Episiotomies: What Your Mom Never Knew

An episiotomy is a surgical cut made in the perineum during childbirth. The perineum is the muscular area between the vagina and the anus. Your doctor may make an incision in this area to enlarge your vaginal opening before you deliver your baby.

Episiotomies in the past

Episiotomies were common decades ago, and for what seemed like good reasons.

In the past, an episiotomy was done to help prevent severe vaginal tears during delivery. It was also believed that an episiotomy would heal better than a natural or spontaneous tear. Experts also thought that an episiotomy would make long-term problems after childbirth, like incontinence and pain during sex, less likely. And they thought that the cut was better than natural tearing.

Episiotomy types

Some studies show that up to 85% of women tear – at least a bit – naturally during childbirth. Tears (and episiotomies) can range from mild to severe (or, as doctors say, from first to fourth degree). The most severe cases can harm the anal muscles and anal lining, which can cause problems controlling bowel movements.

The two most common types of episiotomy are midline episiotomy and mediolateral episiotomy. Both types have various advantages and disadvantages.

In a midline episiotomy, the incision is made in the middle of the vaginal opening, straight down toward the anus. Midline episiotomies are much more common in the United States and Canada.

The advantages of a midline episiotomy include easy repair and improved healing. This type of episiotomy is also less painful and is less likely to result in long-term tenderness or problems with pain during sexual intercourse. There is often less blood loss with a midline episiotomy as well.

The main disadvantage of a midline episiotomy is the increased risk for tears that extend into or through the anal muscles. This type of injury can result in long-term problems, including fecal incontinence, or the inability to control bowel movements.

In a mediolateral episiotomy, the incision begins in the middle of the vaginal opening and extends down toward the buttocks at a 45-degree angle. Mediolateral episiotomies are the preferred method in other parts of the world.

The primary advantage of a mediolateral episiotomy is that the risk for anal muscle tears is much lower. However, there are much more disadvantages associated with this type of episiotomy, including:

• increased blood loss
• more severe pain
• difficult repair
• higher risk of long-term discomfort, especially during sexual intercourse

What we now know about episiotomies?

More recent research, however, suggests that an episiotomy may actually cause more problems than it prevents. The procedure can increase the risk of infection and other complications. With an episiotomy, there may be a chance that the cut may extend farther than a natural tear would have gone, which could damage the anal muscles. Recovery also tends to be lengthy and uncomfortable.

For these reasons, an episiotomy usually isn’t performed. In some cases, however, the procedure may need to be done. Your doctor might recommend an episiotomy if:

• you are likely to experience extensive vaginal tearing during delivery
• your baby is in an abnormal position
• your baby is larger than normal
• your baby needs to be delivered early

If an episiotomy has to be done, talk to your doctor early on about the procedure. Ask them why they want to perform an episiotomy during delivery and how it might help you avoid tearing.