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Episiotomy Trends

It has been several years since the American College of Obstetricians and Gynecologists (ACOG) issued a statement renouncing routine episiotomy -- a procedure that involves making an incision into the perineum, the area between the vagina and the anus, to ease delivery. Prompting the statement was a review of past studies that overwhelmingly shows that the cut poses serious risks to women and offers few benefits, according to an article published in the group's journal, Obstetrics and Gynecology.

ACOG's position wasn't new then, and neither was the article's conclusion: That episiotomy increases a woman's chance for everything from painful infections to persistent sexual problems. And, yet, laboring women admitted to hospitals still have a greater than 40 percent chance of undergoing this dubious procedure when they deliver. Despite two decades of data discrediting the safety and usefulness of episiotomies, doctors keep performing them and women keep paying the price.

Episiotomy has been a mainstay of obstetrical practice since the 1920s, when leading doctors declared that cutting the perineum was best for Baby and Mom, says Ian Graham, Ph.D., assistant professor of medicine at the University of Ottawa and author of Episiotomy: Challenging Obstetric Interventions. Despite a lack of good data, doctors claimed the incision not only protected against tears, incontinence, and weakened pelvic-floor muscles, but also made delivery easier on the baby.

Now episiotomies are a habit that medicine just can't seem to kick. One reason: They conveniently speed up delivery. In fact, Emma Stephens*, a Chicago mother, believes her doctor's vacation plans may have played an unwarranted role in the decision to perform an episiotomy during the birth of her daughter. "After I had been pushing for less than 20 minutes, she said that the skin was stretched paper-thin and that she had no option," even though there were no indications that the baby was in trouble, Stephens says. Getting sewn up delayed that all-important first meeting. "Worse still, it was horribly painful for weeks," she says. "I remember having to take these long baths while the baby was crying and wanting to nurse."

Many physicians perform episiotomies for no better reason than it's what they learned to do in medical school. Others simply may not have kept abreast of the critical evidence. What's more, some older practitioners tend to be slower in changing their techniques, says Dr. Graham. And to be fair, interpreting fetal heart rates can be difficult during delivery and many doctors just want to get the baby out quickly and safely, says Erica Eason, M.D., an associate professor of obstetrics and gynecology at the University of Ottawa.

However, the bottom line is that this procedure really only needs to be done under certain conditions. According to Dr. Eason, an episiotomy is warranted when the baby is in distress; when forceps or a vacuum extractor is used; when the baby is breech, or when the baby's head has emerged from the birth canal but his shoulders are stuck. Otherwise, the perineal tissue should be allowed to stretch on its own. Even if there is tearing (which is possible), the wound is likely to be less severe, says Dr. Eason.

Beth Howard lives in New York City and is the author of Mind Your Body: A Sexual Health and Wellness Guide for Women.

*These names have been changed.

Why You Really Don't Want One

Despite the widely held belief that routine episiotomy prevents postpartum problems, research shows that it actually contributes to them and possibly leads to chronic conditions, says Lisa B. Signorello, M.D., an epidemiologist with the International Epidemiology Institute, in Rockville, MD. First, researchers now believe that instead of protecting against tears, an episiotomy may actually provide the starting place for one. Furthermore, the most recent data from the University of Ottawa found that compared to those without an episiotomy, women with the incision experienced more bleeding, pain, infections, and the lowest levels of sexual satisfaction after three months. Moreover, a study in the January issue of the British Medical Journal found that compared to natural tearing, episiotomies tripled the risk of a woman suffering some loss of bowel control.

According to Paul G. Schoon, M.D., assistant professor of obstetrics and gynecology at Indiana University School of Medicine in Indianapolis, about 5 percent of midline episiotomies (where the incision is made from the vagina straight back) extend into the rectum, which may cause anal incontinence and minor difficulty in holding gas in 25 to 50 percent of those cases. Pelvic-floor exercises like Kegels or using weighted vaginal cones can help improve muscle tone in the anal sphincter, alleviating symptoms, but when such measures fail, surgery may be required.

As if the possibility of fecal incontinence weren't bad enough, about 10 to 20 percent of women will experience sexual problems after their baby is born -- some directly attributable to episiotomy. "When I finally got home, about a week after delivery, I didn't even want to sit down because of the incision," says Ann Devlin*, a student near Danbury, CT, who had an episiotomy six years ago during the birth of her daughter. "Probably about six to eight weeks later my husband and I had sex, but I had developed a sore at the incision, just inside the vagina. Intercourse was painful for months."

Some episiotomies can also lead to chronic pain. As with incisions anywhere in the body, neuromas (noncancerous tumors) may develop in the surrounding nerve tissue. If they don't heal properly, they can cause muscle tension and chronic pain in a small number of women, Dr. Schoon says.

Just Say No

Because many practitioners will continue to perform episiotomies despite the recommendations, it's important to discuss your doctor's or midwife's position on the procedure well before you go into labor, preferably at one of your first visits. If you have a birth plan, your wish to avoid an incision unless absolutely necessary can be a part of it. If you are uncomfortable with your doctor's stance, don't hesitate to switch to one whose ideology matches yours. It can also help to remind your practitioner of your desire when you get to the hospital. Increasingly, women's births are attended by M.D.s that they haven't met, says Dr. Signorello.

Midwives are often more concerned with restricting the use of episiotomies during normal births. In fact, one of the hallmarks of good midwifery practice is keeping the perineum free from injury, Dr. Graham says. To accomplish this, many use techniques such as carefully orchestrating a woman's pushing in the second stage of labor or massaging the perineum during birth to avoid tears or the need for an incision. Perineal massage is also something women can do themselves in the last months of pregnancy. A recent study in the American Journal of Obstetrics and Gynecology found that 24 percent of first-time mothers who performed prenatal perineal massage did not tear, while only 15 percent of those who didn't massage kept their perineums intact. Our own informal poll of nurses indicated that few, if any, of their patients had tried the technique, let alone heard of it.

So here's how to do it: Apply a lubricant around the perineum. Then place your thumbs about 1 1/2 inches inside your vagina, pressing downward and to the sides at the same time. Gently stretch until you feel a slight burning or stinging sensation for several minutes. Next, hold the pressure for about two more minutes or until the tissue begins to feel slightly numb. Massage the lower vagina with your thumbs for several more minutes, avoiding the urinary opening. Perform this technique once or twice a day starting around the 34th week of pregnancy.

Once you're in the delivery room, Dr. Eason says, avoiding injury should be a team effort between you and your health care providers. The best way to escape damage is by controlling pushing once the perineum is taut -- and not having an episiotomy. Debbie Martin*, who gave birth last year, did just that. "My doctor told me he was going to have to give me a little one," says the New York City journalist. "But when he walked out of the room, the nurse said, 'Oh, no, you're not.' She continually massaged my perineal area, and she coached me beautifully when it came to pushing. I'm convinced those things made all the difference." Martin delivered her 8-pound, 11-ounce baby boy without an episiotomy or tear. Hopefully, cases like hers will soon become the norm rather than the exception.