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Hot Topic: Episiotomy

Can an episiotomy be helpful or should it be avoided no matter what? Two doctors weigh in on the debate.

Plus:
What is an episiotomy?
How long does it take to heal from an episiotomy?
Tearing during delivery?


Photo: Getty Images

Episiotomies are Useful Within Reason

David A. Rivera, MD, FACOG

They Should Be Avoided At All Costs

Kurian Thott, MD, FACOG

They can hurry things along.

You do an episiotomy when you think you’re going to need more room -- for instance, if you’re delivering a big baby or if you need to deliver baby with forceps or a vacuum. The American College of Obstetricians & Gynecologists (ACOG) also says that an episiotomy is indicated “if expediting delivery in the second stage of labor is warranted.” So if baby’s heart rate is dropping and we need to get him out now, an episiotomy may be necessary.

If you just wait a little longer, it won’t be needed.

An episiotomy should be one of those procedures that you only do in a very few select cases. Sometimes doctors want to hurry up the birth process and they think, “If I just make a little snip, the head’s going to be there and we’re done.” But a lot of times, if you just give it another five minutes, the head will be out and everybody is a lot happier than they’d be if you had cut.

One cut is easier to sew up than many tears.

Sometimes, a well-timed episiotomy can save having to repair a vagina that looks like someone tossed a grenade at it. There are times now that I wish I had done one because it’s taken so long to sew up the damage from multiple tears. I’ve spent an hour sewing up some really nasty tears!

Tearing is better, even if it’s not neat.

If you don’t do an episiotomy, the patient may tear. That’s typically better for the patient because usually if you tear, even in multiple places, it will be shallow, not deep. You are going to protect the perineum better that way, as opposed to cutting an episiotomy, which can essentially start a zipper effect. As soon as you cut an episiotomy, you pretty much create a path of least resistance, so as baby is crowning, and there’s pressure against the perineum, it can unravel right there, tearing even more. An episiotomy can also increase your risk of tearing during a second birth, because that area is now weak.

Most heal without problems.

Ob-gyns are trained surgeons. Making incisions and repairing them afterward is well within their job description. Most episiotomies heal without any problems. It’s normal to feel a little uncomfortable after birth, whether or not you had an episiotomy. According to ACOG, the science is still out on whether or not episiotomies increase immediate postpartum pain or affect women’s sexual function.

Healing can be tough.

Healing after an episiotomy takes time, and many women complain of pain in the days, weeks and even years after the procedure. In some cases, when you cut an episiotomy, you create a scar line there that can become painful for the woman during intercourse. Everything heals very nicely and looks okay on the outside, but there’s a lot of pain because there’s scar tissue underneath.

Cutting an episiotomy can also turn what would have been a first- or second-degree tear (that just affects the skin or the skin and muscle beneath) into a third- or fourth-degree tear (that extends from the vagina to the anus), which can mean a lifetime of pelvic floor issues, like incontinence.

David A. Rivera, MD, FACOG, is an ob-gyn based in Illinois

Kurian Thott, MD, FACOG is the chief ob-gyn at Stafford Hospital in Stafford, Virginia