What is Episiotomy?

An episiotomy is a surgical to the perineum made during childbirth. The perineum is the area between the vaginal opening and the anal sphincter. In my Gentlebirth workshops, we discuss worries that expectant mums may have about the birth. Having an episiotomy is almost always close to the top of the list.

 

Why Might It Be Suggested?

There are several reasons your doctor or midwife might suggest an episiotomy in the second (pushing) stage of labour. Researchers have been looking into why healthcare providers might suggest it.

Here are the some of the more common reasons that they found:

  • Foetal distress

  • In the event of an instrumental (forceps or vacuum) birth

  • Protect the perineal tissues (reduce tearing)

  • Reduce the risk of prolapse

  • Prevent urinary incontinence

  • If the baby is large/shoulder dystocia

So are any of the reasons given above are actually evidence-based? Well, the World Health Organisation states that episiotomy is only justified in about 10% of births or less. How does that compare to the stats here in Ireland? Well, based on the latest available figures there is a significant chance that you may have an episiotomy that’s simply not necessary. And the chances are even higher if you’re a first time mum. The rates for first time mothers vary from about 6% (in a midwife-led unit) to 44%. You can check out the figures here.

 

What Does the Evidence Tell Us?

How do I know if I REALLY need an episiotomy? There are a few situations in which it may helpful and clinically necesssary. These indications may include:

  • Foetal distress

  • Maternal (mother) distress

  • Forceps birth

Interestingly, one or two studies have been published or are in progress in recent years that investigate the results of a policy of never performing episiotomy. One of these studies, which included 400 women, found that it was possible “to reach a zero rate of episiotomy with a high frequency of intact perineum”. The authors also found “reduced need for suturing, and no adverse outcomes such as severe perineal lacerations”. This is interesting considering that 18 women had a forceps and 6 had a vacuum birth. Importantly, in this study, 85% of women birthed in upright positions. This study raises the question of whether episiotomy would be necessary at all, if we intervened less in the birth process.

So Does Episiotomy Really Protect the Pelvic Floor and Bladder?

The research says no. In fact, if we look at the majority of studies they found that having an episiotomy:

  • Increases your risk of a 3rd or 4th degree tear

  • Is associated with more perineal pain

  • Is more likely to result in dyspareunia (pain during sexual intercourse)

  • Doesn’t protect against bladder or bowel incontinence or pelvic organ prolapse

  • Is associated with significantly lower pelvic floor muscle strength at a year postpartum

  • Possibly increases blood loss after the birth

  • Causes the wound to heal more slowly and not as well

  • Increases the likelihood of wound infection

In conclusion, should we say Yes or No? Well, it’s really up to parents to decide what’s right for them and their family. However, you may feel strongly that you’d prefer to avoid episiotomy. If this is the case, there’s lots you can do to increase your chances of birthing your baby with an intact perineum. I’m going to follow up this article with another, on how you can reduce your chance of having an episiotomy or perineal tear. So keep an eye out!

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