Episiotomy trends are rampant on social media following a recent highly publicized legal case involving a physician performing an episiotomy despite the woman’s protest. In this day, the idea of routine episiotomy sounds crazy to most of us who try to practice evidence based medicine balanced with the art of patient-centered care. What I have found is key to patients understanding episiotomies and feeling good about their birth experiences is proactively educating my patients about why episiotomies are sometimes, but often not, helpful so they know all their options and decisions they may have to make during a delivery.
What is an episiotomy?
During vaginal childbirth 53 to 79 percent of women will sustain some type of laceration or tearing of the lower vagina and surrounding perineal tissues. An episiotomy is an intentional controlled cut made with scissors at the vaginal opening as the head is crowning to allow more space to effect delivery and/or direct forces away from the anal muscles. In 2012, the national episiotomy rate in the U.S. was 12 percent as determined by hospital discharge diagnoses. Episiotomies have not been looked at as national quality measures traditionally so the rigor of reporting these may vary substantially, and 12 percent may be an under-representation.
What are the recommendations for doing episiotomies?
Over the years data has emerged leading to the clear recommendation for restrictive, as opposed to routine, use of episiotomy. The American College of Obstetrics and Gynecology reaffirmed this position in a Practice Bulletin in July 2016. While a 30 percent episiotomy rate at certain institutions reported in a recent news article is way too high, a zero percent episiotomy rate is too low. There are no current guidelines defining exactly when an episiotomy should be done. The decision to do one is made at the time of expulsion, taking into consideration many complex and time-sensitive factors and really defines the challenges and art of being a good obstetrician as he or she is only afforded a few seconds to make a decision that can have life-long consequence for his or her two patients in the one moment. Further complicating the decision is that performing an episiotomy almost never harms a baby but can increase perineal injury for the mom, while not performing an episiotomy can lead to harm for both mom and baby.
It sounds like episiotomies are sometimes indicated to safely get the baby out, but are they every best for mom?
In a few rare instances episiotomies are best for mom.
· Some women delivering in the U.S. were raised in other cultures and have undergone what is commonly known as female circumcision, making their vaginal opening very tiny. For some of these women, spontaneous tears through this narrow vaginal outlet and scar tissue can be devastating and lead to urethral tears and complex lacerations requiring reconstructive surgery; a controlled episiotomy can reduce such complications in certain situations. I have cared for these patients myself.
· Some women have inflammatory bowel disease (Crohn’s or Ulcerative colitis) and it is very important to avoid tearing into the anus or rectum for these ladies to avoid fistula. I care for a significant number of these patients and most have normal vaginal deliveries with no episiotomy, but it is a small sub-population that garners clear benefit from select mediolateral episiotomies. I discuss this issue in detail before birth with this population of patients.
· Occasionally with prolonged pushing, the pressure from the baby’s head will start to breakdown the lower wall between the vagina and the rectum and you will see the head trying to deliver via the rectum/anus instead of out the vagina. This is a rare situation where doing an episiotomy to create a single cut in the anal muscle between the anus and vagina must be done to try to preserve as much of the muscle integrity as possible to afford the best chance of good sphincter repair to reduce her risks of fecal incontinence. When this happens it happens very fast and you have only seconds to make this judgment call. I have had this happen twice in 10 years.
But my doula says she has never seen a case that needed an episiotomy, so why do doctors continue do them?
I hear this pretty often and am not surprised by this fact. Episiotomies are still rare in most places and rare things are not often witnessed. The odds are that many great doulas have seen no, or few, episiotomies or natural fourth degree lacerations. For a doula to see me do an episiotomy, statistically she would have to attend around 50-100 births with me to get a chance to see one; that is a lot of births without episiotomies! This is true for many of the less common problems of pregnancy that you see only when caring for a large volume of pregnant women over many years, such a seizures from preeclampsia, clitoral artery lacerations, amniotic fluid embolisms, uterine rupture, cord prolapse and maternal death to name a few.
I thought I had a great birth experience with an episiotomy, but now I am reading negative stories about episiotomies and now I am questioning my whole experience.
This is one of the dangers of social media as there are many ‘end-of-the-spectrum’ stories. I hope that the outdated use of routine episiotomies becomes obsolete and that the language surrounding episiotomies becomes empowering and leads to meaningful discussion between patient and provider so that when it is rarely needed, women are informed, confident, and trusting of their provider’s medical judgment. Friends, family and Facebook sometimes suggest “If only you had tried this…” or “Not done that” that your birth and birth experience would have been so much better. Even when you are thrilled with your experience these “if only” interjections can taint your memories and leave you feeling cheated or confused; I find this rampant and rarely an empowering experience for my patients. I try to warn patients about this phenomenon and encourage all patients to ask their doctor about anything that did, or did not, happen at their birth if they have any doubts, confusion or want to learn if a different approach is possible for the next delivery. If I perform an episiotomy, or there is any sort of emergent intervention needed, I always return to my patient’s side and review with her what happened, what exactly we did, and why we did it and answer any questions; we often revisit this at her postpartum visit as well.
My mom is telling me I should ask for an episiotomy so my sex life will be better after the baby, is that a good idea?
The data on episiotomies versus natural tearing and sex life are inadequate. The good news is that most women return to enjoyable sex after birth regardless! For many of my pregnant patients all of the conflicting input not only about episiotomies, but about pregnancy and birth (not to mention how to raise a baby!) from the Internet, social media, friends, family, religious leaders, doulas, doctors and midwives becomes very stressful, confusing, overwhelming and can drown her own personal goals and joys of pregnancy. Trying to help our patients navigate this flood of information so she can make informed decisions that reflect her personal values and desires is one of our jobs as her physician. The history of birthing is fascinating and within it is a union of physiology, culture and medicine. With that said, I encourage patients to seek the advice and expertise of their trained midwife or physician. We know from history and around the world still today where women do not have access to trained birth attendants that women suffer far greater complications such as hemorrhage, infection, seizures, fistula, prolapse and even death than they do when they have the expertise of a professionally trained attendant.
Rosanna Gray-Swain, MD, is a member of BJC Medical Group and a part of the West End OB-GYN practice. The practice is located at 1110 Highlands Plaza, Suite 280, St. Louis, MO and can be reached at 314-286-2620. Dr. Gray-Swain is accepting new patients, so BOOK today!