Do I need to have an episiotomy?

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Q: Do I need to have an episiotomy?

A: The latest wisdom on episiotomies is that they are not medically necessary in most deliveries and shouldn't be done routinely. In fact, they may end up causing more serious lacerations than those sustained by women who deliver without an episiotomy.

An episiotomy is an incision in the perineum (the area between the vagina and the anus) made just before the time of birth in order to enlarge the vaginal opening. Doctors used to think that an incision would ease the pressure during birth and would prevent major tearing.

Today, some 80 percent to 90 percent of first-time mothers and half of those having subsequent births still have episiotomies. Many practitioners believe a planned incision heals more easily than spontaneous tears.

Yet recent studies indicate that an incision can cause complications such as rectal injury and sphincter muscle damage.

"The huge studies that have been done are very clear on this topic," says Tekoa King, a certified nurse midwife and assistant professor at University of California, San Francisco. "You should not cut routine episiotomies."

There are cases where an episiotomy may be necessary:

When a delivery occurs too quickly for the vagina to stretch naturally
When the baby's head is too large for the opening
If there are signs of fetal distress
If the baby's shoulders are stuck
During a vaginal breech or forceps delivery

Women should talk to their providers ahead of time if they feel strongly about trying to avoid an episiotomy. When interviewing practitioners, ask what their episiotomy rate is. Midwives generally perform fewer episiotomies than obstetricians. Besides increasing the incidence of serious tears, episiotomies are associated with increased postpartum pain, increased discomfort when sexual intercourse is resumed and increased blood loss at the time of delivery.

To help prevent the need for an episiotomy, women should heed instructions from their caregivers to stop pushing right before birth so that the head can be guided out gently (while supporting the perineum tissue) rather than popping out explosively.

Beginning around the 34th week of pregnancy, you can also try massaging the perineum with Vitamin E oil or pure vegetable oil. This may increase the flexibility and suppleness of the area.