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.