Should delivering-moms expect an episiotomy? Not anymore.

We all understand that childbirth is painful. No one wants to think that the pain might linger for weeks when you’re a sleep-deprived new parent.

But the fact is: Perineal trauma, including vaginal tears, can occur during labor and delivery. Fortunately, there are steps you can take before and during labor to minimize trauma to the perineum – the area extending from the anus to the vulva.

“Lacerations are common after vaginal birth,” according to the American College of Obstetricians and Gynecologists (ACOG). “Trauma can occur on the cervix, vagina and vulva, including the labial, periclitoral and periurethral regions, and the perineum. Most of these lacerations do not result in adverse functional outcomes.”

To make it easier for the baby to emerge, doctors used to commonly perform episiotomies during labor. This procedure is a small cut that’s made to widen the opening of the vagina during childbirth. “It may be done to avoid tearing of the skin at the opening of the vagina (or) … to help with delivery,” according to ACOG.

For years, episiotomies were thought to help prevent larger vaginal tears. “An incision will heal better than a natural tear” was the rationale. The procedure was also believed to preserve the muscles and connective tissue supporting the pelvic floor. Newer research indicates that episiotomies don't prevent those problems – and may create new ones.

Only in emergencies

Episiotomies are no longer recommended – except in emergencies. ACOG recommends they be done only when absolutely necessary, such as in situations when the fetus is stressed and needs to be delivered more quickly.

“OBs have limited the number we do to reduce the risk of perineal trauma and injuries to our patients,” said Novant Health’s Dr. Heather White. “The only time we might do them now is if there’s an indication of fetal heart rate issues and we need to expedite delivery."

‘Gentle care’

But there are steps highly trained birthing teams can do in the delivery room to lessen the chances that an episiotomy needs to be considered. “It’s much more about gentle care today,” White said.

Here are some of those preventive measures to discuss with your doctor.

• Push! During the second stage of labor, there’s “controlled pushing,” which is done slowly and gently. Breathing while pushing (rather than holding the breath and pushing) may reduce the risk of tearing. Controlled pushing, in conjunction with proper breathing techniques, allows your tissue to stretch to make way for the baby.
• Warm up. Placing a warm compress – done by a nurse or your partner – on the perineum during the pushing phase of labor may offer relief.
• Try massage. It’s one way to stretch your vagina to prepare for baby’s arrival. During labor, your partner or a nurse may place two fingers of a lubricated, gloved hand just inside your vagina and make side-to-side motions. “We recently got grapeseed oil in the delivery rooms to be used with perineal massage,” White said. Perineal massage can also be done at the end of your third trimester – by yourself or with the help of your partner – to prepare for labor.
• Sit up. Some positions may reduce the risk of vaginal tears during labor. Rather than lying down flat – as we’re accustomed to seeing in movies – try pushing in an upright position. It can reduce the risk of tearing.

“Ideally, preventive measures like warm compresses should be done for every labor and delivery, except in that rare case where a woman only needs to push for a short while,” White said. “Women who are pushing for more than even a few minutes can benefit from the practices that help prevent perineal trauma.”

Six Novant Health medical centers have received the coveted U.S. News and World Report High-Performing Hospitals designation for maternity care: Novant Health Forsyth Medical Center, Novant Health Thomasville Medical Center, Novant Health Huntersville Medical Center, Novant Health Matthews Medical Center, Novant Health Presbyterian Medical Center and Novant Health New Hanover Regional Medical Center. They are among just 17 hospitals in North Carolina to receive this distinction.

Discuss in advance

White said many of her patients will include “episiotomy” on their birth plans – most often to indicate they don’t want one.

It’s a good idea to discuss the topic with your ob-gyn at one of your prenatal visits. Your doctor will likely only perform one in an emergency, but it’s good for you to know:

• How often your OB performs episiotomies.
• What type is most often done.
• What situations might warrant an episiotomy.

“Having those conversations ahead of time is so important,” White said. “I tell patients that, in the delivery room, we don't always have the luxury of time. Every second counts – so it helps if we’ve discussed this in advance with shared decisions regarding your delivery preferences and a plan if an emergency arises.”

“The last episiotomy I did – and it’s been ages – was in a case of shoulder dystocia, which is when one of the baby’s shoulders gets stuck underneath the pubic bone after the head has delivered. We encounter the need to perform episiotomy when a patient has a very narrow opening with a larger size baby and there’s no vaginal room to either deliver the posterior arm or perform the maneuvers needed to relieve the shoulder dystocia. It’s not common, but when it happens, it’s an OB emergency and justifies the episiotomy.”

If it should happen

An episiotomy is really the only option in a life-or-death situation like that, White said. “If we're worried there could be harm to your baby if we didn’t do this – that’s when an episiotomy would be recommended.”

“If there is potential for harm to your baby if delivery is not imminent, we’re going to encourage an episiotomy. An extensive laceration can be repaired at the time of delivery, and pelvic trauma can be addressed down the road. But we can’t repair a baby who has permanent neurological injuries.”

If a woman does have to have an episiotomy, the sutures OBs use are “delayed absorbable,” meaning they remain intact for up to 60 days before being absorbed. You won’t have to see a doctor to have the sutures removed. New moms who’ve had episiotomies are routinely placed on a bowel regimen like a stool softener, especially if they have a propensity to get constipated. A hard stool can weaken the sutures.

Cleaning the perineum with a peri bottle is recommended for all new moms and especially those who had an episiotomy. “Wiping can potentially irritate the injured area, which is already going to be a little uncomfortable,” White said. “With a peri bottle, you're getting most of the urine or fecal material off the perineum. You should pat dry with a gentle approach.”

But remember, chances are good you won’t need one, and that having a discussion with your physician in advance to learn about his or her approach to the practice is important.