What You Need to Know About Episiotomies and Tearing
When I had my first daughter, I was confident that I wouldn't be faced with an episiotomy. In the hands of a nurse/midwife who boasted a less than 1% rate of making the cut, I felt good that I would be spared the fate of a sliced perineum.
But, as is the experience with many first-time mothers, what I thought about how my baby's birth would go and what actually happened were two very different things, and I did end up getting an episiotomy with not only my first, but also my second birth. With my third child (and a new care provider — this time a doctor), I begged not to be cut and instead tore as a result.
So having experienced both ends of the spectrum, so to speak, I wondered, from a professional's perspective, what the difference was between an episiotomy and tearing and if there was a benefit to one or the other.
Dr. Daniel Roshan, MD, FACOG, FACS, assistant professor at NYU School of Medicine Department of OB/GYN, Division of Maternal-Fetal Medicine Director at ROSH Maternal-Fetal Medicine, explains that, first of all, women need to understand that there are four different categories, or degrees, of tearing during birth:
- First degree: Tearing only in the vaginal mucosa
- Second degree: Tearing in the vaginal mucosa and in the muscle underneath (bulbocavernosus muscle)
- Third degree: Tearing extends to the rectal sphincter
- Fourth degree: Tearing extends to the rectal mucosa
All tears are not made alike, and third- and fourth-degree tears, aside from being extremely painful, can also put women at risk for fistulas, or passageway-like openings, that develop between the anus and the vagina, which is about as horrifying as it sounds.
However, as frightening as the thought of a tear might be, Dr. Roshan says that natural tears are generally “less painful” for women, and after having experienced both, I will attest to that. My episiotomy pain hurt so much worse, to the point that I was in tears weeks after birth.
Recovery-wise, Dr. Roshan states that healing is good usually in both but, again, will depend on the severity of the tear and, in some cases, the skill of the provider who is stitching you up. He also notes that most tears still require stitches for optimal healing.
So how did episiotomies come about? Why the myth that some doctors think it's better to cut the perineum right from the start?
“Usually with the first baby, patients either have a tear or episiotomy,” Dr. Roshan explained. “Some doctors think that with [an] episiotomy the cut is straight and its easier to put together. The laceration sometimes is really hard to fix, as it could be in different direction and hard to repair. Some also used to think that with episiotomy the vagina stays more intact and tighter.”
Dr. Roshan estimates that the average episiotomy rate in his practice is around 35%, mostly done for first-time mothers giving birth. According to the CDC, out of almost 4 million births in the United States in 2010, 320,000 of those required episiotomies, placing the national episiotomy rate closer to 8%.
So what's the answer? Which is better for a woman: an episiotomy or a tear?
“There are many issues involved here, and there is no straight-forward answer to which is better,” Dr. Roshan says simply. He notes that, ultimately, it is up to the doctor's judgment but stresses that without any pressing need or a baby in distress, it's better to aim for a slow delivery to protect a woman's perineum.
However, he cautions that in a situation where a baby's head seems to be very large and there is a fear of multiple lacerations in the front and back, a very small episiotomy might prevent a very bad laceration. “Lacerations are sometimes very hard to put together and are associated with blood loss,” he explains.
Dr. Roshan recommends that women stretch their perineum with oil on a daily basis starting at 36 weeks to prevent tears. “This will allow the perineum to stretch better during delivery of the head,” he notes. He mentions that it's also helpful for women to monitor their weight gain throughout the pregnancy, as the bigger the baby is, the more chance there is for big tears. (Easier said than done, Doc!)
And when it comes time to the big finale of pushing, slow and steady wins the race here. “Controlling the delivery of the head and slow pushes at the end help to decrease the risk of laceration,” he says.
But there is good news on the horizon for us ladies prone to give birth to big babies — more babies usually equals less risk of further damage. “Second babies are usually much easier to come out, and often there is no need for [an] episiotomy,” Dr. Roshan explains.
And allow this mom of four to tell you. After I finally birthed a baby with no tears or cuts whatsoever, it makes a world of a difference. I was up within an hour, and even peeing was not a problem. I never realized it was possible to feel so good after birth. So ladies, oil that perineum up, avoid the brownies, and have a heart-to-heart with your care provider about your delivery goals, because when it comes right down to it, you're the one leading the show during birth.
Did you have an episiotomy during birth?