Everything You Didn't Think You Needed To Know About Episiotomies

Photographed by Aslan Eylul.
For those who have never been pregnant before, just thinking about childbirth can be incredibly intimidating. Not only can it lead to, you know, having a baby, but it's also associated with excruciating pain and wild bodily functions and anatomical changes. One completely normal yet jarring detail that people tend to freak out about is what happens to the skin between the vaginal opening and the anus, aka the "perineum," when a baby is born.
Here's the truth: When someone gives birth for the first time, it's very common for this skin to tear, explains Fahimeh Sasan, DO, an Ob/Gyn in New York City and founding physician at Kind Body, a women's health and fertility clinic. According to the American College of Obstetrics and Gynecology (ACOG), between 53- 79% of vaginal deliveries will result in some type of laceration, although it usually doesn't lead to any kind of functional issues. "It's just a given fact, because the vagina is small, and a baby is six to eight pounds," she says. "It makes sense."
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In the past when doctors would deliver babies, they would make a small cut with scissors to help aid in the delivery of the baby’s head — a procedure called an episiotomy. "The thought back then was that doing a controlled cut, as opposed to letting a woman naturally tear, was somehow better," Dr. Sasan says. In 2006, the ACOG changed its recommendation around episiotomies, stating that there's "no immediate or long-term maternal benefit of routine episiotomy." Since then, episiotomy rates have significantly declined in the United States, which is a good thing.
Doctors know, based on research, that allowing a birthing person to tear naturally actually has some benefits. For one, the perineum heals quicker and better when it tears naturally, plus it tends to feel less painful, Dr. Sasan says. There are various degrees of perineal tears, ranging from a complete tear from the rectum to the vagina that includes pelvic muscles, to just a small tear in the outer skin. There are a number of factors that can influence the degree of the tear, such as the size of the baby, whether it's someone's first pregnancy, and the length of a person's perineum. (Interestingly, perineal massage during labor can help to prevent a tear.) Luckily, a natural tear won't increase the risk of the tear getting worse, she says.
Even though doctors don't perform routine episiotomies anymore, there are some specific cases where the procedure is needed to facilitate childbirth, Dr. Sasan says. For example, if the baby is disproportionately large, or if the baby's shoulder gets stuck in the mother's pelvis, then an episiotomy would be necessary, she says. Only about 12% of vaginal births will require an episiotomy, according to the ACOG. "There are instances where that incision is going to prevent an injury to the baby, and obviously in that case, everyone would agree that should be done," she says. "But those are few and far between."
So, while there are a lot of aspects about pregnancy and childbirth to contemplate, Dr. Sasan says you shouldn't really worry about an episiotomy. It's also important to remember that everyone's birthing experience is different, because every body is completely different. "The likelihood of you having an episiotomy at this day in time is unlikely, and if you do end up having one, then it was probably necessary," she says. "In that case, you’ll be happy you had one, because it probably helped your baby."
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