An episiotomy is a surgical cut to widen the vaginal opening during delivery. Doctors sometimes make an incision in the perineum -- the area between the vagina and the anus -- to help the baby come out.

There are two kinds of episiotomies, midline and mediolateral, differentiated by the direction in which the surgical cut is made. Midline episiotomies are associated with more severe tears than mediolateral ones. Your doctor will likely numb the area with a local anesthetic before making the cut and suture the incision after the baby is born.

The original argument for performing episiotomies was that cutting the vaginal opening would prevent the skin from tearing and prevent damage to the pelvis. However, recent research has largely disproved both counts. Studies show that women who don't have episiotomies recover faster, require fewer stitches, and are ready to have sex sooner than women who have them. In fact, episiotomies may do more harm than good.

A review of 26 studies of episiotomies published in the May 2005 Journal of the American Medical Association showed that episiotomies are linked with a higher risk of injury, more trouble healing, and more pain. Episiotomies also did not help with incontinence, pelvic floor strength, or sexual function. Women who had the procedure waited longer to resume sex after childbirth and experienced more pain with intercourse after birth.

Even more surprising, studies show that severe tears -- known as third- or fourth-degree lacerations (ones that are close to or through the rectum) -- are actually more common with an episiotomy. For example, when doctors at several Canadian hospitals reviewed outcomes in women who had episiotomies versus women who did not, they found that 52 of the 53 women studied who experienced third- or fourth-degree tears had undergone an episiotomy. The researchers concluded that an episiotomy can actually make a severe tear more likely, just as making a snip in a piece of cloth makes it easier to tear.

Most doctors no longer perform routine episiotomies, but use the technique primarily during difficult deliveries when a baby is "stuck" or shows signs of stress. It's an individual call for your doctor or midwife, but many doctors will consider performing an episiotomy if one or more of the following applies:

•Your baby's heart rate slows and the doctor believes he needs to be delivered right away. This may make necessary room to make it easier to deliver the baby quickly.

•If the need for a speedy delivery requires your doctor to use forceps or vacuum extraction to help your baby out. Performing an episiotomy makes it easier to reach the baby in these situations.

•If you experience a prolonged second stage of labor.

Some practitioners will also perform an episiotomy when a baby's head has been delivered but his shoulders are trapped. This is an emergency known as shoulder dystocia. However recent studies show that even in these emergency situations, doctors can often safely avoid an episiotomy. In addition, researchers concluded that performing an episiotomy in most cases is highly unlikely to reduce the chances that a baby will be injured during delivery.

Talk with your health care provider about his or her preference for doing or not doing episiotomies. This will give you a better idea about whether you should choose another provider who doesn't do them routinely.

Also ask your doctor to advise you about controlled pushing to allow adequate time for the perineum to stretch and for a slow, gentle delivery.

Studies show that doctors may be changing their attitudes toward episiotomies and that they are less common than they were in the past. In fact, a review of statistics at one Philadelphia hospital found that the incidence of surgeries plummeted from 69 percent of all vaginal births in 1983 to only 19 percent in 2000. However, it is a clinical judgment call, and your doctor may have his or her own opinion based on past experience.

Your doctor's opinion may be influenced by where he or she practices. A six-year study by the American College of Obstetrics and Gynecology (ACOG) found that 17.7 percent of doctors who practiced at hospitals and universities performed episiotomies, compared with 67.1 percent for private practice physicians. Reassure your doctor that you practice your kegel exercises to strengthen your pelvic floor muscles in preparation for labor and delivery.

-- Melanie Haiken, MA, is the former health editor of Parenting magazine. She has also reported on health and business.

References

First published June 29, 2005
Last updated March 13, 2008
Copyright © 2005 Consumer Health Interactive

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