Unnecessary cuts: Why are American hospitals doing so many episiotomies?

The routine use of episiotomies has been discouraged for a long time. Yet a recent report by USA Today has found that they are still being done at an alarming rate.

An episiotomy is an incision made at the opening of the vagina and into the perineum—the space between the vagina and the rectum—at the time of birth. The goal of an episiotomy is to enlarge the birth canal, providing more space for the baby to come out.

Episiotomies became very common in the mid 20th century. Providers believed that in addition to speeding up delivery, episiotomies would decrease the risk of vaginal and perineal tearing and injury, decrease the pressure put on the baby’s head by the birth canal, and decrease the risk of shoulder dystocias (when a baby’s shoulders get “stuck” in the pelvis, leading to a slower birth with high risk for complications).

The thing is: none of these are actually true.

Researchers have spent a lot of time looking at the differences between routine (meaning that they are standard protocol) and selective (used on a case by case, as needed basis) episiotomies.

Here’s what they’ve found:

• Severe perineal injury and trauma is reduced by 30% when routine episiotomies are not used
• Episiotomies lead to increased blood loss
• Episiotomies take a longer time to heal than tears that happen on their own, and there is a greater risk for extension of the incision with an episiotomy (meaning that the incision ends up being bigger than we intended)
• Infant outcomes remain the same with and without episiotomies

When it comes to shoulder dystocias, the problem is not happening in the vagina—the shoulders are “stuck” behind the pelvic bones. A larger vaginal opening does not change this.

Lastly, episiotomies have a significant psychological impact on women—their lasting pain has proven to be a stressor for postpartum women, and I would venture to say that the emotional trauma has lasting effects as well.

Now, it’s really important to note that like all interventions, sometimes episiotomies are necessary and really helpful. For example, if a special hand maneuver is needed to help deliver the baby in the event of certain complications, an episiotomy can give the provider more space to perform it. They may also help speed birth in the event that a vacuum or forceps become necessary.

The problem is that, as with many interventions, something that was intended to be used in emergency situations is being used routinely.

The World Health Organization believes that an episiotomy rate of about one out of 10 women may be appropriate, though many providers think it should be much lower still. For example, Kaiser hospitals in Northern California have a 3% episiotomy rate. For reference, I’ve attended hundreds of birth as a midwife and I have done maybe five episiotomies.

With all of this information then, the findings of a recent investigative report by USA Today are troubling: They found that some hospitals have episiotomy rates of 20 to 40%. A Cochran Review report corroborates this, finding a rate of 28% in some institutions.

To put it bluntly, this an unacceptable.

For a group of professionals who have taken an oath to do no harm, why are we performing an excessive number of harmful procedures? Fear and disconnection are the reasons for this.

Obstetrics is tied (with surgery) for the most commonly sued branch of medicine. And it should be—the stakes are really high. But the constant threat of legal action leads to fear, and it changes the way people work. There is the omnipresent fear that one day, someone will look back at any given birth and say, “Why didn’t you do something to prevent this?”

And so we are on a constant quest to do. To speed things up, to use technology, to intervene.

Therein lies the disconnect. We are disconnected from the process of birth that happens on its own, powered by nature. We are disconnected from trusting women. And, we are disconnected from the actual human experience of transitioning into motherhood.

Let me be clear about two things:

1. Many interventions are necessary. And when they are, it is a tremendously good thing that they exist.
2. Not all providers are disconnected—most are wonderful, working with the best intentions and most up to date evidence backing their actions.

But the USA Today findings indicate that we urgently need to reevaluate how we are taking care of women.

Now, if you are planning on giving birth soon or in the future, these new findings are probably making you very nervous. Here’s what you can do:

1. Research. Ask your provider (current or potential) what their specific episiotomy rate is, as well as that of the place where they deliver babies.
2. Remember that you are the “customer.” You have a choice. If you went to a restaurant and they served gross food and were rude to you, you would not go back. If you have a medical provider with whom you do not feel comfortable, please do not feel like you have to stay with them. Don’t worry about hurting anyone’s feelings. Choose discomfort over resentment, and find a new provider.
3. Get clear and what you want, and talk about it. Over and over again. If not having an episiotomy unless absolutely necessary is important to you, let everyone know. If you are writing out your birth plan, write “episiotomy only in an emergency scenario.” When you have your prenatal appointments, talk to your provider about how you feel—if there are multiple providers, it’s okay to talk to each of them about it. Don’t assume that your message will be conveyed. When you are in labor, let your nurse know. If your nursing care changes shifts, let the next nurse know too. And when you start pushing, say it again. You are a lovely, polite person—don’t worry about being “annoying” here. THIS IS YOUR BIRTH.

If you’ve already given birth and had an episiotomy, you may be completely at peace with it. It may have been necessary, and you may be very relieved to have had the experience that you had. If all that is true, then that is awesome!

But if you are concerned about the experience you had:

1. Ask questions. In the intensity of birth, especially in the event of an emergent situation, there is potential for miscommunication. Call your provider and ask them for a birth debriefing, so that they can go through what happened and answer questions.
2. Escalate. If you feel that you have been wronged or violated, consider speaking with a local or national patient rights organization. Childbirth Connection is a great place to start.
3. Find a therapist. It is estimated that 9% of women experience post- traumatic stress disorder (PTSD) after giving birth. So if you are having really difficult emotions regarding your birth, please know that they are real and valid, and you are not alone. Seek out a therapist who specializes in PTSD or women’s health (or better yet, both), and get support as you work through this challenge.
4. Find a pelvic floor physical therapist. If you have lingering pain, incontinence (peeing or pooping when you don’t mean to), uncomfortable sex or any other concerns, there is help—this doesn’t have to be “the way it is now.” A pelvic floor physical therapist can work with you to regain your strength and comfort.

And we have to keep talking about it. Because ultimately this is a human rights issue. We need to do better.

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