Is Episiotomy or Tearing During Labor Worse?

When expecting parents make a birth plan, one of the most popular items is no episiotomy under any circumstances. An episiotomy is an incision in the perineum (the skin, tissue, and muscle between your vaginal opening and anus) to enlarge the vaginal opening in order to speed along delivery when waiting longer is risky for the parent and baby.

Episiotomies have gotten a bad rap because historically, they were often done when not strictly necessary, and often without informed consent from the parent. But how should we think about episiotomies in modern times?

Episiotomy Is Often Over-Used

People have good reasons behind their desire to avoid episiotomy: A May 2019 analysis from USA Today of hospitals across eight states found that some hospitals are doing episiotomies more often than necessary, causing unnecessary harms.

According to the report, national guidelines from 2006 state that only emergencies, like a baby with shoulders that are stuck behind the pubic bone. Episiotomies are done so the doctor's hands can fit into the vagina to do the maneuvers to release the shoulders from behind the bone. If these guidelines are followed, episiotomies should occur pretty infrequently.

However, USA Today spent four years analyzing nearly 240,000 people who had recently given birth and found episiotomies occurred at rates of 20% or higher in dozens of hospitals. The authors found that the highest rates included large metropolitan hospitals, mid-sized hospitals in suburban areas, and small facilities in rural communities.

What causes the high number of episiotomies? According to USA Today, outdated medical practices and a desire for speedy births are the culprits.

Pros and Cons of Episiotomy

Episiotomies, when done right, can feel similar to a natural tear. According to USA Today, unnecessary episiotomies can lead to severe health consequences, including:

• Deep lacerations into the anal sphincter
• Infections
• Psychological consequences
• The need for surgical repair of the area

So, when overused, episiotomies have a lot of downsides, which is why the American College of Obstetricians and Gynecologists (ACOG) recommends against routine episiotomy.

But they're not always entirely unwarranted. Sometimes episiotomies are necessary, like in a medical emergency such as fetal distress or to prevent a large tear. An episiotomy can save precious time or prevent more significant damage in these cases.

Tearing Is Common

According to ACOG, lacerations occur 53% to 79% of the time during childbirth. Most do not result in bad functional outcomes. However, using perineal massage and a warm compress during birth can reduce the likelihood of tearing.

First- and second-degree tears

Tearing is graded as first- through fourth-degree. This grading is applied whether your laceration occurs as a result of natural tearing or from an episiotomy.

First-degree is a tearing of the surface layer of vagina only. Second-degree lacerations involve the underlying muscular perineal tissue.

Both first- and second-degree tears are pretty easy to stitch up, and you'll be good as new within a month or so. Most perineal tears fall into these categories.

Third- and fourth-degree tears

A third-degree tear involves the anal sphincter; a fourth-degree involves the anal sphincter and rectal mucosal tissue. Third- and fourth-degree tears are bad news and require a lot of skill and needlework to repair. These severe lacerations are called obstetric anal sphincter injuries (OASIS). They can result in fecal incontinence and are more prone to poor wound healing.

Which Is Worse: Episiotomy or Tearing?

Natural tearing is generally preferred unless complications indicate an episiotomy is medically warranted. With proper perineal support and care during labor, the degree of natural tearing can be minimized, not even requiring repair. In addition, tears are most often minor, sometimes not even requiring repair. So, you may have an easier time with recovery if you have a tear than an episiotomy.

Whether you have an episiotomy or a tear, a health care provider will numb the area with a local anesthetic and stitch it closed if you require a repair. They often use dissolvable stitches, so you don't have to remove them. During your postpartum checkups, a health care provider will examine the area to ensure the laceration is healing correctly and that there are no signs of infection.