In the past, episiotomy (say "eh-pih-zee-AH-tuh-mee") was a very common part of childbirth. Today it is the subject of much debate.

More and more, women are choosing to get involved ahead of time in the decision about episiotomy. Many are asking their doctors to avoid episiotomies if at all possible. If you feel that you want one, talk to your doctor about it. Learn all you can about the pros and cons, and find a doctor or midwife who will support your choice.

Consider the following when making your decision:

• An episiotomy may be needed if the baby is in trouble and needs to be born quickly, or if the baby's position or size looks like it will cause deep tearing.
• Studies show that in normal births, episiotomies do more harm than good.¹ Women who give birth without an episiotomy may have some tearing, but episiotomies are more likely to cause deeper tears that are more painful and slower to heal.²
• Doctors used to think that if a woman had an episiotomy, she would have less pain, would heal faster, and would be less likely to suffer in the future from weakened pelvic muscles. But studies now show that this is not true.¹

What is episiotomy?

An episiotomy is a cut that the doctor or midwife makes in the perineum (say "pair-uh-NEE-um")-the skin and muscle between the vagina and anus. This cut is made just before the baby's head is delivered. It makes the opening of the vagina larger. It may be done to help deliver the baby or to prevent deep tears around the vagina. After delivery, the doctor sews the cut closed.

There are times when this cut is needed. Even though your perineum is made to stretch and be flexible during childbirth, a baby that is larger than normal or is in the wrong position can stretch it too far. If the doctor uses instruments such as forceps, they can add to the pressure. If it looks like the birth is going to cause more than a few small tears, you may need an episiotomy.

An episiotomy may also be needed if the baby is in trouble and needs help to be born quickly.

Many doctors no longer use episiotomies routinely, but a few still do. Although midwives can do episiotomies, they are much less likely to.³

What are the risks of episiotomy?

• Episiotomy cuts are longer and deeper than small tears, so they may take longer to heal. Women who have episiotomies are likely to have more pain in the weeks or months after childbirth.²
• Women who have an episiotomy may be more likely to have pain with sex in the months following childbirth. Because of this, they are slower to resume having sex.⁴
• Women who have episiotomies are more likely to have deep tears, which can happen when the baby's head puts pressure on the cut and makes it longer and/or deeper.¹ Deep tears damage the anal sphincter and/or rectal wall. When this area is damaged, you may lose some control of your stools or gas. Women who have had an episiotomy may be more likely to have this problem.⁴

What are the risks of not having an episiotomy?

• Without this cut, it may take a few more contractions to push the baby out.
• Some women, especially first-time mothers, will have some tearing. But the tears are likely to be smaller than an episiotomy cut and should heal in 2 or 3 weeks.
• Although it is not likely, it's possible that you could have a serious tear that hurts more and heals more slowly than an episiotomy cut.

What are the alternatives to episiotomy?

There are steps you can take to help prevent tearing:²

• Pay attention to your position during labor. You may feel more comfortable sitting upright, lying on your side, or getting down on your hands and knees, for example, instead of lying on a bed with your feet in stirrups. Different positions may put less pressure on your perineum.
• Avoid having anyone push down on your belly in an effort to speed up delivery. To keep from tearing, your perineum needs to stretch slowly and gently.
• Instead of pushing hard when a birthing coach tells you to, push with steady pressure when your body tells you to.
• Have someone provide perineal support, which means pushing against the perineum to protect it from tearing as the baby's head stretches it. This is sometimes done with a hot, moist cloth.
• Do regular Kegel exercises in the months before childbirth. These can strengthen your pelvic muscles.
• Practice perineal massage, which makes the tissue around the vagina more flexible. Some studies show that women who massage this area daily during the last part of their pregnancy are less likely to have tearing.⁵

Your choices are:

• Leave the decision to have an episiotomy completely up to your doctor.
• Work with your doctor or midwife before and during labor to avoid an episiotomy.

The decision whether to have an episiotomy takes into account your personal feelings and the medical facts.

Deciding about episiotomy

Reasons to plan on an episiotomy	Reasons to avoid an episiotomy
An episiotomy may shorten labor by a few minutes. Are there other reasons why you might want to plan on an episiotomy?	There is no evidence that routine episiotomy does any good for you or your baby. Episiotomy cuts usually take longer to heal than small tears. There is a risk of permanent damage to the rectum. Are there other reasons why you might want to avoid an episiotomy?

These personal stories may help you make your decision.

Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about episiotomy. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

An episiotomy is all right if it is needed to avoid a large tear or to protect the baby, but not for any other reason.	Yes	No	Unsure
I would like to avoid tearing if possible, but I would rather have a tear than an episiotomy cut.	Yes	No	Unsure
I want to give birth as naturally as possible.	Yes	No	Unsure
I would like to avoid an episiotomy and try perineal support instead.	Yes	No	Unsure
I have a medical condition that will prevent me from being able to push the baby out without an episiotomy.	Yes	No	N/A
I don't have a preference.	Yes	No	Unsure

*NA=Not applicable

Use the following space to list any other important concerns you have about this decision.

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to use or not use elective episiotomy.

Check the box below that represents your overall impression about your decision.

Leaning toward having an elective episiotomy

Leaning toward NOT having an elective episiotomy

• Labor, Delivery, and Postpartum Period
• Pregnancy

Organizations

American College of Obstetricians and Gynecologists (ACOG)
409 12th Street SW
P.O. Box 96920
Washington, DC  20090-6920
Phone:	(202) 638-5577
E-mail:	resources@acog.org
Web Address:	www.acog.org
American College of Obstetricians and Gynecologists (ACOG) is a nonprofit organization of professionals who provide health care for women, including teens. The ACOG Resource Center publishes manuals and patient education materials. The Web publications section of the site has patient education pamphlets on many women's health topics, including reproductive health, breast-feeding, violence, and quitting smoking.
National Women's Health Information Center
8270 Willow Oaks Corporate Drive
Fairfax, VA  22031
Phone:	1-800-994-9662 (202) 690-7650
Fax:	(202) 205-2631
TDD:	1-888-220-5446
Web Address:	www.womenshealth.gov
The National Women's Health Information Center (NWHIC) is a service of the U.S. Department of Health and Human Services Office on Women's Health. NWHIC provides women's health information to a variety of audiences, including consumers, health professionals, and researchers.
Postpartum Support International
927 North Kellogg Avenue
Santa Barbara, CA  93111
Phone:	(805) 967-7636
Fax:	(805) 967-0608
E-mail:	PSIOffice@postpartum.net
Web Address:	www.postpartum.net
Postpartum Support International offers information and support not only to women who are coping with postpartum depression and anxiety after childbirth but also to their families. The Web site also includes the Mills Depression and Anxiety Symptom-Feeling Checklist for evaluating your symptoms.

Citations

1. Cunningham FG, et al. (2005). Normal labor and delivery. In Williams Obstetrics, 22nd ed., pp. 435–438. New York: McGraw-Hill.

2. Viswanathan M, et al. (2005). The Use of Episiotomy in Obstetrical Care: A Systematic Review. Evidence Report/Technology Assessment No. 112 (AHRQ Publication No. 05-E009-1). Rockville, MD: Agency for Healthcare Research and Quality.

3. Robinson JN, et al. (2000). Predictors of episiotomy use at first spontaneous vaginal delivery. Obstetrics and Gynecology, 96(2): 214–218.

4. Hartmann K, et al. (2005). Outcomes of routine episiotomy: A systematic review. JAMA, 293(17): 2141–2148.

5. Beckmann MM, Garrett AJ (2007). Antenatal perineal massage for reducing perineal trauma. Cochrane Database of Systematic Reviews (1).

Other Works Consulted

• American College of Obstetricians and Gynecologists (2006). Episiotomy. ACOG Practice Bulletin No. 71. Obstetrics and Gynecology, 107(4): 957–962.

• Kettle C (2006). Perineal care, search date April 2006. Online version of Clinical Evidence (15).

Author	Shannon Erstad, MBA/MPH
Editor	Kathleen M. Ariss, MS
Associate Editor	Pat Truman, MATC
Primary Medical Reviewer	Renée M. Crichlow, MD - Family Medicine
Specialist Medical Reviewer	Kirtly Jones, MD - Obstetrics and Gynecology
Last Updated	November 30, 2006