Episiotomy

Childbirth is a transformative and beautiful experience, but it can also be challenging and, at times, unpredictable. In certain situations, healthcare providers may recommend procedures to ensure the safety of both the mother and the baby. One such procedure is episiotomy, a surgical incision made in the perineum during childbirth. In this blog post, we will explore what episiotomy is, the reasons behind its use, potential benefits, (spoiler: scientific research shows there are any) and risks, and alternative approaches.

What is Episiotomy?

Episiotomy is a surgical cut made in the perineum—the area between the vagina and the anus—during childbirth. This procedure is typically performed to widen the birth canal and facilitate the delivery of the baby. The incision is made with surgical scissors, and local anesthesia, and is usually done in a controlled manner. However, the use of a vacuum, for example, might make the cut open even more. In this case, it might not get to the sphincter but can get to the butt of the woman. Although episiotomy has become one of the most commonly performed surgical procedures in the world, it was introduced without strong scientific evidence of its effectiveness.¹ 

Reasons for Episiotomy

Episiotomies were once a routine part of childbirth, but their use has become more selective in recent years. Healthcare providers may recommend an episiotomy for various reasons, including:

Fetal Distress: If the baby is experiencing difficulties during delivery and needs to be delivered quickly, an episiotomy may be performed to expedite the process. However, there is no large-scale study that proves there is a difference in neonatal health status depending on whether an episiotomy is performed or not.² 

Instrumental Delivery: When assisted delivery methods such as forceps or vacuum extraction are necessary, an episiotomy may be performed to "prevent" tearing of 3rd or 4th-degree, which can be more occurrent during instrumental delivery.³ 

Prevention of 3rd or 4th-degree tearing: In some cases, an episiotomy may be considered to prevent uncontrolled tearing of the perineum, which can be more extensive and challenging to repair. The degrees of tearing are as follows: 1st-degree includes only the mucosa; 2nd-degree includes mucosa and muscle; 3rd-degree includes mucosa, muscle, and sphincter; 4th-degree includes mucosa, muscle, sphincter, and rectum. Both 3rd and 4h-degree can impact negatively the health of women. Even though most of them will fully recover, there is a risk of experiencing difficulty in controlling their bowels or passing wind.

Risks and Complications

Episiotomies are not without risks, and complications can arise. Some potential risks include:

Increased Pain and Discomfort: The recovery from an episiotomy can be more painful than healing from a natural tear.

Infection: Like any surgical procedure, there is a risk of infection at the incision site.

Bleeding: It is common for women who had episiotomies to bleed more during birth;

Longer Recovery: Healing from an episiotomy may take longer than healing from a natural tear, and in some cases, the scar tissue can cause long-term discomfort.

Pelvic floor distress: Mediolateral episiotomy is associated with decreased pelvic floor muscle strength.

Dyspareunia: Defined as persistent or recurrent genital pain that occurs just before, during, or after sex.

Alternatives and Considerations

In recent years, there has been a shift away from routine episiotomies, with a focus on allowing natural tearing when possible. Alternative approaches to minimize the need for episiotomies include:

Perineal Massage: This technique involves gently massaging and stretching the perineum in the weeks leading up to childbirth to increase its flexibility. However, there is no scientific evidence of the benefit of perineum massage. Some claim it may avoid 3rd or 4th-degree tearing.

Water Birth: Immersing in warm water during labor has been shown to reduce the risk of perineal trauma.

Hands-off Delivery: Being the protagonist of your birth, changing positions as you want, and pushing whenever you want help in avoiding tearing.

Hands-On Delivery Techniques: Healthcare providers can use hands-on techniques, such as warm compresses, to support the perineum and reduce the risk of tearing. No proof whatsoever, but it is a valid option if you want that.

Rates in the Netherlands for performing episiotomy

Disclaimer: After a lot of research these are the numbers we found. The numbers that will be presented here, were found in a variety of scientific research. Therefore, whenever there are new rates, this text will be adjusted. If you found research with different rates or the Ministry of Health decides to collect information about episiotomy Netherlands-wide, please contact Fern.

• 46% of women in their first pregnancy will have episiotomy giving birth in the Netherlands;

• 14% of women giving birth for the second time will have episiotomy in the Netherlands;

• 42% of the episiotomies were unconsented in the Netherlands.  

To conclude, episiotomy is a procedure that, while once routine, is now approached more selectively in modern obstetrics. Its use is often based on specific medical indications, and the decision to perform an episiotomy should be a thoughtful one, weighing potential benefits against risks by the pregnant woman, after all, it is her choice. Ultimately, the goal is to ensure a safe and positive experience for both the mother and the newborn.

If you have never seen a real episiotomy and would like to, follow this link.