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Are episiotomies necessary?


My jaw dropped when I recently read on the National Core Maternity Indicators (2021) that episiotomy rates in Australia, based on 2018 data, are at 20 - 22%. For every 5 women who go to birth their baby within the medical system 1 of them will come out having had an episiotomy. This is shocking and to answer the titled question, in my opinion, no – episiotomies are not necessary.


 

Two quick notes:

  1. Episiotomies are a cut made by an obstetrician or midwife to the birthing women’s perineum while the baby is moving towards or through the vaginal opening.

  2. To discuss medical interventions during birth is a slippery slope as every interference during the birthing process warrants scrutiny and critical thinking. I strongly encourage every woman interested in having a baby, and their partners, to thoroughly investigate the common procedures that take place in medical settings or in the presence of a medical professional, including homebirth. For the purpose of this article I will only be discussing episiotomies but other interventions referenced, like the use of forceps, should not be presumed to be an evidence based or clinically reasonable intervention.

 

To explain the statistics a bit more, for women experiencing a birth that involves the obstetrician or midwife using instruments, such as forceps, which is 26% of women in a medical setting, the rate of episiotomy is 77.6% on average in Australia, with Victoria and South Australia taking the lead at 82% and 81%. For births that occur in medical environments that do not involve instruments, the rate is 22.3% and again Victoria and South Australia have the highest rates at 26% ("National Core Maternity Indicators, Episiotomy - Australian Institute of Health and Welfare", 2021).


The purported logic or ‘clinical reasoning’ to perform episiotomies is to release the pressure of the perineum (pelvic floor) in order to ease the expulsion of the baby and to prevent tearing of the perineum. A man named Dr Pomeroy was a key proponent of episiotomies and suggested their worldwide use way back in 1918. Subsequently, rates of episiotomies soared throughout the 20th century reaching 70 - 80% in the 1980s.


Anecdotally, many licensed midwives I know report that there is absolutely no reason to perform episiotomies as the procedure does not improve outcomes and only causes harm of the mother. I was recently speaking with a midwife and she recalled that during her midwifery training she was required to complete a certain number of episiotomies to demonstrate her competency. During one birth, she was observing the woman’s vaginal opening and perineum ‘stretching beautifully’ as the baby’s head began to crown. At this moment, her supervisor leaned towards her and instructed her to perform an episiotomy, to which this midwife initially refused and then, feeling like she had no choice, complied to the instructions. To her own heartbreak, she used scissors and cut this birthing woman’s perineum in order to be able to continue her studies. This is not uncommon. So many widwives, most often homebirth midwives and especially non-practicing midwives, report similar stories and how they just scraped through their studies doing the minimum of what was required of them in times of cognitive dissonance to be able to go on and serve women in their own authentic and morally sound way after surviving their training. How many women’s bodies have been cut for a good grade or to pass a unit?


The story above brings to light another enormous red flag relating to episiotomies – informed consent. A quick online search of episiotomies and informed consent will bring up several filed lawsuits against obstetricians that completed episiotomies without discussing it with the birthing woman. There are cases that involve an obstetrician who did inform the birthing woman that they believed an episiotomy was required, to which the woman clearly refused, only for this woman to be cut a few moments later. A 2013 birth video went viral that involved a Californian woman clearly stating ‘Do not cut me!’, seconds later this woman was cut one, two, three, four, five, six... twelve times by her attending obstetrician.


Many birth medical professionals will focus on the 'need' for episiotomies in the context of births that involve epidurals or pudendal nerve blocks. These forms of anaesthesia impede the mother’s ability to respond effectively to the birthing sensations, completely disrupting the physiological process, which can lead to attending doctors or midwives then providing coached pushing, the administering of oxytocin, or a caesarian (here we are on the slippery slope of the cascade of birthing interventions - to reiterate, do not assume these interventions will improve your outcome of birth). This combination is widely believed to almost always require episiotomies. However, a large body of evidence continues to demonstrate the fallibility of the general ‘clinical reasoning’ behind episiotomies.


A study in China (Harvey et al., 2015) of 320 new mothers compared postpartum sexual dysfunction and urinary incontinence in women who underwent three differing midwifery practices during labor: lateral episiotomy, traditional midwifery without episiotomy, and hands-off techniques delivery. The results found the hands-off delivery techniques, meaning no intervention, fared the best in reducing damage to pelvic floor and improving quality of life for women after delivery.


For quite some time, routine episiotomies were previously carried out in order to limit obstetrical anal sphincter injuries, a leading cause of bowel incontinence in women, and they have since stopped being recommended. A 10 year retrospective study (Sideris et al., 2020) confirmed this turnover of policy, revealing that restrictive policies of episiotomy during spontaneous vaginal delivery has maintained a decreased risk of obstetrical anal sphincture injuries compared to when they were recommended.


Shoulder dystocia involves the shoulder becoming impacted behind the pubic bone during expulsion of the baby and is commonly used as clinical justification to perform an episiotomy. Leaving the over-reported rates of shoulder dystocia aside, a retrospective cohort study (Thayer, Owens, Yanit, Garg & Caughey, 2020) was completed to investigate the association between episiotomy and adverse perinatal outcomes in vaginal births complicated by shoulder dystocia. The study found that, despite it being proposed as a method to decrease potential neonatal injury, ‘episiotomy does not improve neonatal outcomes for births complicated by shoulder dystocia. The routine use of episiotomy in the management of shoulder dystocia should be reconsidered.’


Another study in 2019 (Quoc Huy, Phuc An, Phuong & Tam) found the following complaints of women who experienced episiotomy to include pain while sitting (30.4%), which was the most common complaint, urinary incontinence (11.4%), urinary retention (10.8%), and flatus incontinence (8.9%). At three months post-partum, sexual dysfunction was 40.7% with frequent reported concerns relating to desire (68.9%) and pain (58.5%).


As mentioned at the beginning of this article, the ‘clinical reasoning’ of performing episiotomies is to release the resistance of the perineum to ease the expulsion of the baby and to prevent tearing of the perineum. This claim was investigated in a study of 669 women in 2019 (Sagi-Dain et al.) that involved comparison of maternal and neonatal injuries between 334 women who received care involving avoidance of episiotomy, and 335 who received standard care including episiotomy. The results concluded ‘decreased use of episiotomy was not associated with increased rate of advanced perineal tears of any other adverse maternal or neonatal outcomes’.


Perineal tissue is very vascular and is able to heal well because of this. However, this changes if the injury is surgical as the perineum has been observed to recover at a slower rate and less effectively following episiotomy compared to natural tearing. Perineal cells are also unique in that they are designed to be able to stretch more than all other cells in the body. Cutting the perineum is akin to genital mutilation considering the clitoris is well known to extend down and around the vaginal opening. Not to mention scar tissue. All surgical incisions will heal with scar tissue which is required to bring the cut tissues back together and this scar tissue can spread, become rigid and form adhesions. This will impede on the perineum’s elastic qualities and can have ripple effects including weak pelvic floor, prolapse, sexual dysfunction, pelvic pain and incontinence (Blanc-Petitjean, Meunier, Sibiude & Mandelbrot, 2020).


Now you’re familiar with the evidence against episiotomies are you also shocked to know 1 in 5 woman receive them in birthing medical settings in Australia? It is blaringly obvious that current research continues to grow in favour of not performing episiotomies. What do we make of the fact that it continues to happen at such high rates despite this? Needless to say, frequent use of episiotomies is a stark example of medical malpractice in the field of obstetrics and midwifery.


I understand this information may be challenging to read, especially if you’ve experienced an episiotomy yourself. Nonetheless, it is important we speak openly about the experiences and treatment of women, especially during birth. It is clear that women cannot wait on or completely trust health professionals to only provide procedures that are truly indicated and in favour of the wellbeing of their bodies or their baby’s bodies. It is important to discuss these issues ourselves and endeavour to take full responsibility of our birthing experiences with our eyes wide open to harm that takes place in obstetrical and midwifery medical settings so that we may make the best decisions possible for ourselves in choosing with who, where and how to give birth.


If you have ever received an episiotomy and are experiencing any of the listed adverse side effects, Ananda Women can provide support via in person appointments to directly support the tissues or online where you can learn key self-care skills to support your healing.




References:


Blanc-Petitjean, P., Meunier, G., Sibiude, J., & Mandelbrot, L. (2020). Evaluation of a policy of restrictive episiotomy on the incidence of perineal tears among women with spontaneous vaginal delivery: A ten-year retrospective study. Journal Of Gynecology Obstetrics And Human Reproduction, 49(8), 101870. doi: 10.1016/j.jogoh.2020.101870


Harvey, M., Pierce, M., Walter, J., Chou, Q., Diamond, P., & Epp, A. et al. (2015). Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition, and Repair. Journal Of Obstetrics And Gynaecology Canada, 37(12), 1131-1148. doi: 10.1016/s1701-2163(16)30081-0


National Core Maternity Indicators, Episiotomy - Australian Institute of Health and Welfare. (2021). Retrieved 12 July 2021, from https://www.aihw.gov.au/reports/mothers-babies/ncmi-data-visualisations/contents/labour-and-birth-indicators/episiotomy


Quoc Huy, N., Phuc An, L., Phuong, L., & Tam, L. (2019). Pelvic Floor and Sexual Dysfunction After Vaginal Birth With Episiotomy in Vietnamese Women. Sexual Medicine, 7(4), 514-521. doi: 10.1016/j.esxm.2019.09.002


Sagi-Dain, L., Kreinin, I., Bahous, R., Arye, N., Shema, T., & Eshel, A. et al. (2019). 329: The effect of decreased episiotomy use on obstetric outcomes – a randomized controlled trial (EPITRIAL). American Journal Of Obstetrics And Gynecology, 220(1), S229-S230. doi: 10.1016/j.ajog.2018.11.350


Sideris, M., McCaughey, T., Hanrahan, J., Arroyo-Manzano, D., Zamora, J., & Jha, S. et al. (2020). Risk of obstetric anal sphincter injuries (OASIS) and anal incontinence: A meta-analysis. European Journal Of Obstetrics & Gynecology And Reproductive Biology, 252, 303-312. doi: 10.1016/j.ejogrb.2020.06.048


Thayer, S., Owens, S., Yanit, K., Garg, B., & Caughey, A. (2020). 344: The impact of episiotomy on adverse perinatal outcomes in shoulder dystocia. American Journal Of Obstetrics And Gynecology, 222(1), S231. doi: 10.1016/j.ajog.2019.11.360



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