August 31, 2012
Dear Mayo Clinic:
I am pregnant with my first child and was told by my obstetrician that in some circumstances an episiotomy is necessary. I thought this was no longer done and that it is actually harmful to the woman and baby. What is correct?
Episiotomies are much less common now than they used to be. But in some situations, an episiotomy may be needed. Even though they are seldom used today, it is important not to completely rule out an episiotomy before labor and delivery.
An episiotomy is an incision made during childbirth in the tissue from the vaginal opening toward or to the side of the anus. When I first began as an obstetrician in the 1980s, almost all women got an episiotomy for every delivery as a standard practice. That's because an episiotomy was thought to help prevent larger and deeper vaginal tears during childbirth. It was also believed that the incision of an episiotomy would heal better and more quickly than a natural tear.
But over the years, evidence-based medicine has shown episiotomies are not necessary in most cases. Sometimes they actually may cause more problems than they prevent. For example, recovery after an episiotomy can often be uncomfortable, and the surgical incision may be more extensive than a natural tear would have been. In addition, for some women an episiotomy causes pain during sex in the months after a baby is born. An episiotomy also may increase the risk of stool incontinence after delivery. Although most episiotomies heal without difficulty, a small number can result in long-term pain and other problems.
It's important to understand, though, that for some deliveries an episiotomy may be a critical part of the birthing process. A large baby coming through the birth canal in an abnormal position, for example, sometimes can be very hard to deliver without extensive tearing. An episiotomy may be necessary in such cases to avoid significant injury to the mother. If a baby is in distress and is having difficulty progressing through the birth canal, the procedure can be useful then, too. Deliveries that involve a vacuum extractor or forceps may require an episiotomy. But these cases are uncommon. Today, less than 10 percent of deliveries involve episiotomies.
The best approach is to have a conversation with your obstetrician about your preferences regarding an episiotomy before you are in the delivery room. Together you can discuss the situations where an episiotomy might be necessary for you, as well as ways you may be able to lower your risk of tearing the perineum during delivery if you do not have an episiotomy. Write down what you prefer and include it in your birth plan, so all the members of your health care team are aware of your preferences.
In general, episiotomies should be used with caution, only when necessary, but not totally dismissed as an option during labor and delivery. In some situations, an episiotomy still can be a helpful procedure for a safe delivery for both mother and baby.
— Keith Johansen, M.D., Obstetrics and Gynecology, Mayo Clinic, Rochester, Minn.