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Episiotomy Is Not a Routine Procedure: Here's When Your Doctor Is Likely to Perform It
  • Being pregnant is full of excitement and fear — it’s exciting to meet your baby, but you’re a little scared about giving birth, especially if it’s your first time. Often, moms who have been through childbirth warn preggos about the pain and the procedures that come with it, including episiotomy, one of the many labor interventions doctors perform.

    An episiotomy, also known as perineotomy, is a procedure where the doctor makes a clean cut to the pregnant woman’s perineum (the area between the vagina and the anus) and the muscles beneath it to let the baby pass through quickly. The cut is stitched closed after the baby has been delivered. It is also sometimes referred to as “stitches down there” after a vaginal delivery.

    Do all women need an episiotomy?

    In the past, obstetrician-gynecologists performed episiotomies as a routine part of vaginal births. But the World Health Organization (WHO) in 1996 and the American College of Obstetrics and Gynecology (ACOG) in 2006 have discouraged routine episiotomies, and both institutions advise doctors to lower the number of instances they need to perform the procedure.

    According to a May 2019 report by USA Today, however, many hospitals and doctors still perform episiotomies at high instances in the United States. In four years from 2014 to 2017, nearly 240,000 women in 553 U.S. hospitals had episiotomies. That’s a 20 to 30 percent rate, which is more than double the maximum 10% (one in 10 women) set by the WHO.

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    When an episiotomy is prescribed by doctors

    Not all women who give birth vaginally need an episiotomy, though some may benefit from having it done. It’s a case-to-case basis made by doctors, and it is often done when the baby’s heart rate shows signs of slowing. A decrease in heart rate may mean the baby is not getting enough oxygen, so the doctor will want him to be delivered immediately, and that’s when he may do an episiotomy. Other reasons doctors may do an episiotomy are:

    Your baby’s shoulders are stuck behind your pelvis

    Shoulder dystocia, or when the’ baby’s shoulders get “stuck” in the’ mother’s pelvic bones, often leads to slower, more prolonged birth with high risk for developing complications. Doctors will asses the situation since a larger vaginal opening may not address shoulder dystocia entirely. The situation may instead require a C-section.

    “When it comes to shoulder dystocias, the problem is not happening in the vagina — the shoulders are ‘stuck’ behind the pelvic bones,” writes Diana Spalding, a midwife, pediatric nurse, and founder of Gathered Birth, on Mother.ly.

    Your baby has an erratic heart rate pattern during your delivery

    Doctors also previously thought that episiotomies help speed up delivery by decreasing the pressure on the baby’s head as he passes through the birth canal. Studies have shown, however, a baby’s health remains the same with or without it. Having an abnormal heart rate from the beginning is a sign of a possible complication, so it may be best to deliver the baby urgently.

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    You need an operative vaginal delivery

    Your doctor may opt to use tools, such as forceps or vacuum, to deliver your baby. Usually, this is done when the mom and baby needs a little “push” to deliver the baby via vaginal delivery, instead of performing a C-section.

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    Risks of having an episiotomy

    All pregnancies have risks, and your doctor will discuss with their patients beforehand the possible complications that may arise and the medical interventions that could help. During birth, doctors should perhaps make the decision on these interventions, like an episiotomy, with the mother as she’s going to have the deal with the possible consequences.

    The cut does not heal better or faster than a natural vaginal tear

    Doctors previously believed that a clean cut in the perineum area would heal better than a natural tear and preserve the muscular and connective tissue support of the pelvic floor. Studies show the opposite.

    “There’s no evidence for what were believed to be benefits: less pain, faster healing, and sexual functioning,” says Katherine Hartmann, M.D., assistant professor of obstetrics and gynecology at the University of North Carolina, lead author of a review of 986 related studies on episiotomies published on the Journal of the American Medical Association (JAMA).

    Episiotomies actually take a longer time to heal than natural vaginal tears. Without routine episiotomy, severe perineal injury and trauma are reduced by 30 percent. It also weakens the woman’s pelvic floor muscles, which contribute to long-term issues.

    You may have a more significant cut that may need surgery


    Both episiotomies and tearing are graded as first through the fourth degree. The first degree is limited to the skin, while a second degree involves the underlying perineal or vaginal tissue. Both are easy to stitch up and close and will heal in a month or so. Some studies had linked episiotomies with increased blood loss and infection.

    There are cases where an episiotomy cut ends up more significant than required. That’s usually a cut through the third degree which involves the rectal sphincter or the fourth degree, which has to deal with the rectal mucosal tissue. These types of tears or episiotomies are tedious to stitch up and may need surgery to repair.

    Episiotomy may lead to incontinence

    Episiotomy does not just cause urinary incontinence but also fecal incontinence. In both situations, your muscle control becomes weak when you pee and poo). “Women can develop sphincter incompetence and begin leaking stool,” Dr. Amy Rosenman, obstetrician-gynecologist and expert in female pelvic medicine from the David Geffen School of Medicine at University of California, Los Angeles (UCLA), told The Huffington Post. “And unfortunately, there is no good solution for that. It is a life-long issue,” she stressed.

    You may start feeling pain during sex

    Recovering from an episiotomy can be uncomfortable. The stitches used to close the cut are usually absorbed on their own, but your doctor may prescribe you oral pain medication to manage the pain as your incision wound down there heals. A warm compress may also help.


    Your doctor may even give you a stool softener to make emptying your bowels more manageable. In cases wherein the episiotomy cut ends up more extensive than required, is infection is also as risk, and for some women, it can also cause painful sex even months after childbirth.

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    How you can lower your risk of having an episiotomy

    Part of the miracle of childbirth is the dilation of the woman’s cervix that can go up to 10 centimeters to accommodate a typical newborn’s head circumference. But babies get still stuck during labor. You can lower your risk for having an episiotomy and even a natural vaginal tear altogether by doing the following when it's near your due date and during birth:

    Practice Kegel exercises

    Kegel exercises strengthen and stretch your pelvic floor muscles. It can help you push during delivery and strengthen your pelvic and vaginal muscles after labor.

    Just hold the muscles tight and then release. Try stopping in the middle of peeing or passing gas, hold it for a few seconds, and then release it after 10 seconds. Squeeze and hold the same vaginal muscles for 10 seconds and then slowly release. Relax for five seconds and then repeat. Start with five 10-second holds a day and work your way up to 20 to 30 repeats in a day.

    Have a perineal massage

    The massage will help stretch the skin on your perineum, which may help prevent vaginal tearing and avoid an episiotomy. Here’s how to do a perineal massage, according to the American Pregnancy Association:

    1. Make sure you (or your partner’s) hands are clean. Get into a position wherein you can comfortably reach your perineum, such as sitting on the bed with your legs spread and your knees bent or squatting against a wall for support with one leg propped on a stool.
    2. With the help of a specially designed lubricant for perineal massages (avoid water-soluble lubricants and natural oils), put your thumbs inside your vagina and then press down toward your rectum.
    3. Slide your thumbs across the bottom and sides of your perineum, pulling gently outward and forward on the lower part of the vagina with your thumbs hooked inside. Repeat several times.

    Choose your labor positions

    As your cervix dilates and your baby descends from your uterus, labor positions such as squatting may help seep up that process, as opposed to just lying on your back. Try not to hold your breath and only push when you feel the urge.

    Discuss episiotomy with your doctor

    Other women may need labor interventions such as an episiotomy to help save lives and ensure the health of both the new mom and her newborn. Talk to your doctor about it when you discuss your birth plan, and make sure you are both on the same page about childbirth and postpartum care.

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