Episiotomy Complications and Side Effects

An episiotomy is an incision made during childbirth in the perineum, which is the area between the vaginal opening and the anus. It is performed to widen the vaginal opening so that the baby can be successfully delivered in an emergency.

Normally, doctors would wait until the baby’s head is visible and then assist in easing the head and chin out of the vagina. Once the head is out, the shoulders and the rest of the body quickly follow. Occasionally, however, an emergency arises that necessitates an episiotomy. In such cases, an episiotomy is performed to help enlarge the vaginal opening.

According to the American Pregnancy Association, there are several reasons why your healthcare provider may decide that an episiotomy is necessary:

• The mother is giving birth very quickly and there is not enough time for the perineum to stretch naturally
• The baby’s head is very large
• The baby is in distress (allows for faster delivery)
• Doctors need to use forceps or vacuum-assisted delivery
• Complications such as breech position (the baby’s buttocks and feet are positioned down instead of the head)
• The mother is not in control of her pushing

An episiotomy can be classified into two main types:

• Midline episiotomy (median incision): a vertical incision made from the lower opening of the vagina to the rectum. This type usually heals well but may be more likely to tear and extend into the rectal area, called a 3rd- or 4th-degree laceration.
• Mediolateral episiotomy: an incision made at a 45-degree angle on the lower vaginal opening. This type doesn’t tend to tear or extend, however it is associated with greater blood loss and a painful, difficult healing process.

For many years, episiotomies were considered a perfectly normal and healthy procedure to perform during routine vaginal deliveries. It was done to prevent vaginal tears during delivery, as health care professionals thought that a surgical incision would heal better than a natural tear. Additionally, it was thought that an episiotomy would help preserve the muscular and connective tissues that support the pelvic floor.

However, in recent decades, medical research has shown these beliefs to be false. In 2006, the American College of Obstetricians and Gynecologists (ACOG) officially recommended against routine episiotomies in all patients. Instead, episiotomies should only be performed in certain emergency situations. By 2012, fewer than 12% of women who delivered their babies vaginally received an episiotomy.

Episiotomy Complications and Side Effects

As with any surgical procedure, there are risks associated with getting an episiotomy. Unfortunately, the complications and sometimes long term side effects that arise immediately after an episiotomy is done can also affect women long-term. Not only does an episiotomy mean an extended and sometimes very painful healing process in the short-term, but also long-term complications that can severely disrupt daily life.

Short term complications can include:

• Perineal laceration (the incision itself)
• Episiotomy dehiscence (wound separation)
• Stitches
• Hemorrhage and increased blood loss
• Wound site edema (swelling)
• Wound site infection
• Anal sphincter and rectal mucosal damage
• Urethral injury
• Bladder injury
• Perineal hematoma (collection of blood in the perineal tissues)
• Pain

Long-term effects of episiotomies can include:

• Chronic pain and infections
• A small linear scar
• Anorectal dysfunction
• Urinary incontinence
• Pelvic organ prolapse
• Sexual dysfunction (pain during sexual intercourse)

Why was there such a major shift in medical procedure? Episiotomy was first suggested back in the mid-eighteenth century but did not become widely practiced until the beginning of the twentieth century. In 1969, episiotomies were done in 63% of vaginal births in the US.

Doctors thought that episiotomies made childbirth easier because it stretched the pelvic floor less and prevented the perineum from tearing. In the late twentieth century, research (done initially by female doctors) revealed that women experienced less trauma and healed better without episiotomies. The use of episiotomies in normal, uncomplicated pregnancies is no longer accepted medical practice.

Isn’t tearing bad? Actually, 40% to 85% of all women who deliver vaginally will tear. This is simply a result of the natural birthing process. About two-thirds will get stitches. However, these tears are mostly shallow and minor and heal within a few weeks. Severe tears happen in only .5% to 2.5% of vaginal deliveries.

With routine episiotomy, women would always be left with a significant laceration. They never had a chance of having a minor laceration. Additionally, natural tears typically heal better than surgical incisions. There are techniques to reduce the risk of severe tearing and of needing an episiotomy, which are described below.

• Episiotomy rates are dropping
• Well articulated modern view of episiotomies

They are trained to work with you to reduce tension in the perineum and prepare it to stretch naturally during labor. To do this, warm compresses are applied to the perineum both before and during labor. Another technique is perineal massage in the weeks before birth, which helps the tissue to relax and become more flexible. First-time mothers that start perineal massage at 34 weeks of pregnancy have a 10% reduced risk of tearing that required sutures than those who did not practice perineal massage.

You are more likely to experience tearing as a first-time mother. Additionally, episiotomies are more commonly performed in certain hospitals and are less commonly performed in birthing centers. Each of these settings, however, has pros and cons.

While episiotomies are no longer recommended for routine births, there still might be some instances in which an episiotomy is medically necessary. Primarily, episiotomies are medically necessary when the baby is in distress and forceps or vacuum devices need to be accommodated (although this study pushes back on this premise).

These devices allow the baby to be removed quickly if, for example, the baby has an abnormal heart rate during delivery or its shoulder becomes stuck, a condition known as shoulder dystocia.

If your health care provider decides that it is medically necessary for an episiotomy to be performed, there are steps that you can take after the procedure to manage pain and heal properly.

Your doctor will most likely prescribe you pain medication, as there will be some pain at the incision site. To further reduce pain, you can apply cold packs to the perineum, take sitz baths (warm, shallow baths), and use medicated creams or anesthetic sprays. As always, you should consult with your health care provider if symptoms or pain continue.

Medical Literature

• “Long- and short-term complications of episiotomy” by Ismet Gün, et al., Turkish Journal of Obstetrics and Gynecology, 2016.
  While most studies on the effects of episiotomies focus on the short- and medium-term effects, this study looks at short- and long-term effects. The study looks at the long-term influences of episiotomy on urinary and fecal incontinence, pelvic floor dysfunction, sexual function, and dyspareunia.
• “Episiotomy in modern clinical practice: friend or foe?” by Maurizio Serati, et al., International Urogynecology Journal, 2019.
  A study that looks to prove that in both the short- and long-term, selective mediolateral episiotomy has no additional beneficial effects without clear evidence of causing harm to the mother or baby.
• “Selective versus routine use of episiotomy for vaginal birth” by Hong Jiang, et al., Cochrane Database of Systemic Reviews, 2017.
  Study to assess the effects on mother and baby of a policy of selective episiotomy (only if needed) compared with a policy of routine episiotomy (part of routine management) for vaginal births. Review demonstrates that believing that routine episiotomy reduces perineal/vaginal trauma is not justified by current evidence.
• “Episiotomy – risk factors and outcomes” by Anat Shmueli, et al., The Journal of Maternal-Fetal & Neonatal Medicine, 2016.
  A study to identify the risk factors of mediolateral episiotomy and evaluate the risk of obstetrical anal sphincter injury among women with an episiotomy. Concludes that there are several risks associated with mediolateral episiotomy. Therefore, the practice of routine episiotomy should be abandoned while the practice of selective episiotomy should be reconsidered.