Episiotomy: The Birth Intervention I Want Every Woman to Know About About

If you're pregnant and planning a vaginal birth, I want you to know what an episiotomy is—and why I don't believe it should be treated as a normal part of birth.

An episiotomy is a surgical incision made through the perineum—the tissue between the vaginal opening and anus—to make the vaginal opening larger during birth.

For generations, women were told this was a routine way to "help" the baby out, prevent severe tearing, or protect the pelvic floor.

But routine episiotomy is not supported by the evidence.

A Cochrane review of randomized trials found that restrictive use of episiotomy resulted in less severe perineal trauma, less suturing, and fewer healing complications than routine use. The review concluded that the rationale for routine episiotomy to prevent severe perineal trauma is not justified by the evidence. (cochrane.org)

So why are women still consenting to them?

Sometimes, they aren't even given the opportunity to make a meaningful decision.

And that's where this conversation gets much bigger than the episiotomy itself.

An Episiotomy Is an Intentional Injury

Let's call it what it is.

A surgical cut through your perineal tissue.

That tissue then has to heal.

You can experience swelling, bleeding, pain, sutures, scar formation, wound complications, and restricted tissue mobility.

And while some women heal without lasting problems, others don't.

Perineal trauma can contribute to persistent pain, pelvic floor dysfunction, and painful intimacy. Research has found associations between episiotomy and postpartum dyspareunia.

This matters to me as a pelvic floor therapist because I see what can happen after the stitches are gone.

A woman may technically be "healed," but her scar may still be sensitive.

The surrounding pelvic floor muscles may remain guarded or overactive.

She may feel pulling, tightness, tenderness, or pain with penetration.

And she may assume:

"This is just what sex feels like after having a baby."

It isn't something you simply have to accept.

Your Body Doesn't Need to Be Cut to Make Room

Your perineum is designed to stretch.

During birth, your baby's head gradually moves through the vaginal opening, and the tissues of the pelvic floor and perineum stretch to accommodate your baby.

Sometimes, those tissues tear.

And that's not automatically a bad thing.

In fact, most spontaneous perineal tears are minor. RCOG reports that up to 9 in 10 first-time mothers who have a vaginal birth experience some degree of tear, graze, or cut, but most spontaneous tears are minor and heal quickly and are very unlikely to cause long-term problems.

That's an important distinction.

Tearing is common. Severe tearing is not.

ACOG similarly notes that most obstetric lacerations do not result in adverse functional outcomes. It is the less-common severe lacerations extending into or through the anal sphincter complex that are associated with substantially greater long-term risks.

And when a natural tear does occur, it may be smaller and shallower than an episiotomy. One randomized study found that, in non-operative vaginal births, spontaneous perineal tears were easier and faster to repair than episiotomies.

So why do we assume that cutting the perineum is somehow better than allowing the tissues to stretch and, if they need to, tear naturally?

I don't.

I would much rather see a woman's body given the time and space to stretch than have healthy tissue surgically cut in anticipation of a problem that may never occur.

And this is exactly why I want women to understand that "preventing a tear" is not automatically a reason to perform an episiotomy.

And an Episiotomy Can Extend

This is the part I especially want pregnant women to understand.

An episiotomy doesn't necessarily stop where the provider makes the incision.

The incision can extend into surrounding tissue—and if it extends into the anal sphincter, you have an obstetric anal sphincter injury (OASI).

A first-degree tear involves only skin.

A second-degree tear involves skin and pelvic floor muscles.

A third-degree tear involves the anal sphincter.

A fourth-degree tear extends through the anal sphincter and into the anorectal mucosa. (ncbi.nlm.nih.gov)

And this is not a minor injury.

Your anal sphincter is part of the system that allows you to control gas and bowel movements.

Severe perineal injuries involving the anal sphincter are associated with increased risks of fecal and urinary incontinence, pelvic floor injury, pain, and sexual dysfunction, with symptoms that can persist for years after childbirth. (pubmed.ncbi.nlm.nih.gov)

Some women with OASI experience difficulty controlling gas.

Some struggle to control stool.

Some develop symptoms years later.

And in the most severe, refractory cases, where bowel-control dysfunction cannot be adequately managed, a diverting ostomy (stoma) may eventually be considered. This can mean surgically diverting stool through an opening in the abdomen rather than passing it through the anus, and in rare cases may become permanent.

And some require ongoing pelvic floor rehabilitation or additional medical or surgical treatment.

This is why I don't want women thinking an episiotomy is simply "a few stitches."

The location and depth of that injury matter.

The Cascade of Interventions

Here's the conversation I think we need to have more often:

The episiotomy may be the final intervention—but it isn't necessarily where the story began.

A labor may begin without

complications.

Then an intervention is introduced.

Perhaps labor is induced or augmented with synthetic oxytocin (Pitocin).

Perhaps you're connected to continuous monitoring.

Perhaps movement becomes more limited.

Perhaps another intervention is added.

Eventually, there may be concerns about labor progress or the baby's heart rate.

Now you're being told you need a vacuum or forceps.

And then:

"We need to make a cut to get the baby out."

This is what I mean by the cascade of interventions.

I'm not saying that every intervention causes the next one.

I'm saying that interventions can change the circumstances of labor and can increase the likelihood of additional interventions.

And there is evidence to support pieces of this connection. For example, synthetic oxytocin (Pitocin) use has been associated with increased odds of episiotomy in a recent systematic review and meta-analysis. (pubmed.ncbi.nlm.nih.gov)

ACOG has also noted that continuous electronic fetal monitoring is associated with increased cesarean and instrumental vaginal birth compared with intermittent auscultation in low-risk pregnancies. (acog.org)

This is why I don't want you to approach birth as a spectator.

Your birth decisions matter.

Don't Give Away Your Power Before Labor Even Starts

One of the biggest problems isn't simply that interventions happen.

It's that many women enter birth believing:

"My doctor knows best. I'll just do whatever they recommend."

Of course your provider has medical expertise.

But you are still the person giving birth.

You should understand what is being recommended, why it is being recommended, what alternatives exist, and what the potential consequences are.

And you should have these conversations before you're in labor.

Because it is very different to research an episiotomy at 30 weeks pregnant than to hear:

"Your baby needs to come out now. We're going to make a small cut."

You're exhausted.

You're vulnerable.

You're focused on getting your baby here safely.

And suddenly something you never expected is happening to your body.

That's not the time to learn what an episiotomy is.

Your Birth Plan Should Include More Than "No Episiotomy"

I don't want you to simply write:

NO EPISIOTOMY

on your birth preferences and hope for the best.

I want you to understand why you're saying it.

Ask your provider (before hiring them):

• What is your episiotomy rate?

• Under what circumstances do you perform them?

• Do you perform them routinely during assisted vaginal birth?

• Will you ask for my consent before cutting?

• What alternatives will you try first?

• What can we do during labor to minimize perineal trauma?

  
  

And talk about this with your support person, too.

If you're unable to advocate for yourself in the moment, I want the people supporting you to understand your wishes.

Prepare Your Pelvic Floor Before Birth

This is also why I believe prenatal pelvic floor preparation matters.

Your pelvic floor doesn't need to simply be strong for birth.

It needs to be able to relax.

It needs to lengthen.

It needs to coordinate with your breathing.

It needs to respond to pressure.

It needs to allow your pelvic outlet to expand.

And you need to understand how your body feels when you're unintentionally gripping or holding tension.

Birth preparation can include pelvic floor relaxation, breathing mechanics, positioning, perineal preparation, mobility, and learning how to work with your body's natural processes during labor.

No preparation can guarantee that you won't tear.

But I would much rather see a woman enter birth understanding her body and her options than enter birth completely dependent on whatever happens around her.

And remember: a spontaneous tear is not automatically a complication. Most are minor and heal quickly. The goal is not to become terrified of tearing; the goal is to avoid unnecessary cutting and give your body the opportunity to stretch naturally.

I'm Not Neutral About Episiotomies

I'll say it plainly because I don't want there to be any confusion about where I stand:

I am strongly opposed to episiotomies.

I don't believe cutting a woman's perineum should be normalized as a routine part of vaginal birth.

I don't believe women should be told that cutting them is simply "helping" the baby.

And I don't believe the potential consequences should be minimized as "just a few stitches."

We're talking about tissue that is part of your pelvic floor.

We're talking about scar tissue.

We're talking about pain.

We're talking about pelvic floor tension.

We're talking about painful intimacy.

And in cases where the injury extends to the anal sphincter, we're talking about OASI and the possibility of long-term bowel-control problems. (pubmed.ncbi.nlm.nih.gov)

We're also talking about the fact that most women do not experience a severe tear. Most spontaneous tears are minor and heal quickly.

The evidence does not support routine episiotomy.

And women deserve to know that.

You Don't Have to Be Afraid. You Need to Be Informed.

My goal isn't to make you afraid of birth.

It's to make you informed enough to participate in it.

There is a huge difference.

I want you to know what an episiotomy is.

I want you to understand the potential consequences.

I want you to understand how interventions can build upon one another.

I want you to understand that you have a voice in your care.

And I want you to prepare your pelvic floor before you're lying on a delivery bed trying to learn how to relax it for the first time.

Your body is not simply something that birth happens to.

You deserve to understand it.

You deserve to advocate for it.

And you deserve providers who respect your informed choices.

Learn. Prepare. Ask questions. Speak up.

Because protecting your pelvic floor starts long before your baby is born.

This article is educational and is not a substitute for individualized medical care. Discuss your individual birth preferences and circumstances with your maternity care provider.

References

References

• Cochrane. Selective versus routine use of episiotomy for vaginal birth.

• American College of Obstetricians and Gynecologists. Prevention and Management of Obstetric Lacerations at Vaginal Delivery.

• American College of Obstetricians and Gynecologists. Approaches to Limit Intervention During Labor and Birth.

• American College of Obstetricians and Gynecologists. What Is an Episiotomy?

• Royal College of Obstetricians and Gynaecologists. Perineal Tears During Childbirth.

• Royal College of Obstetricians and Gynaecologists. FAQs: OASI Care Bundle.

• Royal College of Obstetricians and Gynaecologists. Third- and Fourth-Degree Tears (OASI).

• Sagi-Dain et al. In women with spontaneous vaginal delivery, repair of perineal tears might be easier compared to episiotomy.