When discussing childbirth, among the things many soon-to-be mothers worry about are vaginal tearing and episiotomy. The thought of having such a delicate area cut or torn is enough to make anyone squeamish. As one who has birthed four babies, I know first-hand what it feels like to tear naturally and to get an episiotomy—and you might be shocked to learn that it’s actually not as bad as you might think.
Truthfully, for one of my births, I’d already had an epidural administered when the episiotomy happened, so that one was a walk in the park. For the other births, I didn’t have an epidural, and yes, it hurt. Interestingly, due to the pain of the contractions and the baby crowning, I didn’t specifically feel myself tear. Nor did I feel the episiotomy because I was already in pain.
It was only after the birth that I realized my lady parts were a little worse for wear. It’s not surprising that a full-term baby may cause some damage when trying to exit such a small canal, but knowing the facts about episiotomy can help an expectant mother be prepared for this particular medical procedure.
What is an episiotomy?
An episiotomy is a procedure often performed during labor and delivery. It involves making a small cut in your perineum (area between your vaginal opening and your anus) to widen the vaginal opening and assist the birth of a baby.
An episiotomy might be recommended in situations where a baby is in distress and needs to be delivered quickly as this procedure can be a good way to speed up the birthing process. An episiotomy can also be necessary when a doctor needs to use birthing instruments, such as forceps or ventouse suction. This was the case during my first birth, and after seeing how huge the forceps were, I was grateful for having had the epidural.
Other reasons for needing an episiotomy include a breech birth, a really exhausted mother, or a range of health conditions that call for a fast delivery, for example, heart disease. Contrary to popular belief, a mother who has had a severe tear during a previous birth isn’t more likely to need an episiotomy in future deliveries.
How is an episiotomy performed?
If an episiotomy is deemed necessary, a doctor or a midwife will make a surgical cut in the perineum. Often, a local anesthetic is used to numb the area around the vagina so that it isn’t too painful. I am actually unsure whether I received a local anesthetic or not for mine as I only remember those painful contractions. The cut itself is a small, diagonal incision directed out to one side. Following the birth, the cut will be stitched back together using dissolvable stitches.
The history of episiotomy
The practice of episiotomy has been around for a long time, but it became a lot more popular during the 20th century. Chicago obstetrician Joseph DeLee advocated for the procedure because he believed that eliminating the pushing stage of childbirth by using forceps under general anesthetic was good practice.
Between 1940 and 1980, it became routine for episiotomies to be performed in many countries, including the USA, the UK, and Australia. By 1979, episiotomies featured in around 63% of vaginal births in the US. Doctors believed that the procedure protected the baby’s head from trauma and reduced incidents of perineum lacerations.
In 1984, research conducted by Jennifer Sleep found that there were no real benefits in performing a routine episiotomy. Her research was backed by several more studies, and it emerged that in many cases, the procedure did more harm than good.
In 2006, ACOG stated that there’s no immediate or long-term maternal benefit of routine episiotomy and changed its recommendations. It’s now widely believed that there are certainly times where an episiotomy is necessary for medical reasons, but the procedure should not be performed routinely.
Research data reveal that the use of episiotomy declined between 2006 and 2012, with 14.4% of deliveries involving the procedure. The World Health Organisation (WHO) recommends a global episiotomy rate of approximately 10% of births, which is roughly where it sits in most European countries.
What is the scale for perineal tears?
Perineal tears are classified on a scale of 1-4.
A 1st-degree tear consists of a shallow tear to the skin of the perineum. These tears don’t usually need stitches and heal naturally on their own. A 2nd-degree tear involves the skin and muscle layers of the perineum. An episiotomy is usually equivalent to a 2nd-degree tear and heals better when it is stitched up following the birth. A 3rd-degree tear involves the perineal muscles as well as the muscles surrounding the anus, and a 4th-degree tear involves the actual anus.
I was unfortunate to experience a 4th-degree tear during my forceps delivery despite having an episiotomy, but this was my first baby, and he ended up being a whopping 9 lbs 1oz (4.1kg). My subsequent deliveries involved one standard episiotomy followed by 2 1st-degree tears. It definitely did get easier each time.
Is it better to have an episiotomy or a natural tear?
Most doctors tend to agree that an episiotomy shouldn’t be used as a routine procedure. A natural tear usually heals much faster and comes with less risks. An episiotomy should not be used in situations where it isn’t completely necessary since it can increase the risk of a severe tear as well as long-term perineal, vaginal, pelvic floor, and anal damage.
The only time a natural tear can be worse than an episiotomy is if it goes upwards towards the urethra. In these circumstances, a doctor will likely perform an episiotomy to prevent long-term issues for the woman.
How long does it take to heal? Whether you have been cut or torn, it is normal to feel some pain and discomfort after birth. The episiotomy stitches should heal within a month of the birth, and a woman will usually experience some pain for 2-3 weeks after delivery.
Some tips I received to help with the recovery process included:
- Taking painkillers such as paracetamol to relieve the pain safely while breastfeeding
- Placing ice packs wrapped in a towel inside underwear
- Pouring warm water over the outside of the vagina while urinating to help ease discomfort
- Using a clean pad to gently apply some pressure to the cut when pooping
- Taking laxatives to make sure poop is softer and easier to pass
Without a doubt, the best of these was the icepacks. You won’t believe how much relief they can bring to a sore perineum.
Prevention of perineal tear during labor
While there are no guarantees, a pregnant woman can do a couple of things to reduce the likelihood of needing an episiotomy during birth. From around 35 weeks of gestation, performing Kegel exercises and perineum massages can help to strengthen and stretch the pelvic floor muscles in preparation for birth.
Although there are circumstances where an episiotomy is medically necessary, here is a useful video that talks about preparing your body for labor to reduce the likelihood of a tear.
If you’re pregnant and particularly concerned about the risk of an episiotomy or a vaginal tear, it’s a good idea to speak with your midwife or obstetrician. There is a reason we call it “labor,” and although childbirth can be scary for women, it can also be a wonderful experience with a pretty awesome reward at the finish line.