What's the problem with episiotomies?

An episiotomy—a small surgical incision made at the edge of the vagina intended to ease childbirth—was thought to reduce the risk of tearing and make for faster healing. But "none of these things turned out to be the case," says Dr. Katherine Hartmann, director of the Center for Women's Health Research at the University of North Carolina and lead author of new study on episiotomies published in the Journal of the American Medical Association. By cutting into healthy tissue, doctors actually put women at risk of additional tearing that can be more painful and take longer to heal than tearing that might happen naturally.

Are there any benifits?

For most women, no. Contrary to long-held belief, episiotomies do nothing to decrease the risk of incontinence and sexual dysfunction after labor. The incision also raises the risk of additional tearing, including a tear extending into the rectal area—a rare but serious complication. "Women who have had episiotomies do report more postpartum pain," says Dr. Michael Greene, director of maternal-fetal medicine at Massachusetts General Hospital in Boston.

Should anyone get an episiotomy?

In urgent cases, yes. An episiotomy can shave 15 to 20 minutes off labor. If the baby is having difficulty fitting through vaginal opening and is in distress (e.g., falling heart rate), doctors may need to make a surgical incision to speed up the birth. "I don't think any woman should put handcuffs on her OB," Dr. Greene says.

Then why were episiotomies so common?

Since the 1930s, doctors have used the procedure frequently in the belief that a straight-line cut could be stitched and repaired more easily than a jagged tear. "It was a belief handed down from obstetrician to obstetrician that was not tested in any scientific way," Dr. Greene says. The new research challenges that thinking. And episiotomies are already on the decline; today they are done in about one-third of vaginal births, as opposed to two-thirds of such births in the 1980s. A new generation of doctors likely will continue that trend: Medical students and residents already are being trained not to do routine episiotomies, Dr. Hartmann says.

What can be done to prevent tearing during childbirth?

Massage, stretching the vaginal tissue in the last weeks of pregnancy and certain exercises may help. Good hydration and a healthy diet are also useful, says Susan Moray, a midwife in Portland, Ore. Still, two-thirds of women who give birth vaginally tear.

So, what should women do?

Some doctors have been doing the procedures for years and believe they are effective. A few states require hospitals to report their episiotomy rates. Otherwise, a woman can ask the hospital for its rate and query her own physician about his or her position on routine episiotomies. Dr. Hartmann advises a woman to discuss the subject with her doctor or midwife just as she would make clear her wishes about whom she wants present in the delivery room and whether she would want a baby boy to be circumcised. Adds Marion McCartney, a director of the American College of Nurse Midwives: "Women should be as assertive about their health care as they are about buying a car."

By Melody Simmons in Washington, D.C.

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