There is one specific event that was the impetus for writing this article. Recently, friends of ours were expecting their first child. When she went into labor, the couple drove to the hospital where she was “drugged, cut and, after a while, out popped the baby.” Disturbed by their story, my husband asked them, “did she consent to the episiotomy or pain medication?” A little confused by the question our friend matter-of-factly replied, “well, no. we didn’t know it was an option.” Later that night, my husband warmly confided that he was so glad that I chose to have a midwife. He couldn’t imagine the alternative of having what the majority of women have: a doctor-controlled birth. It is this all too common scenario that has inspired me to present the following information for anyone who is or knows someone who is pregnant.

Did you know that episiotomies are the most common surgical procedure that obstetricians will perform in their lifetime? Theoretically, it’s intended to facilitate birth in an emergency during labor. But recently, especially in the United States, it has become the subject of much debate due to increased routine use. Resources show that the rates of episiotomy in the U.S. rank among the highest when compared to other industrialized nations. Statistics vary stating that it’s performed during at least 50% (in many cases as much as 75%) of all doctor-attended U.S. births. In contrast, midwife-attended births demonstrate rates of episiotomy that are radically lower, if at all.

I sought to uncover the real story behind episiotomy use, how it is performed and the differences in recovery experiences of those who’ve had it versus those who haven’t. What I discovered is that the current practices are in dire need of change. I learned the shocking reality of the permanent damage inflicted by episiotomies and the alarming lack of concern in the Obstetric community.

An episiotomy is a surgical incision made to widen the vaginal opening. The incision is made through the perineal muscle (perineum) between the vagina and the rectum. In general, there are two approaches. The midline incision cuts straight toward the rectum. The sideline or mediolateral cuts at a 45 degree angle. The more commonly used midline can likely tear straight to the rectum (called a third or forth degree tear) causing severe damage. In contrast, the sideline doesn’t usually tear further, but it causes greater blood loss, does not heal well and can be much more uncomfortable in the long-run. Both types of incision must be sutured directly following birth and are highly susceptible to infection before the mother is even discharged from the hospital postpartum.

The recovery period after having an episiotomy is approximately three to four weeks (in some cases months.) Until fully healed, the repair remains susceptible to infection. Recovery is described by many as being very painful wherein most mothers find it difficult to even walk.

In the recent past, episiotomy allegedly prevented postpartum incontinence or pelvic floor relaxation — a condition which hinders sexual pleasure and perineal muscle control. Research now suggests episiotomy does not prevent but rather causes these afflictions when the muscle is severed. Some women report that their experience of incontinence is far worse than they would’ve imagined. Some young women report having to wear adult diapers or pads because they experience so many “accidents.”

Women who underwent episiotomy were also more likely to report that they were still experiencing pain more than six months postpartum, especially during sexual activity. One of the most explicit long-term effects from the incision is permanent deformity of the vaginal area—a consequence some outspoken activists have compared to female mutilation.

When episiotomy is not performed, women either don’t tear at all or if a tear does occur it can be repaired much easier than a surgical incision. Research proves natural tears heal quicker with much less pain and discomfort initially and long-term. Repaired tears usually heal within a week or so. Likewise, when allowed to proceed without incisions, women were able to quickly resume daily activity (ie: walking) immediately postpartum. Normal functions of continence, physical activity and sexual intercourse resume within three to six weeks postpartum.

Curiously, there is no set criteria for making an episiotomy. Ideally, the procedure is intended to intervene in complications of labor when mother or baby is in immediate danger. However, emergency is rarely a factor in real life hospital delivery rooms. Many resources point to the reality that most doctors simply don’t want to wait for nature to take it’s course. Below are events that most frequently prompt use—the majority of which are doctor-inflicted circumstance rather than naturally occurring emergencies.

• the mother or baby’s heart rate becomes extremely high or low
• rapid progression of labor most often caused by over-medication of the mother; the baby enters the vaginal opening too quickly for the area to adjust and stretch causing potential for an extreme tear.
• though uncommon, sometimes a baby turns into a breech position (laying sideways or “shoulder first”) during labor.
• the doctor decides that baby is too big to fit through the mother’s pelvic canal and cuts a wider opening. *Statistics show a baby is almost never too big to fit through a mother’s pelvis.
• the laboring woman has been over-medicated, barely conscious and can not push; the Ob chooses to use forceps or vacuum to pull the baby out; an incision is made to widen the area.

*Forceps and vacuum are dangerous instruments that have been extensively reported to cause serious damage to both infant and mother.

See Part Two: A Call for Awareness and Change

See Five things you can do to prevent an episiotomy

Resources:
americanpregnancy.org
acog.org
childbirthconnection.org
bmj.com
jwatch.org
midwiferytoday.com
A Wise Birth: Bringing Together the Best of Natural Birth with Modern Medicine by Penny Armstrong and Sheryl Feldman
Ina May’s Guide to Childbirth by Ina May Gaskin

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