Episiotomy / Episiotomies and your Birth Plan

By: Aunt Doula (11/05/2022)

Up until the last decade, episiotomies were practically reaching the point of 100% practice with every birth, regardless of true need as they were considered "better" than risking a natural tear, and for the roughly 40 years prior, studies had not really shown anything to the contrary. It was the accepted practice to perform an episiotomy - but now in 2022 the expected rate of episiotomies for providers in the US is to be below 3% of all deliveries. This has taken a good bit of effort to change the practices over the last 10 years, but it has been a very important change that improves outcomes for mothers.

An episiotomy is a cut made with scissors into the perineum - the skin that connects from the bottom of the vagina to the opening of the rectum. The theory of an episiotomy was that by cutting and allowing room for the baby to exit the vaginal canal, there would be less chances for a tear to occur "naturally" which may be jagged and difficult to repair. However, we now know with well performed studies that routine episiotomies typically cause much worse tearing than if they had never been performed. Think about it as if you had a swim suit in your hands and you tried to tear it - it would stretch, adapt, lengthen and try to hold against the forces being placed on it. No take that same swim suit and cut a line in the collar - when you go to put force on it now, it has no way to stretch and adapt now and resist the forces by distributing it across the fabric - the cut is now a weak point that tears deep and doesn't stop when you exert even minimal forces up it. The exact same outcome was found to be occurring in routine episiotomy use. People who had an episiotomy that was shallow upon administration became a deep laceration that could perforate the rectum and anal sphincter. Could spread deeply through tissues without resistance because the tissue no longer had their resistance and strength due to the cut. Episiotomy cuts cannot be controlled.

Natural tearing is a common concern for a significant portion of pregnant people, however it is typically only seen in approximately 10-15% of births. The biggest "advantage" that natural tearing had over episiotomy was that it showed a self-limiting capability that episiotomy could not match - the tissues would only tear to the point that it allowed the baby to move through the vaginal canal and vaginal opening, rarely more. By allowing the body to retain the full strength of its tissues and remain intact, the body could adjust, adapt, and minimize the impact of tearing during birth.

Tears are graded on a 4 degree scale that denotes how many layers of tissue a tear has impacted, with a 4th degree tear being considered the worst. Most natural tears are 1st and 2nd degree tears that are quickly attended to with stitches if necessary at the time of birth, with dissolvable suture that will not need to be removed postpartum. 3rd and 4th degree tears impact deeper layers of muscle and the rectal space, which may require follow up care to ensure that there is no long term damage. These tears would also be attended to at the time of birth, however it is important that you understand what degree of tear you have experienced so that you can seek follow up care for the proper provider. There is an unfortunate lack of follow up in many countries, but the United States especially, so self advocacy for treatment is a vital part of empowering in your birth journey that doesn't end when you leave the hospital.

As for choices on the birth plan, in general practice an episiotomy should not come up, however I still put this on the birth plan because there are old school doctors that still perform these cuts routinely and without consent - ensure you state "Routine Episiotomy Declined" and then we can get into the nitty gritty of when that 3% can come into play and how to denote on your birth plan that you are well aware of it and how you want it handled.

An episiotomy that is not routine is a possibility to come up if you are in a situation of an Assisted Vaginal Delivery which is performed with the vacuum cup that is attached to babies head or forceps that gently grasps baby's head and either helps guide baby through the birth canal. In the cases of these instrument deliveries, you may have a provider recommend an episiotomy to ease the entry of the instruments into the vagina. There is scant evidence on if this is a good option, and the time to discuss pros and cons is not when your doctor is offering it to you in the birthing room! This is an important discussion to have at a third trimester appointment when you are finalizing your birth plan, ask what their opinion of and recommendations would be if you needed an instrument delivery, that way you can have time to think it over, understand their view points from a medical side and decide if you say Accept or Decline on "Instrument Delivery Related Episiotomy"

The final thing to consider if you have decided to allow or are deeply encouraged at the time of an instrument delivery to accept an episiotomy is to know the two most common types of cuts that episiotomies take - 'The Midline' and 'The Medio-lateral'

• The Midline episiotomy is a straight cut from the bottom of the opening of the vagina straight down to the opening of the anus. It cuts directly through the perineum and leaves no tissue to support the distinction of your vaginal opening and your rectal opening. It is a poor performer in studies because it leads to more complications, especially bowel related issues and is very difficult to heal from. Significant pain when seated, fecal incontinence, infection and repeated tearing of stitches are common in midline episiotomy cuts. It is distinctly to your advantage to strongly state that you do not want a midline episiotomy - this is unfortunately the go-to that was used primarily when they were routine so it is extremely important that you state " Midline Episiotomy Declined Without Exception "

• The medio-lateral episiotomy starts at the bottom of the vaginal opening and goes 45° to the side toward the thigh. Occasionally, there will be a cut performed on both sides if more room is needed, however this is still considered a better option than the midline. This cut still allows ample room for instrument insertion, but avoids unintended spread into the rectal spaces and pelvic floor muscles. The healing involves less mucus membranes so infections are usually less frequent and while it is still not an ideal situation to need an episiotomy, a medio-lateral episiotomy has out performed in all areas of healing and usage. You would denote this on your birth plan as " Medio-Lateral Episiotomy Considered for Instrument Delivery Only - Please Obtain Verbal Consent"

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More and more providers are no longer performing episiotomy routinely or even with an instrument delivery, but until the practice is completely quit, this is still a very important part of your birth plan decisions and I highly encourage including it.

Methods to reduce natural tearing will be covered in another post and linked here when finished, but will include perineal massage beginning in the late second trimester (when approved by your provider), a warm washcloth being pressed gently to the perineum close to the end of the pushing stage to give the tissues some extra stretch, controlled delivery of the fetal head to reduce a fast expulsion that may compromise the perineal tissue, and using birthing positions that take extra pressure off the perineal tissues.