Ep 78: Episiotomy – What It Is, What Q’s To Ask & When It May Be Necessary

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Alright, this is a really important episode  everyone. I have talked about episiotomies briefly on the podcast before, but today we are doing a deep dive into what they are and what you need to know about them before you go into labor.

Episiotomies used to be a pretty routine part of hospital births but their use has declined sharply over the past three or four decades. Thanks to some important studies, we know now that these surgical cuts to enlarge the vagina at the moment of birth should only be done in pretty rare circumstances.

In this episode I'll tell you what exactly an episiotomy is and some of the risks associated with it. We will talk about how episiotomies heal, why they can be helpful for a baby in distress, and how they compare with natural tears that occur during birth.

And most importantly I'll share two questions you should ask your medical provider about episiotomies before you are in labor. I also tell you about a couple things to watch out for so that you know you are giving your full consent before an episiotomy.

In this Episode, You’ll Learn About:

  • What episiotomy is and what it is used for 
  • Why episiotomies are no longer performed as a matter of routine
  • Risks associated with having an episiotomy
  • Why whether or not you have an episiotomy most often comes down to your individual provider
  • Some of the fairly rare reasons an episiotomy may be necessary
  • Two crucial questions you should ask your medical provider about episiotomy
  • Why consent absolutely must be received before a provider conducts an episiotomy

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Speaker 1: In today's episode of the podcast, you are going to learn all about episiotomy.

: Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a practicing board certified OB GYN who's had the privilege of helping hundreds of moms bring their babies into this world. I'm here to help you be knowledgeable, prepared, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at www.ncrcoaching.com/disclaimer. Now let's get to it.

: Hello. Hello. Welcome to another episode of the podcast. This is episode number 78. I am so glad that you're spending some of your time with me today. So in today's episode of the podcast, you are going to learn all about episiotomy. Now I want to say right up front that the good news is that overall episiotomy is actually not very common and it's on the decline in terms of how frequently it's done, however, it does still happen.

Speaker 1: So I want you to have all the information you need to know just in case. So in this episode, you are going to learn what an episiotomy is, how often episiotomies get done, the risk of episiotomies, some factors that are associated with episiotomy use, when episiotomy might actually be necessary, because sometimes it is actually necessary. And then questions to ask your provider about episiotomy, both during your pregnancy and during your birth. Now, learning about episiotomy is an important part of being prepared for those possibilities, that unpredictability of birth. Preparing for the possibilities is part of my beautiful birth prep process within The Birth Preparation ourse. The Birth Preparation Course is my online childbirth education class that ensures you are knowledgeable, prepared, confident, and empowered to have a beautiful birth.

: I recently had a post in the private Facebook group for the all access level of the course, and the all access level is the private group where you get increased access to me. And she wrote in this post how she developed complications and she and her husband had to make some tough decisions that out of necessity steered them away from what they were originally wishing for their birth. But because she and her husband had taken the course, they felt educated. They felt empowered. She had a beautiful baby boy and all is well. Now, if you want that same feeling of feeling empowered and feeling educated and being able to manage that unpredictability of birth, then check out The Birth Preparation Course and that all access level is where you get increased access to me. I do regular Q and A sessions right now. It is very heavily discounted because I want it to be accessible to folks because of COVID. So you can check out the course at ww.ncrcoaching.com/enroll. And I would love to see you there.

: All right. So let's get in today's episode about episiotomy. So episiotomy is a cut in the perineum and I'm going to get a little bit technical and a little urban dictionary. So episiotomy is a cut in the paradigm and the paradigm is the tissue between the vagina and the anus. And I think, I hope I'm not showing my age here, but like the slang for it is like the taint area. And episiotomy is done to enlarge the vaginal opening during the very last part of labor, right as the baby baby's head is coming out. And it can be done either in the midline, which is a straight down like the middle. So think like if the opening of the vagina was a cut, it would be like at 6:00 PM and that straight down or media lateral meaning is kind of off to the side.

Speaker 1: So between like three and six or between like six and nine, so like seven or eight, eight o'clock or four or five, o'clock like a slant slanted cut. And again, it's done to enlarge the opening of the vagina and make space for the baby's head to come out. Now, there was a time when episiotomy was done pretty routinely in the 1970s, the episiotomy rate was over 60% and it was done because doctors thought that it had benefits. So they thought that cutting an episiotomy may reduce trauma to the baby's head. That doesn't make any sense to me. But that is one of the things that is talked about or discussed as was thought to be a benefit. It was also thought that doing an episiotomy would make it easier to repair and lead to better wound healing than a spontaneous kind of jagged cut, because when you do a controlled surgical cut with scissors, it's easier to repair.

Speaker 1: And the thought was that because it's easier to repair that it would improve healing. Now I will admit that a straight cut with scissors is easier to repair, than what can sometimes be kind of a jagged spontaneous cut or spontaneous tear, I should say, rather, that can happen with natural labor. However, that's part of the art of obstetrics, us being able to put back those natural tears in a way that can heal appropriately. There's actually no evidence that doing episiotomy will improve outcomes when it comes to healing. A 2005 review found that it did not make a difference with pain. It did not make a difference in the use of pain medication, whether you did an episiotomy or allowed for a natural tear to happen. So that was debunked. It doesn't make for better repair or better healing.

: Now, another thought behind doing episiotomy is that it was thought that it would preserve the pelvic floor support. So the muscles that are there in the pelvic floor and those muscles are there for lots of different reasons. One of the biggest things that can happen during a tear during birth or an episiotomy that extends, and I'll talk about the risk of episiotomy in a minute, is that it can affect the muscles that control, around your rectum and your ability to like control your gas and control your stool. And it was thought that doing an episiotomy, you could better preserve the pelvic floor because you prevented an unpredictable kind of spontaneous irregular tear. However, studies have since shown that episiotomy does not protect pelvic floor strength and may actually result in a weakened floor when compared to a spontaneous tear. And it has never been shown that episiotomy protects against either future urinary incontinence, so leaking urine or fecal incontinence.

Speaker 1: And then another reason that it was thought that episiotomy should be used routinely is that it may help prevent shoulder dystocia. Now shoulder dystocia is an infrequent occurrence where the baby's shoulder gets stuck on the way out. It gets stuck behind the pubic bone, but no studies have ever shown that episiotomy makes any difference or actually makes any space to help that shoulder get unstuck. So you may use it in the course of treating a shoulder dystocia. And I'll talk about that in a minute, but it does not prevent shoulder dystocia. Now only is routine episiotomy, not beneficial, it actually has risks. One of the biggest risks is that the incision can extend, and that can only to those more severe tears, like third or fourth degree lacerations. Third degree tears affect what's called the anal sphincter muscles. And fourth degree tears go all the way through the rectum.

: And particularly for that median episiotomy, the one that's right at six o'clock since the rectum is right underneath it, there's a risk for it to extend. And a way to think that is, if you take a piece of paper and you start a little small tear in the paper and you tear it, it's much easier to continue that tear through the middle of the paper. So if you had a piece of paper and I'm sitting here, like holding up a piece of paper, like you can see me, but you have a piece of paper and a tear it in the middle. Once you start it, it's easier to pull those pieces of paper apart. Okay. Whereas if there was no cut in the middle of that piece of paper, and you tried to pull the paper apart, then it's hard to pull a piece of paper apart.

Speaker 1: So when you cut that episiotomy and start that tear, it makes it easier for the tissues to kind of continue tearing. There's also a risk in routine episiotomy of having unsatisfactory results in terms of how it repairs. It can lead to things like skin tags or asymmetry in the vagina. The opening to the vagina can get narrowed in the repair. Episiotomy is also associated with increased blood loss compared to a spontaneous tear, as well as higher rates of infection. And then finally, episiotomy will increase your risk of having a more severe tear in subsequent deliveries. I've seen it multiple times where I can almost tell where a woman had an episiotomy because it tears almost exactly in that same spot, in a future pregnancy and in the same way, whereas that doesn't seem to happen if women had tears during their first pregnancy.

: So, because the episiotomy is not beneficial and has risks, for many years, professional guidelines have recommended against routine episiotomy. And ACOG, which is the American College of Obstetricians and Gynecologists, that's our specialty organization that sets standards for practice for OB GYN within the US, and they say about episiotomy, current data and clinical opinion suggest that there are insufficient objective evidence based criteria to recommend episiotomy, especially routine use of episiotomy. And that clinical judgment remains the best guide for use of this procedure. And as I said in the beginning, the rate of episiotomy is actually pretty low. So most providers actually adhere to those recommendations and actually many hospitals track episiotomy rates as a quality measure, meaning that if the rate is too high, then that is considered a problem.

Speaker 1: So the current rate today for the data that we have that's most recently available was about 12%. And that was in 2012. I suspect today, honestly, that is probably lower than that. The World Health Organization recommends a rate about 10%. I am very proud to say that my personal episiotomy rate is well less than 1%.

: So what are some factors that are associated with episiotomy use? So when you see these things, it's potentially more likely that an episiotomy will happen. And I think some of these may surprise you. So having a baby at an urban hospital as compared to a rural hospital, having a baby in a private practice setting, as opposed to an academic or teaching setting, having a baby in a non teaching hospital. So private practice kind of refers to the doctors are not in academics. Non-teaching hospital refers to the hospital itself and the hospital not being a teaching hospital, having commercial insurance, as opposed to a government insurance. So commercial insurance would be like insurance through your job. Whereas a government insurance, the typical government insurance for pregnancy is Medicaid. And then white race. So urban hospital, private practice non-teaching hospital, having insurance or being white, all increased factors associated with episiotomy.

: Now you may hear those and think like what? Because those are not things that are typically associated with being at risk for any type of bad outcome, so to speak. So my personal thoughts on this and why this is the case and why these things are risk factors, is that doctors in private practice and at a non-teaching hospital are more likely to be in a practice structure where patients are waiting in the office and they run over and they do a delivery in the day, or if they are on call at night, they have to work the next day.

Speaker 1: So things like that can lead to pressure to speed up deliveries. That's one of the reasons why hospitalist medicine, which is what I practice, I'm an OB hospitalist, has kind of taken off because it relieves some of that pressure and some of that rush. Also patients who are white or have commercial insurance are more likely to be seen in private practices and non-teaching hospitals. So those things are kind of related. So when you look at it, if you're in a more urban environment, a private practice where the doctors are busy, they're trying to get back to their office to keep seeing patients during the day or during the night, they were going to get back home to get some sleep because they have to work the next day, same thing with a non-teaching hospital. Then that kind of, to me, help explains why those may be risk factors for episiotomy. And again, that's my opinion. Not like research-based now, although these things are risk factors when it comes down to it, there's actually quite a bit of variation in episiotomy rates.

: So at the same hospital, you can see drastically different rates. At the hospital where I currently work, the episiotomy rate across the board is very low. But at the hospital where I worked at before, you could see one provider have an episiotomy rate of 1%, and then you see providers who had episiotomy rates of 60 and 70%. So none of those factors that I mentioned just now are incredibly reliable in terms of risk factors. That one thing that is overwhelmingly most important in determining whether or not you will get an episiotomy is what I just alluded to. And it's the individual provider. So studies show that it's not your characteristics. It's not your race. It's not where you deliver. It's not what insurance you have. It's not anything that's actually associated with your labor. It's not anything that's associated with your pregnancy.

: Studies overwhelmingly show that it boils down to whether or not that individual provider does a lot of episiotomies or not. Period. So it's really down to that individual level. So in a moment, I'm going to give you a couple of questions that you can ask your provider to help you know how frequently she does episiotomy. So then you can better understand if you are at risk for having one. Now, before we get into that, let me quickly go over some situations where an episiotomy might actually be needed. So although episiotomy is not necessary for the vast majority of births, there are occasional times, I would say, even at rare times, when episiotomy is needed and it's needed because it increases the amount of space for the baby.

Speaker 1: And that increase in this space is going to allow the baby to deliver faster. So a common reason that episiotomy may be used is when a baby needs to be delivered quickly because the heart rate is low. The baby is showing some signs of distress, and we want to get the baby out. That is the most common reason that I have done episiotomies. And in the last year, I've probably done two that I can think of. Can you tell that I'm proud of my low episiotomy rate? Well, though, that's again, why I have done it, just because the baby's heart rate is low and baby needed to be born quickly. Now, the other reason that episiotomy may be used is that it will give your provider more room to do maneuvers in case of a shoulder dystocia.

: As I mentioned earlier, shoulder dystocia is that rare event. It's unpredictable. It's when the baby's shoulder gets stuck behind the pubic bone. And we have to do some maneuvers in order to help get the baby out. And some of the maneuvers require us putting our hand inside the vagina to move the baby. And an episiotomy will help make space for that shoulder. Dystocia is a true, true obstetric emergency that can have catastrophic outcomes, if not relieved. Most of the time, it gets relief fairly quickly, but again, episiotomy can help give your provider that room to do the maneuvers, to relieve a shoulder dystocia.

Speaker 2: As far as the type of episiotomy that is recommended if you need an episiotomy. Remember I said, there are two types. There's the median, which is a cut straight down like at six o'clock. And then the medial lateral is off to the side. The medial lateral episiotomy has fewer complications than median. So it is the one that is favored. When you cut off to the side, you don't have that increased risk of the anal sphincter laceration. So you don't have that increased risk of the third degree tears or the fourth degree tears, where it goes all the way to the rectum. That risk is higher with the median episiotomy. And if you think about it, that makes sense, the rectum is right underneath the vagina. So if you cut straight down, you're more likely to like tear into the rectum. Medial lateral episiotomy is associated with increased blood loss, but it's not like that much so that we don't recommend that it's done.

Speaker 2: Now do want to be clear that a provider, even in an emergency situation should always ask explicit consent for a episiotomy. Even when the baby's heart rate is low, your provider can still ask for consent. It would go something like this. So for me, if the baby's heart rate is low, I would say, I need to cut an episiotomy to make extra space for the baby because the baby is in distress and we need the baby to be born quickly. Every time I have said that I have never had a woman say like, Oh no, please don't do that. Whenever I very clearly say that the baby is in distress, we need the baby to be born quickly, I'm going to cut a small episiotomy to make space so the baby can come faster, then people agree and it happens. So it really doesn't take that long in order to explain what's going on.

Speaker 1: And that increased like 15 or 20 seconds or so of just explaining that does not put a baby at more significant risk or distress because you're not hurrying up any faster. There should also be adequate anesthesia. When you have an episiotomy, if you have an epidural, then the epidural will cover you just fine. You will not feel it. It is a cut. So you do need some anesthesia. However, if you are having an unmedicated delivery or if your epidural isn't working as well, then you can certainly get local anesthesia, which is an injection of lidocaine medication, right at the area where the cut is going to happen. That may not necessarily be as comfortable as the epidural, but it will certainly help because it's going to be uncomfortable. It's cutting tissue. I'm just kind of being honest about that.

Speaker 1: Now I do want you to know if you have an episiotomy, most of the time, everything heals fine. There are no longterm problems. Most of the time, when you have an episiotomy, you will need stitches. Even if you have tears from spontaneous tears, you need a couple of stitches, but you'll almost always need some stitches. With an episiotomy, the stitches dissolve on their own. During healing you may have a little bit of swelling. It may be sore for a few days. There is a risk of infection. Again, I talked about that risk of extend into the rectum, but most of the time it does not happen like that. It heals with no problems and people don't have any issues at all after an episiotomy. I can't say that, you know, that happens a hundred percent of the time. Yes, there are some risks and there are complications, which is why we don't do it routinely. But in those rare instances where it is indicated, then most women heal fine.

: So let's finish up with that question of talking to your providers about episiotomy. So even though most providers do not routinely do episiotomies, you definitely want to check with yours to be sure, because remember, like I said, it's the provider or individual level, which has the biggest predictor as to whether or not you have an episiotomy. I will say that my personal experience, it tends to be older physicians who have higher episiotomy rates because they were trained during an era where it was really common. And sometime it's hard for people to let go of the things that they were trained on, the things that they know. So I tend to see it with older providers.

: And I'll be honest, I don't think people are being like mean or like difficult when they have high episiotomy rates. I can think of like a couple of doctors, one who I know in particular, who is very caring, great doctor, and he had a higher episiotomy rate. And just kind of really didn't realize that his rate was so off compared to everybody else. And he was kind of like, well, what do y'all do in order for the baby to get out? It was like, just patience, just wait. So I think sometimes it's easy for you to, when you get out in practice and you're not around other people, then you don't see how other people practice that you get sorta used to doing the things that you normally do. I think that's one of the benefits of publishing things like public numbers and how you compare to your peers in terms of episiotomy, because it helps open our eyes to seeing what other people do and learning how to do something different.

Speaker 1: Sorry, I'm going off on a little bit of a tangent there. Okay. So what do you want to ask your provider about episiotomy? You want to ask two very simple questions. One is how many of your patients get an episiotomy and how do you help moms avoid tearing or getting an episiotomy? Now really important, these need to be how questions and not yes or no questions. So you do not want to ask, do you perform a lot of episiotomies? Because of course the answer to that question is going to be no, nobody's going to say, Oh yeah, my episiotomy rate is 70%. Nobody's going to say that. Okay. So you want to ask them specifically how many of your patients get an episiotomy? That's going to give you more detail. And really the answer should be that they rarely perform episiotomies period.

Speaker 1: If there's a little bit of hemming and hawing, or if it's like, Oh, I'm not sure. Then my guess is that their episiotomy rate is fairly high. The answer should really be that rarely you perform episiotomies because it's just really not necessary. Now, as I said, most times hospitals, or a lot of hospitals, I shouldn't say most, do track episiotomy rates. That information is available and may not be easy to get. And sometimes it is outdated. So be careful when you look on those online things for hospital data, they're often like two years behind in terms of the data that they report. So you may be able to get more specific numbers if you're really interested, but I think you'll get a lot of information just from that general question.

: And then the second question of how do you help moms avoid tearing or episiotomy? Then things that can be done that are effective to help avoid tearing our warm compresses, perinatal massage. And really the biggest thing for avoiding episiotomy is just waiting, just being patient, not rushing delivery as the baby is crowning. Give the baby's head time to let that skin stretch, to let the perineum stretch, to accommodate the baby coming. I have seen instances I'm not gonna lie where it looked like, I mean, I was like my hands because sitting, and waiting and stretching, and I'm like, Oh my God, it looks like this baby is going to explode this poor woman's vagina. But honest to goodness, if you just sit and you let it stretch, you can use things like olive oil. We use tons of olive oil at our hospital. Use things like olive oil to help keep this the skin smooth and just wait and be patient. Then you will avoid episiotomy. And actually you will avoid significant vaginal tears as well.

Speaker 1: You may have like little minor tears, nothing particularly major. If you just wait, be patient and also some control around how you're pushing at the end. You don't want to like push like crazy and like blow the baby out. I think that's something that we don't necessarily do a great job about where we're coaching women, coaching women, coaching women, but we don't help them understand that actually at that last little bit as the baby's coming out, you sorta want to more ease the head out. So you're not like damaging your vagina as much. So patience, let the baby just stretch that skin. And as the baby's crowning, just kind of ease the baby out. That's going to help prevent tearing and episiotomy.

: Now in the course of labor, I do want you to be a lookout for things like these statements. And I'm telling you this, because this came from someone who asked me on an Instagram post and my Instagram DMs, and this was a doula. And she said that during a birth, she heard a provider say, I'm going to make a little space for the baby. And then the doctor proceeded to cut the episiotomy and her client, that birthing person did not understand what that meant. I'm going to make a little space for the baby. So if you hear things in the course of labor, like I'm going to make a little space, or I'm going to make some room for the baby. Then you need to ask, does that mean you're going to cut an episiotomy, or ask, what does that mean, that you're going to make some space? So take that conversation and make it go a little bit further.

: Now I know it's hard in the throws of labor, you may just be like, I just want this baby out. I don't care what you say. So it may be helpful if you have a doula, the doula can ask, what does that mean? Or your partner can ask, what does that mean? Or does that mean you're going to cut an episiotomy and then that can open up a discussion for, are there alternative options? There should never, ever, ever be an episiotomy done without explicit consent. Unfortunately, in our specialty and the culture of OB GYN, it certainly was accepted at some level that doctors could just do this without asking, but that is not okay. There should always, always, always be explicit consent. And like I said, there is often always time to discuss it first.

: Okay. So just to recap, an episiotomy is a cut in the perineum to make space for the baby. Most of the time it is not necessary, but occasionally it is warranted. If the baby's heart rate is low and the baby needs to be delivered quickly, or there's a shoulder dystocia, and we need to make room for getting our hands in there to do some of those maneuvers. You want to ask your doctor how often they perform episiotomies and what they do to avoid it, and then be on the lookout during birth for that sneaky language of I'm just gonna make some space, or I'm just gonna make some room. That's not okay. There should be explicit and discussion about episiotomy before it happens.

: Okay. So that is it for this episode of the podcast, be sure to subscribe to the podcast in Apple podcast or Spotify, Google play, or wherever you listen to this podcast. And I would so love it if you leave an honest review on Apple podcast, it's so important to helping the show grow. It helps other moms find the show and get this great content. I also give shout outs on episodes from those reviews. So if you would do that for me, I would so, so appreciate it. And are you in the All About Pregnancy and Birth community on Facebook? If not, you definitely should be. That is a great community of pregnant mamas. My community manager for the group is a doula Keisha, and I'm in the group as well, but really the best part of the group is being able to connect with like minded pregnant people where there's no judgment, you know, people ask questions and get responses. It's just a really nice, lovely, supportive community. And it's called All About Pregnancy and Birth on Facebook, it's completely free. So definitely check that out.

: Now next week on the podcast, I have Jen McClellan from Plus Size Birth. This is an amazing interview. You are definitely going to want to hear it. So do come on back next week. And until then, I wish you a beautiful pregnancy and birth. Thanks so much for listening to this episode of the All About Pregnancy and Birth podcast. Head to my website at www.ncrcoaching.com to get even more great info, including free downloadable resources on how to manage pain and labor and warning signs to look out for after birth. You'll also find information on my free online class, on how to make a birth plan, as well as everything you need to know about The Birth Preparation Course. Again, that's www.ncrcoaching.com and I will see you next week.