Episiotomy vs Tearing
When it comes to birth, there are many things to learn, and choices to make.
Who will be my midwife or doctor?
Where should I give birth?
Unmedicated birth or epidural?
Tearing naturally or a surgical cut?
Wait … what? A surgical cut or tearing?
While not every woman tears, it’s a common concern among pregnant women, and it does sometimes occur.
As with many aspects of birth, we often have choices. One choice is either to allow your perineum to tear naturally, if it’s going to happen, or to have a routine episiotomy, which is a surgical incision in the perineum (the tissue between the vaginal opening and the anus).
If you’ve talked with other women, especially older women, you might have heard that an episiotomy is cleaner and better at healing. At one time, doctors believed that, and therefore that’s what women heard. However, we now know this isn’t the case in the majority of situations.
So, which is best, tearing naturally or an episiotomy?
What Is An Episiotomy?
During birth, your baby moves down the birthing canal (vagina) and crowns at the opening of your vagina. The tissue between the vaginal opening and your anus is the perineum.
Our bodies were designed to give birth. Therefore the tissue in the vagina and perineum has quite a bit of elasticity, especially when we’re patient, but sometimes the perineum will tear as baby is born.
Instead of waiting to see whether the perineum will tear naturally (or simply stretch and allow for baby to pass), or whether complications will arise, sometimes during birth the doctor will make a surgical incision in the perineum. This is an episiotomy.
In 2005, around 25% of women giving birth in the US had an episiotomy. This is a sharp drop from the days when routine episiotomy was the norm, and when, in some places, the majority of births involved an episiotomy. Nevertheless the figure is still quite high.
We now know routine episiotomy isn’t evidence-based.
For this reason, both ACOG and the World Health Organization (WHO) advise against routine episiotomies.
What Is A Natural Tear Like?
When we think of vaginal tearing it can be quite intimidating. And the fact that nearly 90% of women experience some vaginal tearing might even sound terrifying. However, it’s extremely important to note that nearly 99% of vaginal tears are minor, and heal quite quickly and easily.
Many minor tears won’t even need stitches – just typical postnatal care, and time to heal.
As so many women experience minor tears, it seems it’s a typical part of birth. There are ways to prevent tearing, but overall, even if tearing occurs, it’s often very mild.
As the baby crowns, vaginal and perineal tissue will stretch to accommodate her birth. The very top of the perineum is quite thin when stretched and so, as baby is born, some minor tearing can occur.
Not all women will experience this crowning sensation, and not all women will tear.
Some women refer to the crowning sensation, with or without tearing, as the ‘ring of fire.’ While this can sound scary, the sensation is often short lived, and is your body’s way of telling you to be patient and let the tissue stretch, rather than push with all your might immediately your baby crowns.
While many women feel crowning, few actually feel a tear.
In most situations, tears are superficial, and only involve the skin. This is known as a first degree tear, which might require a few stitches, or none.
A second degree tear goes through the skin and the muscle just beneath it. A second degree tear requires a few stitches.
A third degree tears involve the skin, muscles, and perineal tissue, and requires stitches.
A fourth degree tear is like a third degree tear, but it also involves the muscles around the anal sphincter. Third and fourth degree tears account for just 1% of tears.
While they can happen naturally, third and fourth degree tears are very often the result of an episiotomy.
What Are The Risks Of An Episiotomy?
An episiotomy is one of the most common surgical procedures. While it might seem minor, it is still a surgical incision. And, as with all procedures, there are risks. It’s important to know the risks so that you can decide whether the benefits of the procedure outweigh the potential risks.
Risks of an episiotomy include:
- Damage to muscle tissue, due to a third or fourth degree tear
- Incontinence, due to a deeper tear, especially fourth degree
- Prolonged postnatal healing
- Nerve damage
- Pain, discomfort, and swelling
- The need for stitching, often more than that required for natural tears
- Painful intercourse, due to tough scar tissue after healing
What Are The Risks Of A Natural Tear?
Birth is a normal physiological process. There are still some risks involved, as with pretty much any aspect of life. However, as mentioned above, many women experience vaginal tears which are almost always minor. Therefore, tearing can be seen as a somewhat expected or normal part of birth.
Risks of a natural tear include:
- Infection during the healing phase, although good hygiene is typically enough to prevent this
- Bleeding, often quite minor
- A small risk of third or fourth degree tearing, but this rarely occurs with natural tears where there is no episiotomy
- The need for stitches, typically fewer than after an episiotomy
- Nerve and tissue damage, if a tear goes upwards towards the urethra
Is A Natural Tear Better Than An Episiotomy?
Current evidence doesn’t support the use of routine episiotomy. In most situations, if any tearing is going to occur, natural tearing has less risk and often heals better.
Routine episiotomy increases the risk of severe tears, and long term perineal, vaginal, pelvic floor, and anal sphincter damage.
An episiotomy rarely has benefits over a natural tear. There are two exceptions: in the case of medical emergency, where baby needs to be birthed quickly; or where a natural tear goes upwards towards the urethra.
When Is An Episiotomy Necessary?
Evidence doesn’t support routine use, but there are some situations where an episiotomy is necessary, or has some benefits.
Some situations where an episiotomy might be considered beneficial:
- True fetal distress, when baby is low in the birth canal. In this situation an assisted birth (vacuum or forceps), or a wider opening is necessary to get baby out as quickly as possible
- When a forceps or vacuum assisted birth becomes necessary, an episiotomy is usually required, because of the way these tools are used
- A natural tear going upwards can cause damage to the urethra, and therefore an episiotomy, which is done at the lower part of the vagina, on the perineum, might provide enough ‘give’ to deter the tear from continuing upwards.
- Unique perineum anatomy: some women might have a very small perineum, meaning there’s very little space between the vaginal opening and the anus. If a tear appears likely, or a small tear has begun, an angled episiotomy might be performed, in the hope a tear won’t go through the vagina and into the anal sphincter.
You can read more about this in BellyBelly’s article When Is An Episiotomy (Cut To The Perineum) Necessary?
Can I Avoid Tearing And An Episiotomy?
Although some minor tearing is common, and usually heals quite well, there are many things that can be done to reduce the risk of tearing.
You can read more about reducing the risk of tearing in BellyBelly’s article Tearing During Birth – 9 Ways To Help Prevent Tearing
There are also many things you can do to reduce the risk of an episiotomy. Many prenatal choices, such as your choice of maternity care provider, can reduce the risk.
During birth, you can reduce the risk by remaining upright and active, avoiding an epidural, and limiting other interventions (to avoid falling into the cascade of intervention).
You can read more about avoiding an episiotomy in BellyBelly’s article, 7 Tips To Avoid Having An Episiotomy.