It’s difficult to imagine how something as big as a baby’s head can come out of what appears to be a relatively small space. But during childbirth, the perineum – the area of skin and muscle between the vagina and anus – stretches to allow the baby’s head through.
If the baby is showing signs of distress and needs to be delivered quickly or the mother’s health is in jeopardy, the midwife or doctor may recommend cutting the perineum with surgical scissors to enlarge the opening of the vagina. This is called an episiotomy.
Episiotomies gained popularity among clinicians in the mid-20th-century and became almost routine. They were described as the “unkindest cut” by some and “just a little snip” by others.
We’ve since learnt clinically unwarranted episiotomies can cause unnecessary pain, laceration and more serious perineal trauma when the cut extends. Compared with a natural tear, an episiotomy is generally more painful, leads to greater blood loss and takes longer to heal.
But despite international health bodies advocating a restrictive rather than routine approach to the procedure, episiotomy rates remain high among women who give birth in private hospitals in many countries – including Australia.
A short history of the episiotomy
Historical accounts claim Sir Fielding Ould first advocated the procedure in 1742, describing the head as thrusting against the perineum as “if contained in a purse”.
Episiotomies become much more popular in the early 20th century with the advocacy of Joseph DeLee, a prominent Chicago obstetrician who laid the groundwork for modern obstetrics in the United States.
DeLee proposed eliminating the second (pushing) stage of childbirth by routinely using episiotomies and forceps under general anaesthesia. He described birth as “a decidedly pathological process” which was akin to falling on a pitchfork.
Between 1940 and 1980 episiotomies became routine in the US and, to a lesser extent, in the United Kingdom and Australia. By 1979, episiotomies ware performed in 63% of vaginal births in the US.
Widespread use of episiotomy was promoted as better facilitating the birth, protecting the baby’s head from trauma and preventing lacerations of the perineum and undue stretching of the pelvic floor.
Restricting routine use
It was not until the 1980s that women’s voices were heard in research, when Sheila Kitzinger undertook a study that exposed the trauma women suffered from the procedure.
In 1984, the research of Jennifer Sleep and colleagues showed no benefit from the practice of routine episiotomy. This was followed by several other trials that showed no benefit and more harm, in terms of pelvic floor weakness, painful intercourse after birth and perineal pain.
In 2012, a Cochrane Systematic Review collated the results of all the randomised controlled trials involving more than 5000 women. It showed there were significant benefits to restricting episiotomies, such as reduced perineal trauma, less suturing and fewer healing problems.
Episiotomies have a place in maternity care – and have the potential to save lives occasionally – but they should not be performed routinely.
How common are episiotomies?
We don’t have an optimal episiotomy rate. Some studies show excellent outcomes aiming for no episiotomies and others suggest rates of around 5-10% are ideal. The clinical need for the procedure also varies with different populations.
But health-care provider and place of birth appear to determine whether episiotomies are performed, suggesting they’re overused.
In the US, new data shows episiotomy use overall has declined between 2006 and 2012, to 14.4%. But it remains high in some hospitals, with privately insured women more likely to undergo the procedure.
A slightly different trend is shown in Australia with a decline in episiotomy rates during the 1990s but a steady rise from 12.8% in 2000 to 14.9% in 2006 and to 16.2% in 2012. Victoria has the highest rate at one in five deliveries.
There are several reasons for the Australian trends, including the fact that women are having fewer babies (episiotomy is more common with a woman’s first birth), changes in ethnicity due to migration (rates of episiotomy are higher among Asian and Indian women) and changes in private insurance status (rates are higher under private obstetric care).
In New South Wales, which records hospital-specific episiotomy rates, we see a range from 2.3% at Moree hospital to 43.1% in Westmead Private. The average rate in NSW is 26.3% in private hospitals, 14% in public hospitals.
Developed countries with no private health system, such as the UK, have much less variation in episiotomy rates.
An episiotomy is more likely when:
- Having your first baby
- Having a forceps or vacuum birth
- Having a long second stage
- Having an epidural
- Giving birth lying on your back, especially with legs in stirrups
- The baby’s head is in an abnormal position
- The baby is very big
- You have a private obstetrician as your care provider
An episiotomy is less likely when:
- Having your second or subsequent baby
- Giving birth in a side lying or upright position
- Perineal massage has been done in the late stages of pregnancy
- Your pelvic floor is relaxed
- You birth the baby’s head slowly or between contractions
- You have a baby in a birth centre or at home
- You are cared for by midwives you know and have good support
Protecting the perineum
We now have good evidence about how to prepare the perineum for childbirth.
My research shows that using a perineal warm compresses in the second (pushing) stage of childbirth increases women’s comfort and reduces the severest form of perineal trauma. This is now widely recommended during birth.
We also know that undertaking perineal massage – gently stretching the perineum with the fingers – in the last five to six weeks before birth can reduce the need for episiotomy, especially with first babies.
Giving birth in an upright position also reduces the need for an episiotomy and forceps delivery.
Women have never considered an episiotomy a little snip and while most evidence-based health providers today agree, some are taking longer to change entrenched practices. The internet abounds with stories of women feeling they had an episiotomy against their will and many describe the trauma they suffered.
As with any surgical procedure, if an episiotomy is warranted, informed consent should always be sought and gained before one is ever carried out.
* An earlier version of this article incorrectly said the episiotomy rate at Kareena Private was 39.2%. This has now been updated.
Hannah Dahlen receives funding from the ARC and NHMRC. She is affiliated with the Australian College of Midwives