cutting out the cutting

Do you really need an episiotomy?

Episiotomies are beginning to look like the Pet Rocks of obstetrics: Nobody really wants one anymore, and fewer and fewer of them are being done. But some experts say that too many of them are still being performed. The procedure, which involves making an incision in the perineum — the area between the vagina and anus — was introduced to American obstetrics in the 1920s to hasten delivery and prevent uncontrolled tears, which were thought to be more difficult to repair and slower to heal. By the 1980s, episiotomies were performed in more than 60 percent of all vaginal births, more during first births. But the following new research puts the routine use of episiotomy during delivery in question:

  • According to a Harvard Medical School study, women who have episiotomies are five times more likely to experience loss of bowel control in the first six months after giving birth than those who do not have episiotomies.
  • The American Journal of Obstetrics and Gynecology reported that episiotomies significantly increase perineal injuries in vacuum-extraction deliveries (in which a suction device helps pull the baby out).
  • Various other recent studies have concluded that episiotomies cause as much or more pain, injuries and complications postpartum than the spontaneous perineal tears they were supposed to eradicate.

“Not only does episiotomy not decrease injury, but it actually increases the number of tears that extend into the rectum,” says Lauren Streicher, M.D., an obstetrician-gynecologist in Chicago who performs episiotomies in only about 20 percent of her deliveries of first babies and rarely in subsequent births. “It’s like tearing a perforated paper: If you put a little more pressure on it, it’s going to keep going,” she says. “Then you have more blood loss, delayed healing and more pain down the road.” Occasionally, such tears result in a hole between the vagina and rectum that must be repaired surgically.

There’s no predicting The fact that episiotomies still are performed in at least 30 percent of vaginal deliveries nationwide troubles some critics. But many doctors say that eliminating the procedure entirely is akin to throwing the baby out with the bath water. “There’s a movement out there that says episiotomy is always bad, but that is absolutely untrue,” says Streicher. “But the opposite — that episiotomy is always better — is equally untrue. What really is most appropriate is selective episiotomy.” (See “When Is Snipping Smart?” below.) Until the baby’s head crowns in labor, neither a woman nor her doctor can predict whether she’ll need an episiotomy. But there is one factor the mother can control: her choice of doctor or midwife. “Make sure that whoever is delivering your baby doesn’t routinely do episiotomies,” Streicher suggests. Ask what percentage of his or her deliveries involve the procedure; the figure should fall at or below the 30 percent national average.

Alternatives to episiotomy Several techniques can make episiotomy unnecessary. “The perineum is perfectly equipped for childbirth,” says Susan Moray, a Portland, Ore., midwife and childbirth educator. Still, she adds, it may need some assistance during labor. As the baby’s head starts pressing on the perineum, placing hot compresses on the area can help the latter stretch. When the head crowns, gently massaging the area with oil can further help. (Prenatal perineal massage remains controversial, as some midwives and doctors believe it can weaken the tissue.) The doctor or midwife also can support the perineum to keep it from ripping and cup the baby’s head to ease the chin out. Some say the biggest payoff of giving birth without an incision may be in the recovery. Any small tears heal quickly, Moray says, adding, “I don’t have women sitting on those donuts.” On the other hand, just as getting an epidural when you’d hoped for natural childbirth isn’t the end of the world, neither is having an unwanted episiotomy. Just focus on your new baby, not on how he or she got here.