When you think about childbirth, many worry about the risk of tearing. You may have heard that sometimes your doctor or midwife may need to cut your perineum (the skin and muscles around the entrance of the vagina).
The cut is known as an episiotomy, and whilst rates have decreased in recent years, it is still one of the most commonly performed procedures in obstetrics.
In the UK, over 85% of women who deliver vaginally sustain a tear or cut, many of whom require suturing (1).
Episiotomy is a deliberate incision made in the perineum to help assist vaginal or instrumental delivery. In England, 8.2% of women have an episiotomy during spontaneous vaginal birth. (2)
(Image credit: https://elearning.rcog.org.uk/operative-obstetrics/first-and-second-degree-perineal-tears-and-episiotomy)
In the UK, mediolateral episiotomies are performed, directed at a 60° angle from the midline. This line avoids damaging to the anal sphincter if the tear extends. For every 6° the episiotomy is made away from the midline, there is a 50% reduction in third-degree tear. (3)
The benefits?
Having a deliberate cut in a planned direction compared to an uncontrolled tear has benefits. The cut can be controlled in both size and angle, so the actual trauma to the tissues is less, making it less likely to sustain a significant tear (third and fourth degree) that involve the anal sphincter.
Performing an epsiotomy whilst the baby is crowning can speed up the delivery of the head. A cochrane review found no evidence to support performing episiotomy routinely for every birth. It concluded that instead, episiotomy in certain situations based on clinical judgements is more beneficial (4).
These situations include; where the clinician feels a severe perineal tear will otherwise happen, a prolonged pushing phase, in the event of shoulder dystocia, or to speed up delivery because of concerns over the fetal heart rate.
Risks?
Making this incision can increase risks of blood loss. Women may also experience ongoing perineal pain from the scar tissue as the wound heals. Other rarer risks include that the tear may extend to a third- or fourth-degree tear and cause pain during sex.
Data suggest that women who have an episiotomy do not have a significantly improved delivery and recovery compared with those who do not have one.
For tips on healing from an episiotomy check out this post.
Conclusion
A cochrane review found no evidence to support performing episiotomy routinely for every birth. Episiotomy in certain situations based on clinical judgements is more beneficial(4).
These situations include;
- Where the clinician feels a severe perineal tear will otherwise happen
- A prolonged pushing phase
- Instrumental vaginal birth
- In the event of shoulder dystocia
- To speed up delivery because of concerns over the fetal heart rate.
Remember that it is your body, and whilst your provider may advise an episiotomy you still need to give your consent. Discuss it in advance if you have questions or concerns.
References:
(1) Frohlich J, Kettle C. Perineal care. BMJ Best Practice 2015 [No abstract available].
(2)Health & Social Care Information Centre. NHS Maternity Statistics – England, 2010–2011. HSCIC; 2011.
Royal College of Obstetricians and Gynaecologists. The OASI Care Bundle Project [Accessed 2019].
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000081.pub3/full