Obstetric Lie #81 - An Episiotomy is Better than a Tear

(Picture found HERE- public domain, free to use.)
Is an episiotomy actually better than a tear?

There are some posts that frankly, I can't believe I even have to write.  Isn't it simply mind boggling that somebody would say that an episiotomy (a cut, with scissors) into a mother's vagina is BETTER than a natural tear?  Who made that up?  Obviously not somebody who has actually HAD their vagina cut with scissors. 

Oh, but people DO say it.  "A straight cut is better than a jagged tear."  "An episiotomy is so much easier to stitch up than a tear."  "Babies are so big, you are going to tear anyway, might as well make it faster." 

Ahh....to be a woman in this day and age and to accept so readily the inevitability of our own body's failure.  Well, I for one don't accept it.  It defies logic to say that it is better to cut a stretchable part of the body than to simply let it tear (or even better- NOT TEAR!  Yes, this too can happen!)

(As a side note, do people say these kinds of things about men?  Of course not.  Men made up these things about women.  Nobody freaks out, runs for cover, or gets out a sterilized pair of scissors every time a man gets an erection.  "Get the scissors ladies!  I don't think the semen will FIT!!!!!  We must make the opening LARGER!"  No.  Nobody says that.  So why is it OK to say that about women?)

But I digress.  I will now use studies to sound right and not anger.

A Cochrane Review found that when comparing six studies that,
 "Restrictive episiotomy policies appear to have a number of benefits compared to routine episiotomy policies. There is less posterior perineal trauma, less suturing and fewer complications, no difference for most pain measures and severe vaginal or perineal trauma, but there was an increased risk of anterior perineal trauma with restrictive episiotomy."
They concluded that,
"There is clear evidence to recommend a restrictive use of episiotomy"
While there is a place for episiotomy, it should not be done routinely.  (You can read the entire paper by clicking on this link.)

Another study done in 1990 found that midline episiotomies did more harm than good.  (If you look at the picture above you can see that it shows two different types of episiotomy.  One, a midline, cuts straight back towards the rectum, and the other, a mediolateral, cuts sideways.)

This study found that,
" After statistical adjustment for these risk factors, mediolateral episiotomy was associated with a 2.5-fold reduction in the risk of severe lacerations among primiparous women, and a statistically nonsignificant 2.4-fold increase among multiparous women, compared with no episiotomy. Midline episiotomy was associated with statistically significant 4.2- and 12.8-fold increases in the risk of lacerations among primiparous and multiparous women, respectively"
(You can read the abstract here.)

I should probably admit some bias here.  Though the mediolateral episiotomy seems to show better outcome than a midline, I can't say I would want one of those either.  In fact the idea makes me ill.  But that's just me. 

Why?  Because,
"Women who had midline episiotomies were nearly 50 times more likely and women who had mediolateral episiotomies were over eight times more likely to suffer a severe laceration than were women who did not undergo an episiotomy."
While the chances of severe laceration with a mediolateral episiotomy are lower, it is even lower when a woman is not cut at all.  My understanding is that a severe laceration is a third or fourth degree tear.  

Tearing, cutting, vagina's, etc, this stuff is getting scary!  Seriously though- it starts to sound like bad things happening in the vaginal area are inevitable.  They aren't.

This study done in 1998 found that in home birth practices almost 70% of women birthed with an intact perineum (nothing tore.)
"Results:In this sample 69.6 percent of the women had an intact perineum, 15 (1.4%) had an episiotomy, 28.9 percent had first- or second-degree lacerations, and 7 women (0.7%) had third- or fourth-degree lacerations."
So, when treated rather well, very few women had deep lacerations and the majority didn't tear at all.   They even found some factors that tended to decrease the chance of tearing or episiotomy.  (Read carefully, you might be a little surprised by what they are.)
"Among nulliparas, low socioeconomic status, kneeling or hands-and-knees position at delivery, and manual support of the perineum at delivery were associated with intact perineum, whereas perineal massage during delivery was associated with perineal trauma."  (Check out the abstract for this article by clicking here.)
A little credence to the don't massage the area crowd. 

As time goes on I do believe that the use of episiotomy is going out of style.  It is certainly being done less often where I live, though I know this isn't the case everywhere.  But, if you are paying attention you have probably noticed that the c-section rate is pretty steadily rising.  So the question must be addressed- is a c-section simply better than a vaginal birth when it comes to damage to the vagina? 

A few studies have found that yes, there is some improved findings when the vagina is skipped altogether and the baby is delivered via abdominal surgery. 

It is important to note though that the DID NOT recommend abdominal surgery over vaginal birth.  I do believe this is because the researchers knew that there were OTHER risks to c-section that far outweighed the things it MIGHT avoid. 

From Birth, 2007,
"CONCLUSIONS:Although short-term occurrence of any degree of postpartum stress urinary incontinence is reduced with cesarean section, severe symptoms are equivalent by mode of birth. Risk of postpartum stress urinary incontinence must be considered in the context of associated maternal and newborn morbidity and mortality."
 and from  2003, New England Journal of Medicine
"The risk of urinary incontinence is higher among women who have had cesarean sections than among nulliparous women and is even higher among women who have had vaginal deliveries. However, these findings should not be used to justify an increase in the use of cesarean sections."
As you probably know, there are many risks to c-section and the benefit to urinary incontinence is small and not recommended by researchers as worth the other risks.  

So- to sum up.

Episiotomies are not better than a tear.
Cesearean sections are not better than an episiotomy.
Many women don't even tear!
Having kids makes you wet yourself, no matter how they are born.  (You might as well know this.  Trampolines suck anyway.)

And on a personal note- I had an episiotomy and then tore naturally to the same degree with two other babies.  I can not even put into words the DIFFERENCE in the recovery.  I don't know why but it was much easier and faster to heal from a natural tear than an unnatural cut.  

Our bodies work.  Scissors at birth are optional.  Find out what your care provider thinks about them and adjust accordingly. 


Unknown said…
When I was little my mother would tell me her birth stories. They always included an episiotomy. I always thought "why?". I knew I did not want to be cut and made sure to birth in a safe place where that wouldn't happen.
Alanna said…
When my sister had her first kid, her husband (an anesthesiologist) told her to refuse the episiotomy. His reasoning? Because of COURSE doctors always want to cut you if they can! So I feel like I've heard it straight from the horse's mouth!

One book I read compared it to if you had to squeeze a navel orange through your mouth. Sure, your lips might stretch a bit and even crack. But would you really let someone with scissors come up and say, "Here, let me help you with that!"?????

I think I heard somewhere that having an episiotomy doesn't even guarantee that you won't still tear (or end up with a c-section)! {Shudder} Can you imagine the recovery if you had all three???
momto5 said…
my mother told me she had an episiotomy with me and tore anyway, up and down into her rectum. i often wonder how it would have been had they just let her push slowly, not lying flat on her back, and not cut her.
just another way to tell women their bodies do not work.
carrieg said…
My sister was cut with her first, and tore all the way to her anus, then was sewn up too much. She didn't even consent to it. They just did it!
Kelly said…
Oh, but we do tell men that their bodies won't work...that's what routine infant circumcision is, right? But in that case we get it out of they way when they can't consent, horrifyingly enough.

You are so right though, recovery is wayyyyyyyyyy easier with a tear than an episiotomy, I've had both. No contest at all, soo much easier.
I will take an episiotomy any day over natural tearing because I absolutely had a much easier recovery after my 2nd birth than my first birth where I tore so bad the midwife couldn't stitch me up herself and had to call the doctor in. I needed two shots of demerol just to get me to sit still for the stitching and I could still feel every stitch going in me and it took me weeks to recover and I had lots of scar tissue. Although, I am told the repair was done well. My episiotomy I was stitched up lickity split and was up and about in no time. So yes please doctor give me the episiotomy. I've had both recoveries and the tear was far worse.
Rachel said…
I had an episiotomy with my first birth. I thought it healed up just fine until I gave birth the second time around - nearly three years later. The rest of my perineum stretched just fine (just one bitty anterior tear that didn't need a stitch), but the scar tissue from that old episiotomy? Not so much. That area got so irritated that it took longer to get back to normal than the tear that actually happened DURING the birth. I couldn't believe it.
Keira's Mommy said…
As a first time mom, I made it clear in my birth plan that I do not consent to an episiotomy. Thankfully I didn't have one, more did I tear, at all. The doctors and nurses were even surprised (my DDs head is 90th percentile) that I was totally fine. I delivered on all fours and I know that is why!
Unknown said…
I didn't tear at all having my daughter. She was born in 20 minutes and four pushes and I guess he had expected some damage since she was my only birth. My nurse was amazing with perineal support, which I credit a good part of that to. My husband said she was down there with the KY making sure I stretched and didn't rip.
Tara said…
Is this really still the norm? I've been through about 5 different OB's with my three (thanks to moving during pregnancy), and all of them have told me that it's no longer recommended to do episiotomys at all.
Denisse Edwards said…
My OB didn't deliver and instead I got the on call OB with horrible bedside manner. She came in I believe feeling competitive with our doula since I had my natural birth plan saying no to interventions. It's like the OB wanted to prove her skills or something. She literally introduced herself saying "hi I'm dr G.... How do u feel about episiotomy?" At this point I'm at a 4 progressing fine and there's zero reason besides her guess of me having a "big boy" to be discussing this method. Our doula had to push back a little because I was in such shock I was speechless! OB from h*ll also made the comment "it's like taking apart a carborater that if she did it she could get all the pieces back together but if not..." UGH!!!!! fast forward while I'm pushing she even said "I could make this go faster" thank goodness for our doula educating us and for our confidence in our knowledge and choice to refuse but seriously?! How that woman sleeps at night is beyond me. My "big" 8.5 lb baby came out just fine and I barely tore and healed within a couple weeks... So there!! :)
Rationale said…
There is one thing I always wonder about you guys who use layperson common sense to discredit a professional life saver with 8+ years of higher education backed by centuries of studies. Who do you trust? Are mechanics liars? Do you do all your car fixes yourself because GM is just spewing propaganda when it says combustion is required to propel a vehicle? If you fall out of a tree and break your leg in 2 places, who do you seek for help? Is the hospital credible in that case?

Rationale said…
Denisse she probably sleeps at night because she has saved hundreds of babies lives for every 1 that has fallen out of you on its own. "So there!!" You do realize even though you didn't need these procedures, that they do save lives and are requires sometimes. You realize this right? I got lucky, so that makes me smarter than my OB har. God it makes my head hurt to see this bs. Sentences I would think could only be formed by a computer throwing random words together.

Thank goodness for the Doula educating us? Do you realize that the only difference in a doula and an OB is a vast education?