Delivery is a tight squeeze – it’s a relatively large baby and a relatively narrow exit. Sometimes, the mother’s body can accommodate that squeeze and stretch to fit. Other times, especially if labor is quick, it’s just too much and the body can’t take it. That’s what episiotomies are for.
What Is An Episiotomy?
During delivery, the vaginal opening has to stretch enough to allow the baby’s head through. If it can’t stretch quite enough, the mother runs the risk of a vaginal tear. Typically, that tear runs along the “perineum,” the stretch of skin between the vagina and the anus. Vaginal tearing is painful but also extremely common – as many as half of all women who deliver vaginally will have some amount of tearing. This injury is separated into 4 different levels of severity. The first 2 are the most common:
- first degree tears affect only the skin
- second degree tears affect the skin and muscle
First and second degree tears typically require a few stitches and will take up to a couple of weeks to heal. During that time, you’ll need to keep the wound clean by squirting warm water on it and treat it very gently.
The other 2 types of tears are more serious:
- third degree tears reach the anus
- fourth degree tears affect the muscles of the sphincter
These require more extensive stitching to repair and may result in lasting incontinence and pain. Some studies suggest that these serious tears affect just 3-5% of women, but others have found evidence of sphincter damage in 35-41% of women that experienced vaginal tearing.
So, vaginal tearing is a serious risk and can cause long-term side effects. For many years, the American Congress of Gynecologists and Obstetricians (ACOG) recommended performing episiotomies during vaginal deliveries to help mitigate some of the effects. An episiotomy is a procedure in which the makes an incision in the perineum before it can tear on its own. The thinking was that this clean surgical wound would heal better and faster and be at a lower risk for infection than tears that happened naturally.
The ACOG has changed its recommendations on episiotomies in recent years. While before it was treated as a routine procedure, they now recommend it only in limited cases, such as when the baby’s head is very large or there is a serious reason to speed up the delivery process. They note the risk of “potential adverse consequences associated with the procedure, including extension to a third- or fourth-degree tear, anal sphincter dysfunction, and painful sex.” In addition, they say, “Data suggest that women who have an episiotomy do not have significantly improved labor, delivery, and recovery compared with those who do not have one.”
In other words, episiotomies may not actually help and, in fact, can have very serious side effects.
Some possible episiotomy complications include pain, swelling, and infection of the area. In addition, an episiotomy may actually cause more severe vaginal tearing, increasing the risk that the damage will extend to the sphincter. This severe tearing can cause fecal and urinary incontinence and pain during sex. It can also increase the likelihood of an “obstetric fistula” – a hole or opening between the vaginal and rectal passages. That injury can be extremely painful and also contributes to incontinence and pain during sex. It may also cause nerve damage such that you can’t feel your body’s signals that you need to use the restroom and may require a colostomy.
What Can You Do?
Unfortunately, the risks associated with an episiotomy are generally the same as those posed by a natural vaginal tear, although an episiotomy may increase the risk of a deeper tear than you might otherwise have had. There are some things you can do to avoid tearing or the need for an episiotomy in the first place, including:
- massaging and stretching your perineum with vitamin E during pregnancy
- eating a healthy and balanced diet and exercising regularly during pregnancy (healthier skin stretches more easily)
- doing Kegel exercises to strengthen your pelvic floor muscles
You should also talk to your doctor during your prenatal care visits about whether or not you’re at risk for tearing or an episiotomy and tell your doctor if you want to avoid it. Be sure to include your preferences in your birth plan and make sure your care team is aware of them. Know that sometimes, an episiotomy may be unavoidable – the baby may simply be too large to fit, may be in the wrong position, or may become distressed during labor and the doctor may need to perform the procedure to speed up the process. However, you always have the right to ask your doctor questions and make sure there’s a good reason for doing it.
If you’ve already had an episiotomy, follow your doctor’s after care instructions carefully to avoid infections or further damage. If you notice bleeding, discharge, or severe pain, you should contact your doctor immediately to have the incision checked for infections or other complications.
Other Concerns About Episiotomies
The prevalence of episiotomies and the potential for serious side effects has led to a number of lawsuits over the improper use of the procedure. If your doctor performed an episiotomy that led to more severe tearing, an obstetric fistula, incontinence, pain during intercourse, or other serious health issues, you may be entitled to compensation for your medical expenses and physical and mental pain. If you believe you may have a claim, the Safe Birth Project may be able to help.
Episiotomies are a complicated issue and mothers often have to make a decision in the heat of the moment – during the pain of delivery and under the pressure of deciding what’s best for the baby. The best thing you can do is consider the issue in advance and talk about it with your doctor so that you’re aware of the risks and can make an informed decision.