Top 10 Childbirth Fears (A Series): Episiotomy

Rounding out our series on the top 10 fears about childbirth, we're talking today about number 10: episiotomy. As with each of the fears we've addressed, this too is a hot topic that's always addressed in a good childbirth class. (You can view the whole list and links to the first 9 articles here.)

Let's start with the basics. What is episiotomy? It's a surgical cut in the muscular area of the vaginal opening between the vagina and the anus, also known as the "perineum." The cut is made during birth, often just before baby is born, as a means of enlarging the opening. Prior to 1920, episiotomy -- often referred to as "a little snip" -- was done only in dire emergencies, where baby needed to be born quickly and immediately. It began to come into popularity after 1920, and until 1980, was performed routinely (ie, whether it was "needed" or not) in the United States at nearly every birth. The basis, or underlying belief behind the practice, was that it was better to have a clean cut in order to avoid injury to anal sphincter muscles rather than a natural tear which could result in increased perineal and muscular trauma, leading to significant side effects like fecal incontinence and sexual pain. However, performing episiotomy often resulted more frequently in the dire consequences doctors were trying to avoid, like urinary and fecal incontinence, and painful or problematic sexual intercourse.

In the 1980s and 90s, research surfaced showing that episiotomy was not beneficial as once thought, and in fact, often caused more harm than good. Finally, in 2006, the American Congress of Obstetricians and Gynecologists (ACOG) issued new guidelines telling doctors to restrict the use of episiotomy to only emergent situations. Currently, the rate of episiotomy is less than 12%. However, some doctors and hospitals still use it way more than necessary, despite guidelines and evidence not to.

While episiotomy has fallen out of routine practice, it still should be on your radar as a point of question and investigation with your care provider. Here are some tips to help you avoid episiotomy.

Interview your doctor(s) - This can be done before choosing a doctor for your pregnancy, at your first prenatal appointment, or at any time during your pregnancy. It's almost never too late to switch care providers if you discover information about her practices that alarm you. Ask questions like, "How often do you perform episiotomy?" or "Do you perform routine episiotomies?" or "What reasons would I need an episiotomy?" The only evidence-based reason found for performing an episiotomy is if the baby is experiencing distress (low heart rate) and needs to be born very quickly, or if baby is stuck in the birth canal with something like shoulder distocia. Also ask questions like, "How can you help me prevent tearing during birth; do you use warm compresses or oil during pushing to gently stretch the perineum?" If you are in a practice with several doctors, and will have whoever is on call for your birth, it's important to repeat these questions with each practitioner.

Be aware of interventions that make pushing more difficult - Many interventions can make pushing during birth more difficult, which could lead to baby's distress and a doctor's decision to perform an episiotomy. Interventions like epidural, continuous fetal monitoring, routine IV placement, and movement restrictions all can impact a person's ability to push effectively. That said, the use of interventions often leads back to the importance of choice in caregiver. If a doctor has a high rate of medical intervention use (especially those that are not based in evidence), he or she is more likely to also use or need an episiotomy.

Speak up - If you are in labor, nearing birth, and pushing, and your doctor asks to cut or says he will be performing an episiotomy, ask why (this is also an ideal time for your partner to speak up -- be sure to discuss in advance of your due date and birth). Ask if your baby is ok. If your baby is doing well, an episiotomy should not be warranted. If your doctor still insists, request to try alternative positions or techniques for pushing. If you experience further confrontation from your doctor without a medical emergency, you can ask for a new, on-call doctor. Your wish may not be granted, but it is within your right to request.

Science and medical research is an evolving field. As we learn new things, medical guidelines and practices change accordingly to reflect what's best and most healthy for families. However, it can often take 20 years or more for practices to change or disappear entirely. In the meantime, it's important to arm yourself with current evidence-based information for a safe and healthy birth, and find a doctor or midwife who practices accordingly. Attending a good childbirth class provides the optimal foundation to chart a course in pregnancy, and ultimately birth and postpartum, that will help lead to better outcomes. If you're pregnant and haven't taken a childbirth class or don't have one scheduled, research your classes in your area to find a good one. You'll learn what you need to know about having a safe and healthy birth, all in one place, without having to spend hours online, and wondering if what you're reading is credible. It's an investment of time and money that you won't regret.

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