What You Don’t Know About Episiotomies Can Hurt You
By Jennifer Margulis
This article was first published in The New York Times.
When Cyndi Sellers’s son was born at a hospital in southern Oregon, the obstetrician on call rushed in with wet hair wearing a tie-dye T-shirt, as if she had just been swimming. After only a few minutes in the room, the doctor then cut an episiotomy so long that Cyndi’s mother — who was watching the birth — later described it as “horrifying.”
The doctor delivered the baby, stitched up Cyndi, and hurried out again. In the brief time the obstetrician was in the labor room, she managed to do so much damage that, almost three years later, Cyndi tells me when we talk on the phone, things “still don’t feel right down there.”
An episiotomy is a surgical cut from the vagina to the anus, on the area of a woman’s body known as the perineum. Once routine, it continues to be a “common obstetrical procedure,” according to the authors of the 23rd edition of Williams Obstetrics, the 1,385-page manual that serves as a textbook for obstetricians.
The reason for the episiotomy’s popularity in the 1950s, ’60s and ’70s, when my brothers and I were born, was that doctors believed that a clean downward cut on the laboring woman’s perineum was safer for the baby and better for the mother than letting a woman’s perineum tear during pushing. A straight cut was easier to stitch than a jagged tear, and doctors argued that a woman would feel less postpartum pain and have fewer future problems with pelvic-floor complications (like urinary incontinence).
More than half a dozen scientific studies done since the 1990s suggest that those doctors were wrong. Episiotomies are actually associated with more postoperative pain, a much greater likelihood of tears in the anus (ouch), and other complications. One study showed that women who had episiotomies were as much as six times more likely to report fecal or flatus incontinence than women who delivered with an intact perineum.
“The biggest problem with any type of episiotomy is the lack of control of the cut once it’s done,” explained Louana George, a registered nurse and certified professional midwife who delivered babies for 25 years. “It’s not unusual for a cut to extend unintentionally into the rectum, necessitating extensive suturing to repair the damage.”
Another midwife demonstrated the problem to me by taking a piece of paper in two hands and pulling it apart. The paper started to give but did not tear. Then she put a cut in the top of the paper and pulled again. This time the paper ripped cleanly in half. “That’s what happens to a woman’s perineum when you do an episiotomy,” the midwife explained, sending shivers up my spine.
“You have a greater chance of having a much more severe tear,” she went on. “Then there’s the problem that you’re cutting through muscle — when you tear it usually only goes through tissue — so it can cause significant damage that needs to be repaired and leave a woman with pain, numbness and lifelong problems with sex.”
Some cuts are necessary. If a woman has an unusually tight perineum (because of her anatomy or because tight scar tissue has grown over a previous episiotomy) and the tissue just isn’t stretching, an episiotomy may be indicated. If a baby close to being born is showing signs of distress and needs to be born quickly, an episiotomy can facilitate birth. Sometimes the practitioner can see that a very large head may cause a rectal or urethral tear, and a cut may help avoid that potential damage.
But these instances are few and far between. “If they have an indication, it is rare indeed,” Paul Qualtere-Burcher, an obstetrician who has participated in over 4,000 births and who teaches at the Albany Medical Center, wrote in an e-mail. Dr. Qualtere-Burcher can’t remember the last time he cut an episiotomy. “They clearly increase lacerations into the rectum, they hurt more and take longer to heal,” he explains.
Most American doctors still believe episiotomies help prevent injury in the case of stuck shoulders. But a new study examining 94,842 births over a 10-year period suggests that assumption is also wrong. “Despite historical recommendations for an episiotomy to prevent brachial plexus injury when a shoulder dystocia is encountered,” the authors conclude, “the trend we observed does not suggest benefit from this practice.”
Though it is no longer the “standard of care,” many obstetricians continue to perform episiotomies, arguably for the wrong reasons and often without asking consent.
“Fifty percent of the episiotomies I’ve done were because my supervising staff wanted to go back to bed,” one obstetrician, who recently finished her residency, told me. This doctor has a colleague, an obstetrician in private practice, who “loves epis” and cuts them during almost every vaginal birth.
The American College of Obstetricians and Gynecologists recommends that doctors rely on their “clinical judgment” when it comes to episiotomies. Pregnant women who would prefer to assess that judgement ahead of time (and to find a practitioner who won’t come at their privates with a pair of blunt-tipped scissors) should talk episiotomies before they’re in the delivery room.
Or they can follow my mom’s lead when she was giving birth to me in 1969. Alone in the delivery room, on her back with her feet in cold metal stirrups, she saw the doctor coming closer to her vagina with a scalpel.
“No!” she managed to cry before another contraction consumed her concentration. “I told you I didn’t want that! NO EPISIOTOMY!”
“O.K., lady,” the doctor said, laughing, putting down his knife.