What Is an Episiotomy?
When it comes to childbirth, there are a lot of unknowns. To prep for labor and delivery—both physically and mentally—it’s helpful to brush up on some of the procedures that your doctor might recommend during the birth. So if your doctor tosses out the term “episiotomy” after you’ve spent a good while pushing, you know exactly what it means, what’s involved and how to come to an informed decision together with your medical team. Here’s what you need to know.
An episiotomy is a surgical procedure where a small cut is made to the perineum (the area between your vaginal opening and anus) in order to widen the opening of your vagina while you give birth. It can be done to aid baby’s delivery or to help avoid extensive vaginal tearing.
Episiotomies used to be much more common than they are today. “Rates of episiotomy have generally been in decline, especially in the last decade,” says Michael Cackovic, MD, a maternal fetal medicine specialist at The Ohio State University Wexner Medical Center. Data show that 63 percent of all US births in 1979 included an episiotomy—with even higher rates for first-time moms—but rates began to drop in 2006 when the American College of Obstetricians and Gynecologists (ACOG) first recommended against doing episiotomies during routine childbirth, since data fails to show any long-term benefit to Mom (and in fact increases risk of incontinence after birth). An analysis of birth data collected between March 2012 and February 2017 show that the episiotomy rate is now somewhere around 7 percent.
While episiotomies are “not common at all anymore,” they may be performed in “certain clinical situations where more room or space is required” at the perineum, says Shweta Patel, MD, an ob-gyn at the University of Alabama at Birmingham. An episiotomy may also be needed if baby’s heart rate is abnormal, in order to speed up the delivery, Cackovic says.
An episiotomy calls for some form of pain control. Unless you’ve already had an epidural to manage the pain of childbirth, which would double as a pain blocker for an episiotomy, your doctor will likely use local anesthesia on the area to minimize your discomfort, Patel says.
Your perineum is then cleaned and your doctor will make the cut with a surgical instrument, such as scissors, explains Christine Greves, MD, an ob-gyn at the Winnie Palmer Hospital for Women & Babies in Orlando, Florida. The type of incision, and how deep it goes, can vary depending on your doctor and medical need.
There are two different types of episiotomies that doctors can perform:
• Midline episiotomy: A midline episiotomy is done vertically by cutting straight down the perineum toward your anus, explains Julie Levitt, MD, an ob-gyn at the Women’s Group of Northwestern. According to the Mayo Clinic, it’s easier to repair but has a higher risk of extending into the anal area.
• Mediolateral episiotomy: A mediolateral episiotomy is where the incision is made at an angle off to the side, Levitt says, adding that it’s “a little more old-fashioned.” It’s often more painful and harder to repair but is better at preventing an extended tear.
The “degrees” of an episiotomy are used to document the type of cut a woman had during birth, Patel says. “The degree is assigned based on what tissues were lacerated,” she explains. “This helps guide management and possible long-term symptoms and outcomes.”
• 1st degree episiotomy: This cut only goes through the vaginal epithelium (the tissue lining your vagina).
• 2nd degree episiotomy: This episiotomy goes through the muscles in your perineum but leaves your anal sphincter alone.
• 3rd degree episiotomy: “An episiotomy, by definition, invades only the skin and muscle of the perineum,” Cackovic explains. “Occasionally, this may extend into a third or fourth degree laceration.” In this instance, the tear goes through the perineal muscles and external anal sphincter.
• 4th degree episiotomy: This is when the laceration goes through the perineal muscles, external anal sphincter and inner lining of the rectum. “One of the reasons that episiotomy placement is decreasing is to avoid these extensions and the damage they cause,” Cackovic says.
After your episiotomy and the birth of your baby, your doctor will give you stitches to help repair the cut. The stitches typically dissolve on their own. As you heal, you may experience symptoms such as pain, itching and burning when you urinate, Greves says.
To care for your episiotomy stitches and scar, Patel recommends using a perineal rinse bottle when you pee, patting the area dry (instead of wiping) and keeping the spot clean and dry. “No special soaps or scrubbing necessary,” she says. If you’re uncomfortable, place an ice pack on the area or use an anesthetic spray to try to ease the pain.
How long does it take for an episiotomy to heal?
Everyone is different, but Patel says the episiotomy healing process generally takes about four to six weeks in total. “Women will start to feel better around two weeks,” she says.
Signs of an episiotomy infection
Episiotomy infection is a risk, but thankfully it’s rare, according to Cackovic. If you do happen to develop an infection after the procedure, he says, you may develop the following symptoms:
- Foul smelling discharge
- Increased pain
- Redness in the area
If you suspect you have an infection, call your doctor to have them evaluate.
There’s a big debate about this, Levitt says. With a tear, the “edges can be very jagged, versus cutting, where you have a clean surgical wound—that’s very easy to put back together,” she says.
Cackovic agrees. “Simply speaking, an episiotomy is surgical and easier to repair because it’s a surgical incision, while a laceration is less painful to heal as it occurs at the natural point of less resistance on the perineum,” he says.
But episiotomies are not without risk. According to the Mayo Clinic, sometimes the surgical incision is more extensive than a natural tear would have been; it puts you at risk of third- and fourth-degree tears, which are severe and can potentially lead to fecal incontinence. “Risk of 3rd and 4th degree laceration—without significant added benefit—is the reason episiotomy has fallen out of favor,” Patel says.
Recovery is uncomfortable and infection is possible. Some women who have had episiotomies experience pain during sex in the months postpartum. Also, Cackovic says, having an episiotomy as a first-time mom puts you at increased risk of a severe vaginal tear during subsequent births.
The ACOG recommends against routine episiotomies, given that doctors can use other tactics to prevent severe vaginal tearing, and encourages doctors to do them “only when it is absolutely necessary.” But sometimes an episiotomy really is called for. It takes time for baby’s head to stretch the vaginal tissues and make way for the birth, and there are times when baby needs to be delivered before that stretching can happen on its own.
Patel recommends talking to your doctor during your pregnancy about how often they perform episiotomies and under what circumstances. “Women can make their wishes and thoughts of episiotomy known with their OB to allow for a shared decision-making,” she says.
But Levitt says there’s only so much you can do to prevent an episiotomy in certain circumstances, given that the size of your baby and how baby reacts to delivery are factors in an episiotomy. A perineal massage—where you gently stretch your perineal tissues to prepare for birth—may help, although study results are mixed on whether this actually reduces the chance of an episiotomy. “You can decide with your physician if you want to do perineal massage," Levitt says. “It may or may not work to your benefit.”
Using a heating pack on your perineum before you start pushing may also lower your risk of needing an episiotomy, Levitt says.
Ultimately, it’s best to go into delivery with an open mind. “As a doctor, we don’t even know if you’re going to have to do an episiotomy,” Greves says. “Our goal is a healthy baby and a healthy mom.”
About the experts:
Michael Cackovic, MD, is an ob-gyn specializing in maternal fetal medicine at the Ohio State University Wexner Medical Center in Columbus. He earned his medical degree from Hahnemann University College of Medicine in 1997.
Shweta Patel, MD, is an ob-gyn at the University of Alabama at Birmingham, where she earned her medical degree in 2015.
Christine Greves, MD, FACOG, is an ob-gyn at the Orlando Health Winnie Palmer Hospital for Women & Babies in Orlando, Florida. She received her medical degree from the University of South Florida College of Medicine.
Julie Levitt, MD, is an ob-gyn at The Women’s Group of Northwestern, in Chicago. She earned her medical degree from Northwestern University Feinberg School of Medicine in 1994, where she now serves as a clinical instructor.
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