Is episiotomy really
a necessary surgery?

One of the most commonly performed surgeries in the country, the episiotomy, could actually cause more harm than benefits, according to a recent federally funded study. Undergone by more than a million women a year during labor to prevent tearing, the results have caused doctors to question the need for the procedure. Dr. Iffath Hoskins, the executive director of the Women's Health Institute at Memorial Health University Medical Center in Savannah, GA, was invited on “Today” to explain what this study means for women and to answer some commonly asked questions about the procedure.

What is an episiotomy? 
It is a simple cut in the perineum, the area of the body between the opening of the vagina and the rectum.  It is usually performed to create more room in that area to assist in the delivery of the baby's head, and to avoid that area from tearing during the birth process.

How large is an episiotomy incision?
Usually the cut is planned to be as small as possible, approximately 1-1/2 inches long, but sometimes it can extend a bit.  It usually does not cause pain to the mother because the doctor anesthetizes that part of the body.

In the past, why were episiotomies performed? What did doctors hope they would prevent?
The general opinion was that the more controlled episiotomy would be as short as possible, not jagged like a tear, and easier to repair and heal than a tear.

What are some of the more adverse side effects of an episiotomy?
There are several side effects. Although most of these are rare, they are still known to occur.

• The cut extends and gets longer, sometimes going as far as the rectum area
• Infection is possible, and in very rare cases it may result in an abscess
• Bleeding, which may result in a hematoma, a collection of blood in the tissue, although this is very rare
• Future pain in that area. For example, while sitting, horseback riding or during intercourse
• Fistula formation — a small opening between the outside area, i.e. the surface, and the inside of the vaginal area.

A federally sponsored study showed that many episiotomies were unecessary. Can you further explain these results?
In short, they found what we have known for a long time — it seems to be better to "take a chance" and get a tear than to cut an episiotomy in advance of the baby's birth. You're trading a 100 percent chance of getting a cut, i.e. the episiotomy, versus a chance of getting a tear. The tear, if it does occur, may not be as long as the episiotomy cut, so why cut more than needed?

Although this all has been found before, this particular study is a good thing because the numbers are large and they reiterate what we have known and have tried to practice for many years.

What other options do women have instead of an episiotomy?
The most important tip for women is to discuss all options with your doctor ahead of time.  You can accept that there might be a tear and that it will be stitched up correctly. We now know the tear is usually only what's needed by the baby's head. The doctor or delivery person can also support the perineum and use massage, too, which may help avoid a tear.

When should an episiotomy be performed?

• If the delivery has to occur faster than it would naturally; for example, if the baby's heartbeat drops
• If additional room is needed for the baby's head
• If the patient says she doesn't want a tear
• If there are medical conditions, such as warts that would bleed
• If a tear occurs, then the episiotomy can be more controlled in length and also in direction. It doesn't always have to be a straight line going down toward the rectum. There are other options
• If a baby is being delivered by forceps or vacuum, the doctor may intentionally do one (though not always).

What advice do you have for women who are preparing for childbirth and may be faced with having an episiotomy?
I tell them first and foremost to discuss their wishes with the doctor, and to understand the doctor's policy on episiotomies. Try to do this long before labor, which is the worst time to discuss important information like this. Accept that if you do need an episiotomy or get a tear that it is not a failure in your ability to have a successful birth, because the ultimate goal is a healthy baby and mother. If this is what is needed to get to that end, then it’s a good thing.

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