What's the deal with episiotomies?

I wanted to take a few minutes to discuss episiotomies and their effect on the pelvic floor. I was recently asked whether an episiotomy is better or worse than a significant tear.

Cloth and flowers - Darren Nunis

First a little a little history lesson.

When episiotomies were first used it was theorized that by making a clean cut in the perineal tissue it would improve healing and reduce the likelihood of bad tears. Unfortunately, this proved to be completely inaccurate.

It turns out that our skin and tissues are both similar and dissimilar cloth in important ways.

How our tissues are similar to cloth:

Tearing fabric is a very difficult task, so is tearing skin or tissue. If you apply pressure to two different nearby locations on your body and pull your skin apart, then you will not be able to tear it. It is through extreme pressure or scraping that our skin is broken. If you take the edge of your shirt and pull it apart, then it will take significant force before the material tears. Now, if we cut either your skin or the material of your shirt, then you will easily be able to continue the cut by tearing. In the case of vaginal tissue, when an episiotomy is cut it will easily continue tearing further.

Because our body tissue has this similarity to cloth, episiotomies angled to the side (away from the anus) are preferable. This way if the tear continues it will be less likely to include the anal sphincter and rectum.

How our tissues are dissimilar from cloth:

When sewing cloth together it is preferable to have two straight edges with clean cuts. This makes it easier to stitch together securely and cleanly. In the case of our body tissue, clean cuts are not ideal. The clean cuts are easier to stitch together, but the healing is less ideal. It is harder for the muscles to function well and muscle performance seems to be impaired long-term.

In summary,

I would always advise to decline an episiotomy unless absolutely necessary. There may be a slight shortening to labor time, and if a baby is in true distress then it may be necessary to speed up labor. In all other cases it would be preferable to let the vaginal tissue remain intact with risk of a natural tear. Maybe you will not tear at all, maybe you will tear some (less or around the same length as an episiotomy), or maybe you will tear further. In the case of a severe tear without episiotomy, the likelihood is the same tear would have been worse if the tissue was cut.

Whether an episiotomy or a natural tear occurs pelvic floor muscle dysfunction is expected, but can absolutely be treated with physical therapy. I hope this helps your decision making, helps you understand some of the reasons for the recommendation, and helps validate your decision if you declined an episiotomy but experienced a significant tear.

I always love to answer questions so get in touch if you have any questions about this or any other post.