas help their clients avoid unnecessary perineal trauma?

A critical review of the literature by Paula Flynn, MD, CCFP, et al, studied more than 80 papers and 16 in detail and identified five factors that affect perineal integrity: episiotomy, third-trimester perineal massage, mother’s position in second-stage labor, method of pushing, and administration of epidural anesthesia. They concluded that “only limiting episiotomy can be strongly recommended. In the absence of strong data to the contrary, women should be encouraged to engage in perineal massage if they wish and to adopt the birth positions of their choice. Caretakers should be aware of the possibility of interfering with placental function when women hold their breath for a long time when pushing” ⁵. Doulas can therefore help by informing women of the studies on episiotomies so that they might go to their caregivers armed to respond to those who ‘are favorable’ to episiotomies (as the practitioner cited above).

Secondly, the doula can instruct the woman on proper perineal preparation. Avery and Burket found a marked increase in intact perineum’s and first degree tears and a marked decrease in episiotomies and lacerations requiring repair in women who had practiced perineal massage compared with those who had not. Perineal massage should be limited to regular stretching of the perineum by women or their partners for several minutes daily during the third trimester in hopes of increasing the flexibility of the perineal muscles and surrounding tissue ⁵.

Thirdly, the doula can assist with upright positions during second stage. Flynn, et al, found that supported upright positions decrease the length of second-stage, decrease the number of instrumental deliveries and allow more women to maintain intact perineums. ⁵ Also important is frequent position changes (at a minimum interval of 10 to 15 minutes) to prevent perineal edema and potential excess blood loss. ⁷ At present they recommend avoidance of rigid birth chairs, stools or similar devices until further studies can be done ⁵.

Fourthly, pelvic floor integrity seems to have more to do with do with exercise and genetic factors. Exercises as described by Dr. Arnold Kegel seem to do more to prevent the pelvic floor relaxation leading to incontinence, backache and a feeling of heaviness ². Penny Simkin, co-editor of ‘Episiotomy and Second Stage Labor’, believes that pelvic floor relaxation may be more related to bearing down efforts (during second stage) that involve prolonged breath-holding and maximal straining (so called ‘purple pushing’) than to the use or non-use of episiotomy. She and others, including Flynn and Klein, recommend spontaneous bearing-down efforts in conjunction with the natural ‘urges to push’ that occur several times during each contraction. ^2,5. Simkin stated, ” Maternal positioning for comfort, progress, and avoidance of stress on the perineum also protects the fetus from the secondary effects of supine hypotension and reduces the need for forceps. In the same manner, spontaneous (short and intermittent) maternal bearing-down efforts alternated with breathing will stretch perineal tissues more gradually than prolonged breath-holding and straining, and thus allows for fetal oxygenation.” ⁵ Doulas, therefore, can educate women prenatally helping them understand how their body works and, later, assist with bearing down efforts during second stage. Anesthesia, while cited as a factor, was not identified as within the scope of these studies.

In Conclusion

While modern studies show that routine use of episiotomies, supine positions, and second stage management have an impact on perineal outcomes, their use is still omnipresent. Avoiding episiotomy is not just a selfish desire on the part of an expectant woman. Well armed with the truths of modern studies and the knowledge of the real indications for use, we can help avoid the consequences that routine use of episiotomies brings forth.

*All quotes used by express permission to the author alone and may not be reproduced.

References

1) Klein, Michael C., Episiotomy: A Window on All of Maternity Care. 1997 DONA Conference Manual, June 20, 1997.

2) Campen, Jean Marie, Routine Episiotomy: Medical Dogma versus Medical Wisdom. Childbirth Instructor, Vol. 1, No. 1, Winter 1991, pps. 529-33.

3) Klein, Michael C., Gauthier, Robert J., Robbins, James M., Kaczorowski, Janusz, Jorgensen, Sally H., Franco, Eliane D., Johnson, Barbara, Waghorn, Kathy, Gelfand, Morrie M., Guralnick, Melvin S., Luskey, Gary W., and Joshi, Arvind K. Relationship of Episiotomy to Perineal Trauma and Morbidity, sexual dysfunction, and Pelvic Floor Relaxation. American Journal of Obstetrics and Gynecology, Sept. 1994, pps.38-45.

4) Klein, MC., Kaczorowski, J, Robbins, JM., Gauthier, R, Jorgensen, SH, and Joshi, AK. Physicians’ Beliefs and Behaviour during a Randomized Controlled Trial of Episiotomy: Consequences for Women in Their Care. Journal of the Canadian Medical Assoc., Vol. 153, No. 6, Sept. 15, 1995. pps. 46-56.

5) Flynn, Paula, Franiek, Janet, Janssen, Patricia, Hannah, Walter J., and Klein, Michael C. How Can Second-stage Management Prevent Perineal Trauma? The Canadian Family Physician, Jan. 1997, Vol 43, pps. 57-68.

6) Shiono P., Klebanff M., Carey J. Midline Episiotomies: More Harm Than Good? OB-GYN 1990; 75: 765-70.

7) Shermer, RH, Raines, DA, Positioning During the Second Stage of Labor: Moving Back to Basics. JOGNN: 26: 6, Nov/Dec. 1997; pps. 727-734.

Additional Reading

1) Cunningham, FG., Macdonald, PC., Grant, NF. Williams Obstetrics. 18^th Ed. Norwalk, CT.: Appleton and Lange. 1989:252, 315, 323-5, 727.

2) Kitzinger S, Simkin, P. (eds.). Episiotomy and the Second Stage of Labor. Seattle; Pennypress, 1984:61.

3) Petersen, L, Besuner, P. Pushing Techniques During Labor: Issues and Controversies. JOGNN, 26:6; Nov/Dec. 1997; pps. 719-726.

4) Sleep, J., Grant, A., Garcia, J., Elbourne, D., Spencer, J., Chalmers, I. West Berkshire Perineal Management Trial. BMJ, 1984:289; 587-90.

5) Sleep, J., Grant, A. West Berkshire Perineal Management Trial: Three year Follow-up. BMJ 1987: 295;749-51.

6) Thacker, SB., Banta, HD. Benefits and Risks of Episiotomy: an Interpretive Review of the English Language Literature, 1860-1980. Obstet Gynecol Surv. 1983:38; 322-38.

© 1999 Cheryl Adams. Reproduction restricted to permission by author.