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. 

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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. 

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Image via Flickr/ Lars Plougmann

Dr. Daniel RoshanMD, 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.

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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? 

What do you think?

What You Need to Know About Episiotomies and Tearing

Chaunie Brusie is a coffee mug addict, a labor and delivery nurse turned freelance writer, and a young(ish) mom of four. She is the author of "Tiny Blue Lines: Preparing For Your Baby, Moving Forward In Faith, & Reclaiming Your Life In An Unplanned Pregnancy" and "The Moments That Made You A Mother". She also runs Passion Meets Practicality, a community of tips + inspiration for work-at-home mothers. ... More

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1 comment

  1. Profile photo of Ash Ash says:

    Thank you for discussing this very important birth topic. As a mother of four who has birthed children 8-10lbs naturally and vaginally, I have some insights and opinions on this. But also, as a writer who has researched childbirth, I also have some facts and studies to share.

    First off, I must say that don’t agree with this doctor’s stance at all. He’s obviously lacking data on some very relevant stats.

    For one thing, I think it’s important to note that this doctor is assisting births which I’m sure almost ALWAYS involve a woman lying on her back. This is probably the worst position a woman could birth in because it narrows the pelvic opening, it doesn’t utilize the help of gravity, it inhibits the use of the core muscles rather than activate them, and it doesn’t enhance pushing like a squatting or hands-and-knees position.

    (Check out this video for a visual explanation: http://www.daniellopezdo.com/why-the-traditional-birthing-is-not-ideal/)

    If you’re delivering babies born to women who are pushing in a position which reduces the efficiency of pushing and narrows the birth canal opening, then a birthing woman is obviously going to need assistance. But if this doctor had this woman change up her birthing position, or encouraged her to push in a way which felt natural and comfortable to her, then I’d bet $10K that his episiotomy rate would drop by half. Easy.

    Episiotomies are performed with the idea that they will help the baby to be delivered quicker and easier (especially suspected big babies). Some women may indeed lack the wide opening their baby requires– especially if they were sewn up too tightly after a previous episiotomy — but this intervention is often performed to speed up birth. Whether the desire to speed up birth is medically-justified or not, this “help” often pairs an episiotomy with assistance via forceps or the vacuum cup. Forceps and vacuum cups are actually the NUMBER ONE risk factor for shoulder dystocia.

    http://www.aafp.org/afp/2004/0401/p1707.html

    But it would be worth the pain if an episiotomy would reduce the risks of baby developing a permanent brachial plexus injury from shoulder dystocia. Right? Of course it would be. But a 2010 report by the American Journal of Obstetricians and Gynecologists found that this is not the case. After looking at 11 years of data involving over 94,000 births, they concluded that episiotomies DO NOT reduce the risks of brachial plexus injury from shoulder dystocia.

    http://www.ajog.org/article/S0002-9378(11)00452-2/abstract
    The other issue with giving episiotomies is suspected big babies. Larger babies are at higher risk of shoulder dystocia and brachial plexus, however the chance of a woman delivering a “large baby” (8lbs 15oz or more), is less than 8%. However, far more than 8% of expectant mothers are being told their baby is large. The survey Listening to Mothers looked at women who had born told their baby was large. For every five women suspected to be carrying a large baby, four gave birth to a baby weighing less than 8lbs 15oz. Meaning, they didn’t fit the medical definition of large baby.

    Why does it matter is a baby is suspected to be large or not? Well, a 2008 report by Obstetrics and Gynecology found that, compared to women who birthed unsuspected large babies, women who birthed large babies which had been suspected to be large had three times the rate of induction, more than three times the occurrence of c-section, and over four times the rate of maternal complications. This is a problem, because when a woman is coached on the possible risks and problems of her upcoming birth, this instills her with fear and doubt. Because she’s hearing all the risks of birthing a big baby — which she only actually has an 8% chance of birthing — she is far more likely to agree to interventions like episiotomy and c-section which she may not actually need. She’s not being told about the inaccuracy of third trimester weight estimates, and she sure as heck isn’t being educated on the different positions which can help her (ie. The Gaskins Maneuver). Instead of being assisted and served for her birth, she’s being told what to do and she has any sense of control and self-efficiency dissolved.

    In 2015, the CDC created a report on birth data from 2013 titled When Are Babies Born: Morning, Noon, Or Night? (see here: https://www.cdc.gov/nchs/data/databriefs/db200.htm). In this report, you see data for in-hospital births as well as non-hospital births. What’s really interesting, is the data which breaks hospital births down according to c-section without labor, and c-section with labor attempted. It also compares data for c-section births, induced vaginal births, and non-induced vaginal births. The results of the data are shocking. For expectant mothers and present mothers, it should be infuriating.

    C-section births for mothers who attempted labor spike at 8am and noon (which just happens the most common times for scheduled c-sections — two birds with one stone?). C-section births with labor reached their highest peak at 5 and 6pm, then spiked again at 8pm. Is is just a coincidence that these peaks fall along dinner time? Maybe. But this data reveals that non-hospital births are more likely to occur between 1am and 5am. Meanwhile, the vast majority of hospital births happen between 8am-5pm. Work day hours. If the time of day puts a woman at higher chance (aka risk) of c-section, then it stands to reason that it also puts a woman at higher risk of episiotomy.

    So, needless to say, I think the doctor interviewed here needs to be updated on some rather vital stats and findings.

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