DEAR MAYO CLINIC: I am 32 weeks pregnant with my first baby. At my last appointment, my doctor mentioned that an episiotomy is sometimes needed, but I really don’t want one. What circumstances would make it necessary, and is it reasonable for me to ask that it not be done no matter the situation?
ANSWER: Episiotomies used to be a routine part of labor and delivery, but that’s no longer the case at most medical centers. There are some situations, though, where an episiotomy is used to help speed up delivery and ensure the health of the baby. If you feel strongly that you don’t want an episiotomy, let your doctor know. Having a conversation about it now will make it easier to arrive at a decision if a situation comes up during your labor that would typically call for an episiotomy.
An episiotomy is an incision made in the perineum — the tissue between the vaginal opening and the anus — during childbirth. In the past, almost all women who delivered a baby vaginally had an episiotomy. They were done in an effort to prevent more extensive vaginal tears during delivery. Research now shows, however, that, in uncomplicated deliveries, routine episiotomy may increase the risk of an extensive tear. Today they tend to be used only in specific situations where the possibility of a serious laceration is high.
An episiotomy may be necessary if the baby appears to be in distress. For example, if the fetal heart rate is dropping and delivery is not imminent, an episiotomy can be used to accelerate the birth to protect the baby’s health. If forceps or vacuum extraction is required, an episiotomy is sometimes necessary to prevent serious tears. It also may be considered if a baby is large or in an abnormal position for delivery. Some women opt to have an episiotomy when labor is long, and they are exhausted from pushing, because the incision can shorten the time to delivery.
In an effort to lower the risk of complications, the technique many doctors now use for an episiotomy is different than it used to be. Traditionally, a midline or median incision was used. This type of incision extends from the vaginal opening straight down toward the anus. An alternative approach that is becoming more common is a right mediolateral incision, or RML. It’s done at an angle away from the vaginal opening.
An RML usually is preferable because it reduces the possibility that an extended tear during delivery will affect the anal area. That kind of tear is called a third- or fourth-degree laceration. It can lead to fecal incontinence and other related problems after delivery.
Before you decide whether you want an episiotomy, talk to your doctor. Ask in what situations he or she usually does them, as well as what the risks and benefits of declining an episiotomy in all circumstances would be. If a doctor knows you have a strong preference against an episiotomy, he or she may be able to take steps to help reduce your need for one. Understand that if you decline an episiotomy in some cases, such as when the health of the baby is at risk, the alternative may be a cesarean-section.
Keep in mind, too, that you don’t have to make a firm decision about this right now. It’s perfectly reasonable to express your desire not to have an episiotomy. Then if a situation comes up during delivery that may call for one, you and your doctor can talk about it and decide what’s best, given those circumstances. With this topic — and many others regarding the birth of your baby — open, honest communication with your doctor can help to ensure that your labor and delivery are meaningful and satisfying for you. — Dr. Vanessa Torbenson, OB-GYN, Mayo Clinic, Rochester, Minnesota.