When Is An Episiotomy (Cut To The Perineum) Necessary?

When Is An Episiotomy (Cut To The Perineum) Necessary?

Tearing, and having an episiotomy are common concerns for many pregnant women.

Taking steps to reduce the risk of tearing, and to avoid having an episiotomy is a significant component of birth preparation.

Evidence shows that routine episiotomies aren’t beneficial. Even in situations where tearing occurs, natural tears typically heal better than episiotomies. The World Health Organization (WHO) encourages using episiotomies only when medically necessary.

At one time, the episiotomy was a routine obstetrical procedure. Now, we know it’s best to avoid performing an episiotomy simply as part of routine care.

There are some situations, however, where an episiotomy is beneficial and necessary.

What Is An Episiotomy?

The perineum is the tissue between the vaginal opening and the anus is. An episiotomy is an incision made in the perineum, during the second stage of labour – the pushing stage.

An episiotomy is performed to widen the vaginal opening during birth.

Is An Episiotomy Ever Necessary?

Many obstetrical interventions originally came about due to either an actual need or a perceived need. Our bodies were designed to give birth. When it occurs in a safe environment, where physiological natural birth is facilitated, birth often unfolds quite well.

As with all bodily processes, during birth things occasionally deviate from normal or safe. In these situations, it’s wonderful that we have access to modern obstetrical interventions.

All intervention comes with risk, but in some instances the benefit outweighs the potential risk. Understanding the risks of intervention, including the risk of the cascade of interventions, is essential to making a fully informed decision.

As with all procedures, there are risks associated with episiotomies. They include:

  • Infection
  • Bleeding
  • Damage to muscle tissue
  • Incontinence
  • Prolonged postnatal healing
  • Pain, discomfort, and swelling
  • The need for stitching, which can lead to tough scar tissue

Considering these risks, there isn’t evidence to support routine episiotomies, which is why the WHO and American Congress of Obstetricians (ACOG) no longer support doing episiotomies on a routine basis.

Even with preparation, and after taking steps to avoid an episiotomy, it occasionally becomes necessary. Knowing when it might be necessary can help you make an informed decision about whether the benefit of the procedure outweighs potential risks.

Here are 3 situations where an episiotomy might become necessary:

#1: True Fetal Distress When Baby Is Near Birth

Heart decelerations can occur during a healthy labour and not be of concern. However, certain fetal heart rate patterns, decelerations which don’t correct after a contraction ceases, and other FHR concerns can be signs of true fetal distress.

In the absence of clear, true fetal distress, some healthcare providers might suggest, among other things, a mother changes position, or rests on the left side, to see if there is a positional reason baby isn’t tolerating contractions.

There are several reasons true fetal distress can occur – one example is cord compression. When fetal distress occurs, a quick birth becomes a necessity. If it occurs during the first stage of labour, or at the beginning of the second stage, a c-section birth is necessary.

If fetal distress occurs when baby is low in the birth canal, and close to crowning, an episiotomy is performed. This either speeds up labour, as baby can pass through faster, or creates space for a vacuum or forceps assisted birth.

#2: Natural Tears Occurring Towards The Urethra

In almost every case, natural tearing will heal better than an episiotomy. An episiotomy is often much deeper and more severe than a natural tear.

The exception to this is when there is an upward tear, rather than a perineal tear. A tear going upwards can cause more nerve and urinary tract damage, including damage to the urethra. This is harder to recover from, and can cause long-term damage and problems. In this situation, an episiotomy might carry less risk than a natural tear.

#3: When A Forceps Or Vacuum Assisted Birth Become Necessary

Forceps and vacuum assisted birth are typically used for true fetal distress. However, sometimes they’re used when a mother has struggled for a long period of time, and cannot push effectively. If mother and baby are tolerating the second stage well, there’s no strict time limit. Occasionally, however, mother or baby cannot tolerate the second stage, or the length of time has become a concern.

This is more common among women who have received epidurals, spinals, or strong pain medication. When a mother doesn’t feel the urge to push, she might struggle to push effectively, which can prolong the second stage. If little progress is made after an extended period of time, an assisted vaginal birth might be recommended. Because of  the way the tools are used, an episiotomy is almost always necessary.

Needing an episiotomy after an epidural is an example of the cascade of intervention which you can read more about in BellyBelly’s article The Cascade Of Intervention – What You Need To Know.

Are There Other Times An Episiotomy Is Necessary?

Some sources suggest an episiotomy for cephalo-pelvic disproportion (CPD). However, actual CPD is when the baby’s head will not pass through the pelvis, and therefore an episiotomy (which affects only the vagina and perineum) wouldn’t help baby to move through the pelvic bones.

Some sources might recommend an episiotomy for a larger baby. While that might sound necessary, in many cases, with some patience and perineal support, the tissue can stretch and allow for baby to pass without severe tearing.

Occasionally, a mother might have a very small perineum, meaning there’s very little tissue between her vaginal opening and anus. If it looks as though she might tear deeply, an episiotomy might be performed on an angle, in the hope of preventing a tear straight through the vaginal opening into the anus.

In situations like these, it might be helpful to take steps to reduce the risk of tearing, which might then reduce the risk of needing an episiotomy.

You can read more about preventing tearing in BellyBelly’s article Tearing During Birth – 9 Ways To Help Prevent Tearing.

Whether you experience a natural tear, or an episiotomy becomes necessary, there is the potential for both to heal quite well.

You can read more about perineal healing in BellyBelly’s article 6 Ways To Heal Your Perineum After Giving Birth.

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Maria Pyanov CPD, CCE CONTRIBUTOR

Maria Silver Pyanov is a mama of four energetic boys and one unique little girl. She is also a doula and childbirth educator. She's an advocate for birth options, and adequate prenatal care and support. She believes in the importance of rebuilding the village so no parent feels unsupported.


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