While many healthcare providers and birth facilities are making an intentional policy and practice shift away from routine episiotomies, some continue to perform them routinely, often justifying the intervention as a ‘medical decision’ and necessary for mother and baby wellbeing. Questions need to be asked why there is a routine need for Episiotomies and what practices have been put in place for a mother to avoid having an Episiotomy unnecessarily.
What is an Episiotomy?
An episiotomy is an incision made on the perineum – the tissue between the vagina and anus – during birth. This procedure is performed during the second stage of labor, the pushing stage. The purpose of the procedure is to make the vaginal opening wider for birth.
Routine episiotomy was a standard obstetric procedure for several decades, but now we are seeing a decline. Why? There is no evidence to support routine episiotomy.
Routine episiotomies were thought to prevent pelvic floor damage and reduce the risk of tearing. We now know that is not true. The World Health Organization recommends restrictive use of episiotomies. Meaning, they should only be used when medically necessary.
Tips to help you avoid having an Episiotomy
If you are concerned about getting an unnecessary episiotomy, here are some tips to help you:
#1: Choose A Provider That Doesn’t Perform Routine Episiotomies
When selecting your midwife or doctor, it’s important to ask how they typically attend to birth. Choosing a provider you’re comfortable with and one that has a similar birth philosophy as you can help you have a positive birth experience.
Choosing the right provider can lower your risk of interventions including unnecessary cesareans and routine episiotomy. When interviewing different providers, you may want to ask under what circumstances do they recommend an episiotomy.
You may also want to ask if they seek verbal consent in the moment if they believe an episiotomy is necessary. You may have already given written consent via admission papers, but many mamas would like to make an informed choice, rather than allowing the provider to simply perform a procedure at their own discretion.
#2: Make Informed Decisions About Medicinal Pain Relief
Having an epidural during the second stage of birth (pushing) is not usually recommended, but having one can increase the need for intervention. Inability to feel the urge to push might make it difficult to push effectively. If you’re unable to push well you may need an assisted birth which requires an episiotomy.
If you choose an epidural, your provider may turn off or lower the dose during the second stage. This might help you feel the urge to push and lower the risk of needing an assisted birth.
Being aware of the possibility of needing an assisted birth and episiotomy can help you weigh the benefits and risks of using medicinal pain relief.
#3: Choose An Upright Position For Birth
It isn’t uncommon to believe giving birth on your back is the normal position. While this is often the norm in Western culture, it isn’t the most effective position for laboring or pushing.
When you’re on your back, you’re losing gravity, as well as putting more pressure on your pelvic floor, and having to work hard to help baby navigate the birth canal. This can slow down pushing and even make it seem like baby is struggling to fit. If baby seems to be struggling, your provider may feel assisting baby is necessary which would necessitate an episiotomy. Being upright may prevent this altogether.
Remaining upright and listening to your body to find a comfortable position can help you push more effectively. When baby is descending well and you are both tolerating second stage well, there is less of a chance of needing an assisted birth. Being upright may reduce your risk of episiotomy and even the risk of natural tearing.
If you need to be lying due to an epidural, fatigue or other medical reason, left side-lying can help keep pressure off the pelvic floor and help baby navigate the birth canal.
#4: Try To Facilitate Optimal Fetal Positioning
Babies descend easiest when they are head down, facing mama’s spine, and with their back to one side of the front of mama’s tummy. In this position they can easily flex their head and navigate the birth canal. This position is known as occiput anterior, or OA — you may see this or a variant of it scribbled on your notes.
If you want to find out what position your baby is in when you’re getting closer to giving birth (bearing in mind it can change!), simply ask your healthcare provider what position the baby is in.
When babies are in a different position to OA it can make it trickier for them to descend. If they are posterior (OP), facing the stomach rather than facing the spine, a larger part of the head is birthed first. This makes it more difficult for them to maneuver through and can increase the need for an episiotomy.
Being upright, remaining mobile and the use of a rebozo are all ways you can help facilitate space for baby moving into optimal fetal positioning.
#5: Avoid Directed Pushing
Pushing without the natural hormonal urge can cause unnecessary exhaustion and may lead to premature engagement of your baby, who may not yet be optimally positioned for a vaginal birth. Both of these scenarios can lead to an assisted birth.
Listening to your body can help you be sure you and baby are ready to push. Working with your contractions and your body’s urge to push helps each push be more effective. This can help ensure baby is in a good position and you’re not wasting vital and precious energy. Both can help reduce the risk of needing an assisted birth and episiotomy.
#6: Request Perineal Support
Having a birth attendant support the perineum (i.e. with a warm compress) during pushing and crowning can help prevent tearing and facilitate tissue stretching.
If the tissue is allowed to slowly stretch while being supported the need for an episiotomy is reduced.
#7: Patience While Pushing
When mama and baby are tolerating labour well, the clock doesn’t always mean a lot. Giving mama plenty of time to give birth can help reduce the need for interventions.
Listening to your body and pushing with the urge often provides the best outcome for birth. Listening when to pause is also important. While you may have the urge to push, during crowing you may feel the ‘ring of fire’. This strong sensation is due to tissue stretching. Pausing when you feel this can allow your tissue to stretch. Pushing through can increase the risk of tearing and a provider may feel an episiotomy is necessary, to prevent worse tearing.
If baby is close to birth and mama and baby are doing well, there isn’t a need for rushing. Allowing mama’s tissue to stretch rather than performing an episiotomy is often a better option. When you ask your prospective providers about their use of episiotomy it’s good to find out if they feel pushing should take a certain amount of time.
Listening to your body, being patient and choosing a care provider who understands and supports natural labour and birth can all reduce the risk of an episiotomy.
When Is an Episiotomy Necessary?
Routine episiotomy is no longer recommended, but occasionally medical reasons arise. These are a few reasons an episiotomy might be necessary:
- Baby is close to birth and is experiencing true fetal distress, making speeding up birth necessary
- Cord compression during pushing, necessitating a quick birth
- Natural tears occurring at the top of the vagina, near the urethra
- If mama has had an epidural and is unable to push effectively, requiring an assisted birth with a vacuum or forceps
- Some sources state that an episiotomy may be necessary for CPD (cephalo-pelvic disproportion), which basically means baby is too big for your pelvis. But if the baby can’t fit through your pelvis, it doesn’t make sense that a cut to your perineum will free your baby from your pelvis, or that you can pull the baby out. If you have true CPD (which is rare), then you will likely need a c-section. CPD is overdiagnosed. A baby, big or small, may have shoulders stuck due to positioning (which is named shoulder dystocia), but the Gaskin Manouver has been successfully used by care providers to rectify the problem.
Being an informed, active participant in your birth preparation, labour and birth can help reduce the risk of an episiotomy. Birth is unpredictable, yet being empowered with information and knowing your rights in childbirth can have a great impact on your birth experience and most importantly, how you feel about your birth.
Medical interventions such as episiotomies are necessary when mother and/or baby become compromised. Should you require an episiotomy during your birth (for whatever reason), there are things you can do to facilitate your recovery and healing.
