by Jessi Vining
I was nineteen the first time I saw a woman cut without her consent. As a wide-eyed baby doula I watched, my mouth hanging open, while the doctor sliced into my client’s flesh without using any anesthesia. She cried out in pain and surprise, and looked up at me in shock. This wasn’t supposed to be happening anymore, I thought.
I had just finished reading Episiotomy and the Second Stage of Labor by Sheila Kitzinger and Penny Simkin – a small book summarizing the research and evidence showing routine episiotomy to be harmful, rather than beneficial for parent or infant. That book had been published in 1984, and so I had assumed that by 2011 most (if not all) doctors would have abandoned the surgical procedure altogether. Sadly, no.The last eight years of birth work have shown me that the practice of routine episiotomy still hasn’t been eradicated like I once assumed, or even truly restricted to the “emergency-only” status many care providers like to claim.
The History of Episiotomy
An episiotomy is a surgical cut to the perineum with scissors or scalpel to increase the size of the birth canal and hasten the birth of the baby. The procedure is done during the second stage of labor.
Though first described by a Scottish midwife in the 1740’s, episiotomy didn’t become a routine procedure in the U.S. until the 1920s. It should be noted that this was long before it was considered necessary to have research or evidence that a procedure was beneficial before adopting its widespread use. Despite the lack of evidence, episiotomy would remain a routine practice in the United States for the remainder of the century and by 1979, the overall rate of episiotomy in birth was 60%. Finally, in the 1980s and 1990s the first research papers on the effects of a procedure that had been used for decades were published and made available to practicing physicians.
There have historically been two primary reasons used to justify episiotomy: 1. To prevent severe tearing and promote better healing by creating a clean, controlled cut and 2. To reduce trauma to the fetal head or reduce the length of time the head is in the birth canal (such as in cases of fetal distress).
It was immediately clear from the research that routine episiotomy did not carry the benefits many physicians believed, and in fact resulted in MORE severe tearing, increased pain and serious complications with healing postpartum. There were no clear benefits of routine episiotomy for the infant either.
In 1996 the World Health Organization issued a recommendation that rates of episiotomy not exceed 10% and finally rates in the U.S. began to fall. By 2006 the rate of episiotomy in the U.S. had dropped to 25% of all births, and by 2012 it had dropped to 11.6%.
Despite decades of research which show definitive evidence against routine use of episiotomy, it can be hard to shift long-held medical opinion or practitioner routines. And so some providers have just kept on performing routine episiotomies.
Rates of episiotomy are still anecdotally higher in some practices with older physicians and in more rural areas. And though the overall number of episiotomies in the U.S. has been steadily going down, so has the number of vaginal births. With rates of cesarean section at 32% as of 2018, when you combine our rates of episiotomy, statistics reflect that roughly 43% of all births in the U.S. are accomplished involving some form of surgical procedure.
The American College of Obstetricians and Gynecologists (ACOG) now actively recommends against the use of routine episiotomy in birth, as does the American College of Nurse Midwives (ACNM), and they advise that the procedure only take place when “medically necessary.”
However, the challenge with this recommendation is that no clear evidence exists to support any indications for the use of episiotomy, and so practitioners now perform episiotomy on an individual basis, as they see fit. While there are theoretical benefits to the use of episiotomy in certain situations such as in cases of identified fetal distress, to protect a preterm infant’s head, or to assist in dislodging shoulder dystocia etc, the actual benefit of episiotomy in these cases is unknown. As stated in the 2017 update of the Cochrane review of the research on episiotomy, “Clinicians must acknowledge that little, if any, evidence is available to define indications for use; however, it is clear that maternal benefit is not an indication.”
This remaining lack of evidence makes the use of episiotomy murky territory when it comes to informed consent. Because there are no evidence-based guidelines holding providers accountable for its use, patients have to rely on the expertise and knowledge of their care provider to determine when or if an episiotomy is actually necessary.
And the majority of the time it isn’t necessary at all.
Implications for Current Practice
In 2015, a woman sued her doctor for assault and battery after he performed a brutal episiotomy, in which she was cut 12 different times without her consent. The video of this birth and the doctor’s actions is available on YouTube and went viral following its release. While difficult to watch, it is perhaps most shocking in its familiarity to birth workers. Rather than representing something outside of the norm, the deference to the physician and the vulnerability of the patient giving birth is replayed in thousands of birth rooms across the nation every day.
We watch on a regular basis as our clients’ attempts to advocate for themselves or decline procedures are ignored, invalidated, or mocked by other care providers or (shamefully) by ourselves. Often, unnecessary or harmful interventions are initiated due to routine or familiarity, rather than actual medical necessity. Nowhere is this perhaps more true than in the case of episiotomy.
I wish I could say that midwives were immune to this problem, but we simply aren’t. Last year I personally witnessed a midwife perform two episiotomies simply because “the pushing stage was long and she would’ve torn anyway.” The potential for unnecessary intervention to take place is possible for all care providers, and it is up to us to monitor and police ourselves in the restrictive use of episiotomy – because there is no evidence to back us up when we make the choice to initiate this unique intervention. Practitioners rely solely on their own intuition and intentions, and so it is up to us to hold ourselves accountable and keep rates of episiotomy low in our individual practices. Perhaps one day soon we will be able to look back and say that the use of routine episiotomy is truly a thing of the past.
Jiang, H., et al. (2017). Selective versus routine use of episiotomy for vaginal birth (Review). Cochrane Database of Systematic Reviews, Issue 2. doi: 10.1002/14651858.CD000081.pub3.
King, T., Pinger, W. (2014). Evidence-Based Practice for Intrapartum Care: The Pearls of Midwifery. Journal of Midwifery and Women’s Health. 572-585.doi:10.1111/jmwh.12261
Searing, L. (2017). The big number: 21 percent of babies are born by C-section, nearly double the rate in 2000. The Washington Post. https://www.washingtonpost.com/national/health-science/the-big-number–21-percent-of-babies-are-born-by-c-section-nearly-double-the-rate-in-2000/2018/11/16/ae539bfe-e8ef-11e8-bbdb-72fdbf9d4fed_story.html
Smith, E. (2017). ICEA Position Paper: Episiotomy. https://icea.org/wp-content/uploads/2015/12/Episiotomy-PP-2017.pdf
Zhang-Rutledge, K., et al. (2017). An Initiative to Reduce the Episiotomy Rate. Obstetrics and Gynecology, 130:1, 146-150. doi: 10.1097/AOG.0000000000002060
Jessi Vining is a Certified Professional Midwife licensed in Oregon. She feels passionate about all things reading, writing and birth related. She co-owns Wilder Midwifery, a bilingual, LGBTQ+ positive and gender inclusive homebirth practice.