Here at 5 Point PT we treat many postpartum patients, and I’ve always wondered why a physician would choose an episiotomy for a patient during a vaginal delivery. While researching, I found that in 2006, the American Congress of Obstetrics and Gynecology recommended “restricted use of episiotomies.” Meaning that physicians should only use this technique when its absolutely necessary for the safety of the baby and mother.
Episiotomies are necessary in certain cases, and it’s important to educate yourself on when it is appropriate. An incision is the right course if there is an issue with the fetus and you may need a quicker delivery than what is currently going on. It may be the course of action when the baby’s head or shoulders are too big for the mother’s vaginal opening, or if labor is stressful for the baby and pushing needs to be shortened. It is also necessary when instruments are used, such as forceps or vacuum, to let the baby out, or when the baby is in the breech position, to allow for delivery safely. If your baby is premature, episiotomies also may be used to ease the pressure of the mother’s perineum on the baby’s head, which can trigger bleeding in the brain.
Risks
Unfortunately there are risks when having an episiotomy. They have been linked to severe lacerations of the pelvic floor muscles. Just to note, a majority of the pelvic floor muscles attach to the perineal body which is what is cut during an episiotomy!! When you have an episiotomy there is a chance for more bleeding, scarring and increased pain, sexual dysfunction and increased costs. They do NOT prevent postpartum pelvic floor pain or dysfunction or pain with intercourse. However, women with episiotomies, women without, and women who have had c-sections can all experience some type of discomfort or pain with intercourse postpartum.
Research shows that the rate of episiotomy with all vaginal deliveries decreased from 60% in 1979 to 25% in 2004.
Both tears and episiotomies must be properly cared for and stitched post birth. There is a possibility to develop painful scar tissue from her episiotomy. Some physicians will treat the area with silver nitrate in order to cauterize it and assist in the healing process.
Bring up the subject with your practitioner. It is NEVER too early to ask.
Questions to ask your practitioner:
- What percentage of your births involve an episiotomy?
- What do you do to avoid it?
- What are your best suggestions on how can do to avoid it?
But how can we help ourselves in avoiding an episiotomy?!
You can do your own perineal massage! Antenatal perineal massage reduces the likelihood of perineal trauma and decreases reporting of ongoing perineal pain. A study in 2012 actually showed that there was a reduction in 3rd and 4th degree tears with massaging the perineum. There is also no evidence that it can hurt you, so it is definitely worth doing. The purpose of your own massage is to make the skin more supple and elastic so it stretches more easily during birth. You can start it around the 34th week of pregnancy.
The Journal of Midwifery and Women’s Health advises:
- relax with your knees bent, have back support
- lubricate your thumbs and perineal tissues using water soluble jelly, vitamin E or almond oil, or your body’s natural vaginal lubricant
- place your thumbs about 1-1.5 inches inside your vagina, press down towards anus, and to the sides until you feel a slight stretching sensation
- you can slowly massage the lower half of the vagina and concentrate on relaxing muscles
- 10 minutes a day is appropriate
If your partner performs it, they would use their index finger instead of thumbs and make sure you have good communication. During the delivery, perineum massage can also be performed by physician, nurse or midwife!
Super crowning is a technique used by certain midwives and physicians in which at the time of crowning in which the baby’s head comes through in a more controlled manner. The midwife or physician holds it steady or even push it slightly for a couple of contractions to get the tissues to stretch slowly and naturally. Some believe this can reduce vaginal lacerations during labor and delivery.
After hearing so many stories from women, I believe that it is incredibly important to have all of the facts about episiotomies. You need to keep open communication with your physician and nurses and make sure that your expectations are clear. I think the bottom line is this: every delivery is different and your birthing plan may not come to fruition exactly as you imagined. However, we always recommend having a doula to advocate during labor and delivery.
(Recommended reading: Your best pregnancy, by Jill Joefs and Denise Jagroo)