*This post comes with a trigger warning – brief mentions of birth trauma, sexual assault and female genital mutilation*

 Before I begin, as always, I need to remind you that I am not a medical professional, so  information given should not replace medical advice from your healthcare provider.

The Episiotomy was once a routine practice for maternity care providers, in the bid to reduce perineal trauma. However, in recent years, routine use of episiotomies has come under scrutiny by the growing body of research that now supports a more selective approach.

It’s just a little cut.. what’s the big deal?

A small cut is made at the base of the vaginal opening, and runs down towards the anus; this space is called the perineum. This is not just a superficial cut to the skin; the muscles in the perineum are also cut – causing perineal trauma. If you wanted to compare an episiotomy to a vaginal tear (which has 4 degrees of severity with the 1st being the least, and 4^th being the most severe) then it would equate to a second-degree tear, as it has muscle involvement. Evidence by Lappen & Gossett (2014) also shows that episiotomies may also increase the likelihood of pelvic floor dysfunction in the future.

There are two kinds of episiotomies; the midline episiotomy and the mediolateral episiotomy.

Midline episiotomy (See figure 1)

This is where the cut runs vertically down towards the Anus.

According to research and the QLD Health Clinical Guidelines, this method is does not effectively protect the perineum and in fact, has been found to significantly increase the risk of OASIS (Obstetric Anal Sphincter Injury/s).  

Mediolateral episiotomy (See figure 2)

This is where the cut runs at an angle (generally 60 degrees or greater), away from the Anus, generally to the right. According to research and the QLD Health Clinical Guidelines, this method is the preferred method of the two as there is some evidence to show that it could reduce the risk of OASIS during instrumental births in particular.

Evidence from Patel et al. (2018) also shows that mediolateral incisions actually cut through more nerves in the perineal structures [which stem from the CLITORIS]; they even say that midline incisions may be the more suitable option as the wound from a midline excision that then extends causing trauma to the anal sphincter would likely heal within a few weeks postpartum with nerves likely still in-tact, in comparison to having definite denervation in perineum with a mediolateral incision.

Will I feel it?

As per the QLD Health clinical guidelines – an appropriate analgesic should be given locally prior to an episiotomy incision. However, the guideline also states that under the circumstance where the infant is medically unstable and needs to be delivered quickly, that analgesia won’t be given [due to the time it takes to be effective]. Therefore, the woman would likely be offered gas/air to help her manage, however this doesn’t fully numb the pain, it more so dampens it a little. Anecdotally I’ve also heard women who have needed an episiotomy and the OB gave local anaesthetic but didn’t wait until the area was numb so that was quite traumatic for them – so PLEASE dear mama (and support person!) if baby isn’t in imminent danger, USE YOUR VOICE and tell them to WAIT!.. If they DON’T wait and continue the procedure this is called Obstetric Violence and needs to be reported!

A side note on obstetric violence

Please – if the above happens to you (or any other procedure that you do NOT give consent to) get your support person to send themself an email with what happened and by who (include any witnesses) – so that you have written evidence with a timestamp of the event, that can be used as evidence against the healthcare provider. You can even ask the midwife to have it documented in your chart if she was a witness; though she really should be pulled into question too if she didn’t do anything to prevent them from performing the procedure.

Why should routine Episiotomies be avoided?

In addition to all the risks mentioned above, what healthcare providers often neglect to advise women, is that they could experience:

• Infection at the site
• Chronic/ongoing pain
• Urinary incontinence
• Pelvic organ prolapse (where organs in the abdomen drop down through a weak or loose part of the pelvic floor, into the vagina); the pelvic floor normally acts as a sling that holds up your organs.
• Dysfunction of the rectum and/or anus
• Sexual dysfunction which can involve significant and long lasting pain during sexual intercourse, as well as reduced libido and a condition called Vaginismus (involuntary tightening of the vagina – I’ll talk about this in a moment)
  • Please click here to read my blog post about Vaginismus after Episiotomy
• You will also be left with a small scar

When are Episiotomies medically indicated?

According to the QLD Health Clinical Guidelines:

• When there is suspected fetal compromise (i.e. baby’s health is at imminent risk) so birth needs to happen quickly
• Instrumental birth is required (that said – I have heard from colleagues that there are skilled obstetricians out there who can successfully perform instrumental deliveries without the need for episiotomy)
• The woman has a history of FGM (Female Genital Mutilation)
  • According to Rodregues et al. (2016) “Anterior episiotomy … is the opening of the scar associated with FGM, most commonly used with women living with FGM Type 3 [13]. It is frequently performed during labour, to allow for cervical exams and to prevent obstructed labour[14, 15]”
• Soft tissue dystocia
• When severe injury is anticipated
• When the woman has medical indications that would constitute a shortened second stage of labour
• Or if the woman requests it

How can I prevent having an episiotomy?

• If hiring a private provider, find one that has a low episiotomy rate
• Explicitly state in your birth preferences that you’d rather tear than have an episiotomy
• Make sure you have this conversation with your care provider during pregnancy if you know who your midwife will be (or OB); otherwise make sure they’re aware on the day.
• Avoid being induced unless absolutely medically necessary
• Avoid being on your back for birth
• Avoid the epidural so you can feel the sensations in your perineum and can know when / when not to push (if at all)
• Keep your body relaxed so your pelvic floor can relax
• Birth your baby’s head slowly, between contractions

How can I prevent perineal tearing?

• Antenatal Perineal Massage – There is some evidence that shows a reduction in perineal trauma requiring suturing in mothers who are having their first vaginal birth, do this, however there is no significant research that can suggest the appropriate duration and frequency of this. However, the QLD Health guidelines says you could try it from around 35 weeks; one to two times per week; and for around five minutes per session.
• Aim for a physiological labour
• Avoid induction if possible – Syntocinon use increases the likelihood of perineal trauma as it causes labour to progress a lot faster than normal, so instead of baby making a slow decent and the body being able to move, stretch and accommodate for the baby to move down and out, the Syntocinon causes more forceful and more frequent contractions, not giving the perineum enough time to soften, relax and stretch the way it needs to
• No coached pushing (i.e. no one telling you when and how to push)
• Protect the perinium with a warm compress if you’re not already in a birth pool
• Side lying could help relieve some of the downward pressure on the perineum
• Encourage women to listen to what their body is telling them.. if it’s telling them to stop pushing then stop
• Avoid use of forceps in delivery as this can significantly increase the risk of perineal trauma

I hope this information has provided you with a thorough foundation to be able to make an informed decision that’s right for you. To conclude, I’d like to leave you with this quote from Dr Rachel Reed:

“Even if episiotomy does reduce the chance of severe tearing (which we don’t have the evidence for) – having an episiotomy during a non-instrumental vaginal birth would be trading a 2% chance of significant tearing with 100% chance of perineal damage via a cut.”

References

Dr Rachel Reed – https://midwifethinking.com/2016/01/13/perineal-protectors/

Lappen JR.  & Gossett DR. (2010) Changes in episiotomy practice: evidence-based medicine in action, Expert Review of Obstetrics & Gynecology, 5:3, 301-309, DOI: 10.1586/eog.10.21. 

Patel et al. (2018). Midline Episiotomy May Post Less Risk of Nerve Damage Than Mediolateral Episiotomy: A Cadaveric Anatomical Study. The FASEB Journal, 32:1.https://doi.org/10.1096/fasebj.2018.32.1_supplement.516.4                                    

Queensland Clinical Guidelines – Perineal Care (2023) – https://www.health.qld.gov.au/__data/assets/pdf_file/0022/142384/g-pericare.pdf

Rodriguez MI, Seuc A, Say L, Hindin MJ. Episiotomy and obstetric outcomes among women living with type 3 female genital mutilation: a secondary analysis. Reprod Health. 2016;13:131.(PubMed)

Signorello LB, Harlow BL, Chekos AK, Repke JT. Midline episiotomy and anal incontinence: retrospective cohort study. BMJ 2000;320(7227):86-90.

Stedenfeldt M, Pirhonen J, Blix E, Wilsgaard T, Vonen B, Oian P. Episiotomy characteristics and risks for obstetric anal sphincter injuries: A case-control study. BJOG 2012;119(6):724-30.