Protect Your Perineum-Part Two

Lisa Baker is a childbirth educator and mother of two in Calgary, Alberta. You can reach her by email at lisabakerlcce@gmail.com

In part one of this series we defined perineum and perineal trauma and discussed factors that can help reduce the occurrence or severity of tears during childbirth. In part two of this series, we look more closely at the topic of episiotomy.

 An episiotomy is a surgical cut made at the vaginal opening in an attempt to widen it. This cut may extend from the vagina straight down towards the anus (median or midline incision), or it may extend from the vagina toward one side or the other (mediolateral incision).  In terms of perineal trauma, an episiotomy is comparable to a second-degree tear in the fact that it involves perineal muscle and requires stitches to heal properly.

Episiotomies are being done in Canadian hospitals, but they are not a routine procedure that all labouring women will experience. In a recent Canadian survey of maternity care policy, none of the hospitals questioned have a policy that all women are to receive an episiotomy (1). In most hospitals (74%) there is no policy on episiotomy. Rather, it is left up to the individual physician or midwife to decide an appropriate course of action. The results of the survey suggest close to 20% of Canadian women receive an episiotomy, although rates vary across individual provinces and territories (1).

There is certainly a time and place for episiotomies.  In the event that a baby is close to being born and shows signs of distress, an episiotomy may help to deliver the baby as quickly as possible.  However, such cases are not the norm. It has been suggested that episiotomy rates can be safely lowered to 7% or less of labouring women (2). This means that some of the episiotomies occurring in our country are likely not necessary. Unless there is a health concern for you or your baby, avoiding an episiotomy may help lessen the occurrence or severity of perineal trauma.

The act of having an episiotomy is, by itself, a form of perineal trauma. In addition, the results of several large trials indicate that routine use of episiotomy in hospitals increases the number of third and fourth degree tears involving the rectum (3).  Episiotomy has also been shown to increase one’s risk of healing complications one week after birth (3). It is interesting to note that the direction of the incision plays a factor here. The median incision, which runs from the vagina towards the anus, increases the risk of third and fourth degree tears (2). The mediolateral incision does not increase the risk of third and fourth degree tears, however it can involve a longer, more painful healing period and scar complications (2).  As mentioned before, most Canadian hospitals do not have a policy on episiotomy so the direction of the incision is made at the physician or midwife’s discretion.  Although there is a higher risk of third and fourth degree tears and healing complications, most women with an episiotomy will not experience these side effects. There are some simple self-care tips you can do to promote healing and get pain relief if you receive an episiotomy during childbirth.

You can take several steps to reduce the likelihood of an episiotomy. The first step, perineal massage, was highlighted in post one of this series. The second step is to talk with your birth team (doula, nurse, midwife or doctor) about your reasons for wanting to avoid an episiotomy and discuss strategies to reduce your chance of receiving an episiotomy unless medically necessary. This article from Childbirth Connection outlines reasons for an episiotomy that are not supported by research and may be helpful if you are feeling pressured into an episiotomy for something other than a clear medical reason.  The third and fourth steps, upright positions for birth and perineal support with warm compress, are the subjects of next week’s post.

To protect your perineum, avoid receiving an episiotomy unless medically necessary. Although routine episiotomies are no longer the case in Canada, some practitioners are more likely than others to perform them. Try to discuss your preferences with your birth care team when you arrive at the labour and delivery unit of your hospital. Despite efforts to avoid an episiotomy, it may become necessary for the health of you or your baby. In the event of an episiotomy, discuss self-care techniques with your doctor or nurse and allow time for a healthy recovery in the postpartum period.

(1) Public Health Agency of Canada. Canadian Hospitals Maternity Policies and Practices Survey. Ottawa, 2012.

(2) Childbirth Connection. Episiotomy. http://www.childbirthconnection.org/article.asp?ck=10203. Retrieved on January 9, 2013.

(3) Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD000081. DOI: 10.1002/14651858.CD000081.pub2.