October 28, 2011

Episiotomy or Natural Tear?

There are so many decisions to consider when approaching birth. Where should you deliver? With whom should you put your trust to give you care? Which interventions do you feel comfortable with and which ones would you like to avoid? While sorting through all these options, it can be easy to be overwhelmed by the choices or even bypass some of the interventions you might face.

In this blog, I compare the pros and cons of an episiotomy to that of a natural tear of the perineum. My goal is to offer you enough information to either make an informed decision with what you are most comfortable with or at least open the discussion about this matter with your care provider.

What is an episiotomy?
An episiotomy is a surgical incision at the perineum (the region between the anus and the vagina). The intention of an episiotomy is to provide more space for the baby to pass through the vaginal opening. The cut of an episiotomy can be a midline cut– a cut straight down from the vaginal opening to the anus or a mediolateral cut– an incision angling from the vaginal opening to the side, cutting more into the muscle rather than tendon. Nowadays, the mediolateral cut is primarily used over the midline cut to preserve the integrity of the pelvic floor.

As of 2005, twenty five percent of women who gave birth in the US had an episiotomy. This is a decrease from the previous decade. Even though the rate of episiotomy usage is going down, according to ACOG (American College of Obstetrics and Gynecology), it is still the most commonly used procedure in obstetrics. Lamaze International states in their Care Practice Papers, the episiotomy rate can be safely lowered to 10% or even lower. I would suggest asking your care provider what his/her episiotomy rate is and under what conditions would he/she feel it necessary to perform this intervention.

What are the benefits?
There is a bit of controversy about the benefits of an episiotomy. Those supporting the use of the procedure believe that if there was an emergency and an immediate need to get the baby out, extra space at the vaginal opening would allow for an easier instrumental birth, i.e. with the use of forceps or vacuum extraction. Some providers also see the usefulness of an episiotomy for larger babies to give the baby more room to come through. I have also heard of care providers performing an episiotomy if they believe the perineum is going to tear on its own. The logic being that it is easier to repair an episiotomy compared to a natural tear. With an episiotomy, the cut should be in a straight line as a opposed to the ragged edge of a natural tear.

A news release from ACOG states, “The best available data do not support the liberal or routine use of episiotomy. Nonetheless, there is a place for episiotomy for maternal or fetal indications such as avoiding severe maternal lacerations or facilitating or expediting difficult deliveries.”

What are the risks?
Some of the risks of an episiotomy include, extension to a third- or fourth-degree tear, subsequent pelvic floor dysfunction, anal sphincter dysfunction, painful sex, infection and fecal and urinary incontinence.

What are the benefits of a natural tear?
Many care providers and medical studies are supporting the occurrence of a natural tear of the perineum over an intentional cut of an episiotomy during childbirth. Part of the reasoning for this is 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 (ACOG statement). Also, by foregoing a routine episiotomy, the mother has a chance to stretch the perineum during the course of second stage (the pushing phase) and may avoid any perineul damage altogether. With an episiotomy, the connective tissue, muscles and skin are cut and therefore the strength will permanently be compromised.

What can be done to prevent the need for an episiotomy or tearing?-

There are many ways to help keep the perineum intact. First, having a regular kegels routine will help keep the perineum strong and flexible. This exercise offers the benefit of strengthening the muscle but also teaching how to relax it, too. (For more details on Kegel exercises, please reference my blog, Get To Know Your Muscles “Way Down There”, The Importance of Kegels)

Interestingly, the presence of stretch marks has also proven to be a fair predictor of tearing. They most likely are correlated with poor skin elasticity in general. A woman’s basic physiology also affects her likelihood of tearing. Women with a short perineum, when the anus is close to the vagina, are more likely to tear during delivery. (3)

The position a woman pushes in can also have an effect on the probability of tearing or not. (On a personal note- after 5 hours of pushing, I did not suffer from perineum tear. I credit this to pushing my son out in a side lying position.) Certain positions put more strain on the perineum than others. Unfortunately, the most commonly used position, the supine position, can put a lot of stress on the pelvic floor. Side lying, an all 4 position or standing and leaning forward are more optimal for perineal health.

Another method to avoid perineal damage is to avoid the use of an epidural if possible. As just discussed, the least effective way to keep the perineum intact is pushing while on the back. With the use of an epidural, the pushing options are more limited. Although, side lying pushing should still be an option for women with an epidural. In one study, women with no anesthesia had the highest rate of intact perinea (34.1%), while women with epidurals had the highest episiotomy rate (65.2%). Another study shows that women who had an epidural were more than three times as likely to suffer third- or fourth-degree tears. (4)

Perineal massage is another method that can be used to help prevent tears or an episiotomy. One study out of the Department of Obstetrics and Gynaecology, Watford General Hospital, Hertfordshire, UK came to this conclusion antenatal perineal massage appears to have some benefit [reduction of 6.1%] in reducing second or third degree tears or episiotomies and instrumental deliveries. This effect was stronger in the age group 30 years and above. Click here for direction on how to perform perineal massage.

Midwifery Today
(Issue 65) focused on the perineum. There were some very helpful tips on reducing perineal damage. Here are some of their suggestions.

l. Forget those little gauze sponges and ask the nurse to bring in ten facecloths from the linen cart. Put some hot water from the tap in a beaker and applies gentle, hot compresses for the woman to push toward gently. If they are contaminated by any feces, the nurse can throw the dirty one away and stack the facecloths on the bed using them one by one as she goes through them. (They are removed later.)

2. Encourage the woman to hold and support her own tissues. Women instinctively slap any hand that is put on the crowning head. This is to be encouraged because it helps her stay in control.

3. Care providers can help by using reassuring words such as “you are stretching beautifully,” “there’s lots of room for the baby to come through,” and “I know this burning is intense but you’re doing this nice and easy”–makes such a difference. Practice saying these phrases in the mirror so they come out easily.
-Gloria Lemay, British Columbia

It’s natural for the baby to progress and regress over and over. This allows the perineum to stretch effectively. Then, massage the perineum with vernix from the baby’s head.
Dr. John Stevenson, Australia

Apply warm compresses everywhere on the woman’s body so there is less focus on that one spot (the perineum). The woman relaxes, the midwife relaxes.
-Naoli Vinaver, Mexico

Healing from episiotomy or tear
If you do end up with either an episiotomy or tear, there are many ways to help the healing process.
The area will be sensitive for a while and you will have dissolvable stitches, so sitting for a prolonged period of time might be uncomfortable. Unfortunately, new mothers sit a lot since you will likely be feeding your baby for many hours through the day and night. You may want to consider an inflatable doughnut. These are often used for helping the discomfort of hemorrhoids (those little buggers may also be a result of pushing your baby out!)

I would also recommend either applying witch hazel pads to the perineum of sitting in a sitz bath for 10-15 minutes. My doula recommended making a strong solution of certain herbs, including rosemary, comfrey and yarrow, and adding that to the sitz bath, (For those in NYC- you can get them at Flower Power) I did a sitz bath twice a day and it was a nice time to be by myself and not be on “baby duty”.

To help dilute the acidic effect of urine, I would suggest using a peri bottle while peeing. The hospital will give you one before you leave. If you are having a home birth, it will likely be in your home birth kit.

Last but not least… kegels! Kegels will help encourage healing by bringing circulation to the perineum. Do not be surprised if the pelvic floor muscles feel very weak at first. It will take time and effort, but the strength will eventually return.

I hope you are now armed with some good information that will help you make a choice that is best for your body. Here’s to a happy and healthy pelvic floor!

1. http://www.acog.org/from_home/publications/press_releases/nr03-31-06-2.cfm ACOG News Release :ACOG Recommends Restricted Use of Episiotomies
2. Excerpt from “Care Practice Papers” from the Lamaze Institute for Normal Birth.
3. Elizabeth Bruce, excerpted from “Everything You Need to Know to Prevent Perineal Tearing,
4. Elizabeth Bruce, excerpted from “Everything You Need to Know to Prevent Perineal Tearing,




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