The Myth and The Reality of the Episiotomy

As I dive deeper into the birthing world, I’m still sparked. It’s a deep dive! I recently audited a birth class (Inspired Birth with Katie Wise, hosted at The Mama Hood in Boulder & Denver). Just for fun, to learn, and to know what’s available locally as resources and referrals. Katie said she used to audit birth classes and that she considers herself “addicted to birthing”. It seems I can relate!

This post is about the episiotomy. If you don’t know what this means, you may want to take a deep breath. Maybe it won’t bother you, but when I first learned, I had a really hard time metabolizing it and understanding why it’s done routinely. An episiotomy (also known as perineotomy) is a surgical incision of the perineum and the posterior vaginal wall. It is performed by a midwife or OB during the second stage of labor to quickly enlarge the opening for the baby to pass through. The incision is performed under local anesthetic and is sutured closed after the the delivery of the baby. It is one of the most common medical procedures performed on women.

In simple language, this procedure stems from the myth that women can be (or that they simply are) “too small to give birth.” We can be taught that the female body is incapable of getting big enough. The fear is real! I can relate. When I first attempted to wrap my mind and body around the concept that a baby whom could weigh up to 10-11 pounds (or as small as 2) is going to come out of my vagina, it seemed impossible. I witness it on the faces of people I talk to about it and in the birth class and birth circle I am part of as a doula. This post is to help us unpack it, because it is possible and natural. Unfortunately, culture and society teaches us that it is not and many of us have no real life examples to go on to show us otherwise.

The reasoning behind this post is that if birthing professionals (and all of us really) could understand that female genitals have similar abilities to grow as male genitals do, the episiotomy and laceration rates could go way down. Unfortunately, earlier generations have helped us learn to believe that nature cheated women when it comes to the tissues of the vagina and perineum. Many have bought into the idea that their genitals are made of “bad goods”. No one expects that a penis can be pulled and stretched to the size that it attains when it’s erect without engorgement. Why do we expect the female genitalia to expand and stretch to the full capacity without being properly engorged? Sounds silly when we get down to the reality of it.

Ina May discusses that during her birthing lectures, she asks the group “What happens when you kiss?” Eventually some brave person answers while pointing to their genitals “it gets tingly.” From this place, engorgement happens. Birth is an act that enlarges the vagina, and sexual foreplay is another. One of the differences between us is that engorgement of the penis can be visibly noticed, and the engorgement of the female genitalia is largely internal and not easily seen. The engorgement of the female is just as important, even though it’s mostly hidden. If the tissues are not engorged, then when the baby’s head begins to emerge, the uterus will keep pushing the baby’s head and force its way through the vaginal tissues that aren’t softened or opened fully. Ouch!

A simple rule to remember is: engorgement = less stitching.

Hypothetically, let’s believe that nature designed the female body to get as huge as needed for the baby to easefully come out. Of course it will be easier if the atmosphere is right. A person kissing their partner through the pushing process may have a largely different experience than one who is uncomfortable and attempting a conversation with a medical provider they may not even know well. To quote Ina May (again): It is the competent care provider and other kindly helpers in constant attendance during labor who carry along the knowledge of what the undisturbed body / mind is capable of in birth. What actually happens can be incredibly difficult to believe to the person who doesn’t know the potential and possibilities.

 A Meditation: The thing about mental / meditation techniques is there’s no negative side effects from giving it a try. Ina May (one of the nation’s leading midwives) talks about a birth experience she had with a client whom had a big fear of not being able to open or get big enough for her baby to come out. The entire time she was birthing, she used a mantra of “I am going to get HUGE!” I’m going to discuss why this really is possible below. But if you stop reading here, staying with the concept of getting SO big, appears to be fruitful.

The logistics of the Episiotomy: One of the most common operations in North America, it is seen by some as a deliberate injury to the female body. Ina May goes so far as to say it’s this culture’s version of female genital mutilation. The belief is that inflicting this trauma on the female body does the following:

  • Prevents the laboring person from a more serious tear
  • Improves the partner’s (and possibly the laboring persons sexual life)
  • Saves them from urinary tract infections
  • Saves the baby from shoulder dystocia (which is easily maneuvered with proper technique and skill of the provider)
  • Makes the job of the medical provider easier
  • Prevents oxygen deprivation / brain injury to the baby

Is this really true or necessary? I can’t seem to believe that it is. Here is the reality of the Episiotomy based on research:

  • Causes pain that sometimes lasts for weeks / months
  • Increases blood loss
  • Causes more serious tears because a cut perineum is not as resistant to laceration as an intact one (the concept of once you cut a small incision, the tear has a lot more freedom to get larger)
  • Often becomes infected
  • Associate with wound breakdown, abcesses, permanent damage to the pelvic-floor muscles, and other complications that cause incontinence
  • Prevent many women from breastfeeding because of the pain

The times it’s justified might include when a baby is about to be born in distress, when a breech male baby’s testicles are the leading part to be born, and other rare and unique complications that literally equal an episiotomy leading to less harm being done. A careful review of evidence shows that the episiotomy rate of over 20% cannot be justified on any grounds.

Ina May’s Tips on How to Avoid an Unjustified Episiotomy / Laceration:

  • Choose a caregiver whom has an episiotomy rate lower than 20%
  • Choose a caregiver who performs median rather than mediolateral episiotomies (a cut from the bottom of the vagina straight down toward the rectum rather than an oblique cut from the bottom of the vagina toward the buttock). Mediolateral episiotomies are especially painful while healing
  • Push only when the urge comes. Allow for it to be a process of opening that has a natural rhythm
  • Take a quick breath between the pushes
  • When the baby’s head is about to come out, slow down the pushing as much as possible
  • Some people like to stimulate the clitoris as the baby emerges. This can increase vaginal engorgement which could explain why there are very few lacerations for people whom use this method of relaxation. A question to reflect on is would you discuss this with your provider and do it if you knew it were likely to help you? If not, perhaps take a visit to Eve Ensler’s show Vagina Monologues if you have a chance (they typically happen every February)
  • If making noise helps as you push, keep the sound in the lowest register possible so that the vibration comes to the lower part of your body. Low, sexy moans.

What about the receding? It can be helpful to know that babies’ heads typically advance towards birth during a push and then recede (go back in) once the push is over. People whom don’t understand this process sometimes feel they’re not making progress. This process is good! It helps the vulva gradually open and attain the necessary size. Circulation to the genitalia increases with the alternating stimulus of pressure, release, pressure, release.

Acceptance and power: As long as the episiotomy is continued to be accepted as a routine process, they will continue to be performed. That means accepted by you and me. Providers. Nurses. Anyone in relationship to the birthing process. Only when people take action by questioning the groups in power and refusing to hire professionals with high episiotomy rates will this practice change. It is important to realize how many people have very little choice about their care providers and practices. Even so, the fight can be fought and won in these environments with information and any type of support that is available. It is unfortunate that there is so much profit stemming from birth that this personal, intimate, intensive physiological process has become political. For me, this isn’t about politics, it’s about choice and power. Who has the power in your birth?

As always, thank you for your presence here reading! Please feel free to reach out with questions / concerns / needs for resources and referrals. I may not always know the answer but I have a brilliant network of supportive, well trained, highly competent and skilled people around me whom I work with that could help provide objective, unbiased information.

A Doula Offering: As I’ve announced in my newsletter email, I am working with the Boulder Doula Circle as an apprentice. I am SO THRILLED to be joining this group of women for this very unique time of initiation of myself into the birthing world. I’m offering my doula service at a reduced rate in relationship to the Boulder Doula Circle. Their regular rate is $1495, and my rate will be $500. This is a great option if you would like the support of a doula and the Boulder Doula Circle and all the versatility the group practice offers, but cannot afford the full rate. If you choose to work with me as your doula, you will have:

  • Prenatal and postpartum visits with me
  • The backup support of the Boulder Doula Circle so that you will not be without support during your labor. Visit the BDC website to read more about the other wonderful women in this circle whom bring a wide variety of expertise to your birthing experience.
  • The option to come to the Birth Cirlce at The MaMa’Hood (a monthly group to support pregnancy / families as they prepare and transition into being parents)
  • For more information, please visit my website here and contact me with any questions about hiring a doula whether it’s me or if you need a referral

On that note, I’m finally beginning to come toward the end of this birthing blog series. My last few posts will cover the final phase of birthing, the postpartum period following birth, and resources and self care around that tender time. With care, Alicia

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About Alicia Patterson

Alicia Patterson is a Psychotherapist / Dance Movement Therapist, Birth Doula, Energy Worker, Dance and Yoga Facilitator in the Boulder / Denver area.
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