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Episiotomy and Natural Tear

Rachel O'Reilly

Once a routine part of childbirth, an episiotomy is now recommended in certain cases only.

First and foremost: what is an episiotomy exactly?

  • An episiotomy is an incision made in the perineum - the tissue between the vaginal opening and the anus - during childbirth.

And why would you want anyone to cut your vagina during childbirth??

  • For years an episiotomy was thought to help prevent more extensive vaginal tears during childbirth and heal better than a natural tear. The procedure was also (incorrectly) thought to help preserve the muscular and connective tissue support of the pelvic floor.

Thankfully over the years research suggests that routine episiotomies don’t prevent these problems after all. The recovery is very uncomfortable since it requires a deeper layer of tissue to be stitched. And it’s often said that the incision is more severe than a natural tear would have been. One midwife helped me understand this by explaining trying to tear or rip a piece of fabric with my bare hands. She said it’s very challenging and takes a lot of effort. But, if you just snip a little bit of the fabric with scissors and then pull it’s a breeze. The incision in your pelvic floor tissue reacts very similarly. Once you cut the tissue it gives much more leeway to cause a deeper longer tear from the pressure of your baby making its way out. OUCH. NO THANK YOU.

Just like any medical intervention during birth, I’d prefer something like an episiotomy to be done only when it is really necessary. Often during emergency cases your healthcare provider will need the extra space at the vaginal opening to allow for an easier instrumental birth, i.e. the use of forceps or vacuum extraction. A few other reasons I’ve heard of episiotomies being absolutely necessary are if:

  • Your baby is in an abnormal position and needs more assistance to make it out

  • Your baby is very large (fetal macrosomia)

  • Your baby needs to be delivered quickly

Now that episiotomies are not a routine function in birth (please ask your healthcare provider what their percentage of episiotomies are, some still practice them more frequently than I’d like to see) there are a few things that many healthcare providers suggest doing in preparation for birth and during the birth process to lower the chances of needing an episiotomy.

Once you are 34 weeks it’s common for your healthcare provider to recommend doing perineal massage at home. This can be an uncomfortable exercise for some, but if it can help avoid a longer, harder recovery from birth, it’s worth reaching out of your comfort zone and getting busy. Make sure to have natural lubricant near by and lay in a supported position on your bed so that you are able to reach both of your thumbs to your vaginal opening. Place your thumbs just inside and press downward toward your rectum. Hold for one to two minutes and repeat for a total of ten minutes. If you are enjoying baths in your pregnancy this is a great place to give yourself a daly perineum massage and even more effective when your tissues are relaxed and warm.

During the second stage of labor, your OBGYN, Midwife and sometimes a nurse or doula will often use a hot compress to apply pressure against the perineum and vaginal opening. Sometimes a warm oil will be used along with applied pressure to the lower part of the vagina to encourage stretching (not too warm, don’t worry!). The goal is to soften the tissue with heat to allow it to stretch easier and to avoid tearing.

What are the benefits of a natural tear?

There have been several studies conducted to show the frequency of a natural tear versus an episiotomy during childbirth. Many studies show the occurrence of a natural tear of the perineum over an intentional cut of an episiotomy during childbirth. Part of the reasoning for this is the data suggest that women who have an episiotomy do not have significantly improved labor, delivery, or recovery compared with those who do not have one (ACOG statement). Also, by foregoing a routine episiotomy, the mother has a chance to stretch the perineum during the course of the second stage of labor (the pushing phase) and may avoid any perineal damage altogether. With an episiotomy, the connective tissue, muscles, and skin are cut and therefore their strength will be permanently compromised.

I know I want to give my body the chance to do what it is naturally capable of and to be supported during the second stage of labor in a way that allows my perineum to take its time to stretch and allow my baby to enter this world with as little medical interventions as possible.

Have you ever experienced an episiotomy or severe natural tear? If so, how was the recovery for you? How long do you feel like it took to have your body feel normal again?

This brings me back to thinking about postpartum support and care after delivery. It’s essential after all types of birth, especially when your pelvic floor experiences any trauma due to tearing or cutting, to search for additional support to help heal your body from birth.