You’re going to cut me…where? It may not be in your birth plan, yet circumstances could prompt your practitioner to suggest an episiotomy during labor.

As a natural mama who wants a gentle and natural birth, what do you do?

What is an episiotomy?

An episiotomy is a surgical incision used to enlarge the vaginal opening to help deliver a baby. Invented in the late 1700’s, episiotomies became routine in hospital births by the 1920’s and 1930’s. Since the majority of first-time moms will tear naturally during birth, the idea was that episiotomies could help the process along, make the tear “neater,” and also potentially make a woman’s perineum, after repairing with stitches, even better (and tighter) after birth.

What is an episiotomy diagram medio lateral episiotomy Mama Natural

Medio-lateral episiotomy illustration by Jeremy Kemp.

The problem with episiotomies

It wasn’t until the 1980’s that medical professionals started looking at the evidence and realized that, in nearly all cases, episiotomies did not improve fetal or maternal health or outcomes. In fact, they found some pretty nasty side effects to this routine procedure.

Clinical trials conducted in the ‘80s and ‘90s found that episiotomy cuts can, in fact, turn into even deeper lacerations during delivery, damaging the area around the rectum… [leading to issues] such as painful sex and possible incontinence. (Source.)

Other women had reported feeling violated, ashamed, damaged, and less confident after having an episiotomy. Finally, in 2006, the American Congress of Obstetricians and Gynecologists came out with a statement discouraging the routine use of episiotomies and recommended “restricted use” and only when medically necessary. (Source.)

Fact is, receiving an episiotomy won’t prevent further tearing, and can even cause more tearing. 

What are the potential side effects of an episiotomy?

When it comes to any surgical procedure (even a minor one), it’s best to be aware of the risks. Side effects of episiotomy may include:

  • Bleeding
  • Bruising
  • Extended healing time
  • Incontinence
  • Infection
  • Painful scarring
  • Sexual dysfunction
  • Swelling
  • Feelings of sadness, low self-esteem, shame, etc.

Women report that recovery from an episiotomy is both longer and more painful than a natural tear. Additionally, a study by the University of Michigan found that women who had episiotomies reported decreased sexual satisfaction and a poor body image following the procedure.

How common is the episiotomy today?

Birthing experts say that episiotomies are medically necessary in fewer than 10 percent of births. It’s common for midwife offices to have episiotomy rates of 3% or less.

Yet in the U.S., approximately 20 percent of birthing women undergo an episiotomy. 

Still, this represents a vast improvement from where we were 40 years ago…

“As recently as the late 1970s, episiotomy was used in more than 60 percent of vaginal deliveries across the U.S., because doctors believed a clean incision helped prevent tears between the vagina and rectum.”

As stated earlier, that belief is simply not true. Unfortunately, some practitioners continue to perform routine episiotomies despite a lack of evidence supporting their use.

Why is an episiotomy used?

Are you thinking what I’m thinking? If there’s no evidence that routine episiotomy is necessary and research shows negative long-term effects, why are episiotomies used—ever?

While many of the reason aren’t justified, a provider may perform an episiotomy for the following reasons:

  • Birth is imminent and the perineum hasn’t had time to stretch
  • Baby or mother appears to be in distress
  • Baby’s head appears too large for the vaginal opening
  • Baby is in a breech presentation
  • Mother is exhausted and requests the procedure
  • Mother is facing a forceps or vacuum-assisted delivery
  • Mother has had a previous pelvic surgery
  • Mother isn’t able to control her pushing
  • The physician practices routine episiotomy and does out of habit
  • A severe tear is imminent

When would an episiotomy be necessary?

According to a 2009 review involving more than 5,000 women, in most cases, an episiotomy doesn’t help and is associated with significant problems. However, there may be a few instances when an episiotomy is useful or necessary:

  • If an episiotomy helps a woman avoid a Cesarean surgery
  • If extensive vaginal tearing is likely
  • If mother or baby are exhibiting signs of severe distress

Some moms may even request one because they are so exhausted and just want baby out.

On the other hand, there have been moms who did not want an episiotomy and ended up with one. That’s why it’s so critical to have discussions with your provider or a solid birth plan, as the heat of labor isn’t the greatest time to be making decisions.

Call your hospital and ask about their rate of episiotomy. Look for a 5-10% occurrence rate. If your hospital has a 20%+ rate, FIND ANOTHER PLACE TO GIVE BIRTH! Midwife practices have rates closer to 1-3%.

What’s it like to get an episiotomy?

Does an episiotomy hurt? How much?

Mamas with an epidural won’t feel anything. However, if you’ve chosen a natural birth without pain medication—rest assured, you’ll be numbed first.

Here’s how an episiotomy is performed:

  • To start, you’ll be injected with a local anesthetic (called a pudendal block) in your perineum (the area between your vagina and rectum).
  • Next, a mediolateral incision (angled down away from the vagina and the perineum) or a midline incision (straight down into the perineum) will be made to increase the size of your vaginal opening.
  • Finally, once you’ve delivered your baby and placenta, your provider will suture your incision. Just so you know, it’s common for more anesthetic to be administered at this point in case the original dose has worn off—thank goodness, right?
  • To finish up, an ice pack will be placed against your perineum to ease the initial pain and swelling.

Whether a mediolateral or midline incision is made, the degree or severity of an episiotomy (or tear for that matter) can vary.

  • First degree: A first-degree episiotomy consists of a small cut that only extends through the lining of the vagina. It doesn’t involve the underlying tissues.
  • Second degree: This is the most common type of episiotomy. It extends through the vaginal lining as well as the vaginal tissue. It doesn’t involve the rectal lining or anal sphincter.
  • Third degree: A third-degree tear involves the vaginal lining, the vaginal tissues, and part of the anal sphincter.
  • Fourth degree: The most severe type of episiotomy includes the vaginal lining, vaginal tissues, anal sphincter, and rectal lining.

The following measures can reduce the need for an episiotomy:

Some women neither tear nor require an episiotomy, so it is possible to give birth unscathed. Preparation is key, so here are some ways you can reduce the likelihood of tearing—or need for an episiotomy in the first place.

  • Birth Position: Research suggests that upright (standing, squatting, on all-fours) or lateral (side-lying) positions lead to fewer lacerations.
  • Good Nutrition: Practice good nutrition throughout your pregnancy—healthy, hydrated skin stretches more easily!
  • Pelvic Floor Exercise: With your doctor or midwife’s approval, do squats, kegels and other core work to support your birth. Exercising those pelvic floor muscles will help them do their job when the time comes—reducing the need for forceps or vacuum extraction too! (Here are 7 simple exercises you can do daily.)
  • Mother-led Pushing: A slowed second stage of labor (pushing phase) where pushing is led by the mother (rather than the doctor) in a controlled manner rather than forced, allows more time for your skin to stretch.
  • Perineal Massage: Doing perineal massage beginning as early as 34 weeks pregnant is found to reduce trauma that requires suturing. And, during labor, perineal massage is associated with fewer third and fourth degree lacerations.
  • Perineal Support: Your provider or delivery nurse can use their hands to provide manual support of your perineum during the second stage of labor.
  • Warm Compress: A warm compress during the second stage of labor is associated with a reduced rate of third-degree and fourth-degree lacerations. Also, many women report that this feels amazing—so bring on the warm compresses!

Episiotomy care:

Despite the most thorough preparation, birth can be unpredictable. If you end up having an episiotomy or tearing, here are some tried and true episiotomy care solutions to ease postpartum pain and discomfort:

  • Cold Pack: Applying a cold pack helps to reduce swelling and pain that is common after birth. Look for the flexible fabric kind which are softer; or you can make your own “padsicles” using maxi pads, aloe vera and witch hazel.
  • Donut Seat: Consider purchasing a healthcare seat ring (a.k.a. donut seat) to take some of the pressure off your wound. You’ll be sitting a lot those first few weeks, especially when feeding your baby, so a little extra cushion may be just the ticket.
  • Fiber: Constipation, hemorrhoids, and pressure from the uterus on the rectum can cause extra discomfort. To combat this, be sure to eat a fiber-rich diet and drink at least eight, 8-ounce glasses of water daily. Chia seeds and pears are particularly helpful. You can also look into magnesium supplementation if need be.
  • Peri Bottle: Most hospitals will send you home with a perineal irrigation bottle (peri bottle) you can use to clean the affected area each time you use the bathroom. Make sure to clean the bottle thoroughly and replace the solution often. Then, gently dab yourself with toilet paper instead of wiping.
  • Physical Therapy: There are a variety of techniques a trained physical therapist can use to ease your discomfort and hurry up the healing process, like intravaginal and intra-rectal pelvic floor muscle stretching, soft tissue massage, scar mobilization, trigger point release, myofascial release, and pelvic floor muscle strengthening. (Source). Look for a therapist who is trained in women’s health and postpartum care.
  • Sitz Bath: Soak the affected area in a clean bathtub or a portable sitz bath that you place over your toilet seat. The water only needs to be high enough to cover your wound and you can even add Epsom salt for its extra soothing properties. I also loved using this Sitz Spray after every toilet stop since it was much easier!
  • Witch Hazel: Make your own witch hazel pads from organic cotton cosmetic rounds and organic witch hazel or buy them pre-made at the drugstore. Store these in the refrigerator for even more soothing relief.

What about you?

Did you have an episiotomy? Would you do things differently? What helped the healing process? Tell us in the comments below.