Episiotomy Explained: Understanding the Why, When and How

In this episode, Dr Rangi is joined by Melanie Francis, Clinical Midwifery Educator and Head of Operations ANZ for GynZone.

Together, Rangi and Mel explore the important topic of episiotomies. They explain: 

• What is an episiotomy?
• Why an episiotomy may be recommended during birth and when it can be beneficial for both mother and baby
• Common misconceptions about episiotomies
• What the procedure involves, including the different techniques used
• What to expect during recovery and practical tips for healing

Whether you're preparing for birth or simply want to better understand your options, this episode provides practical, evidence-based information to help you feel informed and confident.

Transcript

SPEAKER_00 0:01

Welcome to Prepare, the Mercy Perinatal podcast dedicated to helping parents prepare for the journey of pregnancy, childbirth, and early parenthood. Mercy Perinatal would like to begin by acknowledging the Rawundri Wuiwarung people, traditional custodians of the land on which we gather today, and also the traditional custodians of the lands in which you're listening from today. We'd like to pay our respects to the elders past, present and emerging, and we extend that respect to Aboriginal and Torres Strait Islander peoples listening today.

SPEAKER_01 0:31

Hi everyone, welcome to Prepare. My name's Dr. Rangi, and I'm an obstetrician and gynecologist here at Mercy Perinatal, and we are so excited to be welcoming Melanie again, who is our amazing clinical miniwi-free educator from Gynezone. And we had a chat to Mel on our last episode about perineal tears. And this episode is following on from that about epissiognomies. Welcome Mel. Thank you. Thanks so much for joining us. For those who haven't listened to our previous episode, can you give us a quick intro into your experience and why this area is such an important area for you?

SPEAKER_02 1:09

Yeah, so I've been a midwife for about 10 years now and always had a passion of just general women's health and particularly around tears and repairs and pelvic floor, that's always been a really big passion of mine. I mean it's probably grown even more since I had my own baby and having gone through that journey myself. But having been a clinical educator in a public hospital as well, more recently, just ensuring that our clinicians, our midwives, and our obstetricians are well educated and supported with clinical skills regarding how to manage and reduce risks of tears. But I guess particularly for this sort of topic, episiotomies, it is something that does require training. And particularly for midwives, we don't do them very often. So making sure that we're feeling confident with our skills so that when it needs to happen, we can do it and ensure that it's the right outcome for the woman. Yeah, perfect. So I suppose to start with, what exactly is an episiotomy? So an episiotomy is a procedure. I think sometimes there can be a misconception that it's a tear. And while it causes a tear in the same muscle area as what a second degree spontaneous tear would be, it's important to know it's a procedure. So we're manually making a cut in that perineal body, in that tissue, in those muscles, to create space for the baby's head to come through. And there's a number of reasons why we would do it, but essentially it's yeah, to create space to allow the baby to pass through without potentially causing more trauma and a larger tear, essentially, in that perineal space.

SPEAKER_01 2:38

Yeah. And as you said, we only really recommend an episiotomy if we think it's necessary.

SPEAKER_02 2:44

Yes, we don't do them routine. In the past it was a routine. If you look at stats sort of over the last 20, 30 years, you'll see a very big, like just mountains up and down, up and down of stats. Um it used to be a routine for every woman having their first baby because it was believed that it would reduce the risk of severe tears, but we know now that it actually doesn't really make too much of a difference. So we need to look at ensuring that we've got a really good reason for making that cut for that woman.

SPEAKER_01 3:12

And what are some of those reasons? You said number one would be to reduce the risk of more severe tears. Yeah. Namely, one of those tears would be to stop it going down to the bottom. Correct. One of those third or fourth degree tears.

SPEAKER_02 3:26

Yeah, and it's important to know that we're not doing that prophylactically where we would make that decision because we could already potentially see that maybe a tear is starting to occur before that baby's head's really started to come up. So that could be in the sign of some bleeding, or we can see the discoloration or changes in skin colour in that perineal body of that woman, and that might be an indication that we need to make that cut so that it doesn't start to tear before the baby's head is born. Another reason could be for, and I think you'll go into this in a bit more detail, but instrumental birth, so a vacuum or a forceps can sometimes be necessary to use a pisiotomy as well. But also if we're concerned about baby's well-being. So if baby's severely distressed and we can see that birth might still take a little bit longer if we don't create that space and help them along their way, that's another reason for why we would do it. Other more or less common reasons might be previous trauma to that vulva or vagina area. So female circumcision is often a reason to do one as well. But as midwives or doctors, we're usually already aware that there's a need for this, and the woman herself is usually understanding and aware that this is going to need to happen as well.

SPEAKER_01 4:38

Yeah. And is it, as you said, sometimes people might know about it beforehand, such as the example that you just talked about, where perhaps there's been female circumcision or cutting in that area beforehand that makes a space smaller. So we have to create space for the baby to come out. But is it something that we uh usually discuss beforehand, or is it a decision that is made at the time in your experience?

SPEAKER_02 5:05

I would say my experience is usually a decision that's made at the time and not a lot of conversation happens before that. But I think that's to the detriment of the woman, unfortunately. So it should be the other way around. So as part of your birth prep meeting, it should be part of that conversation to understand what it is and when it might need to happen, so that women can have the opportunity to consider whether that's something that they are willing to consent to, because despite our recommendation and and while we know why we might need to do it, it's still important that we're gaining that consent before we actually go and perform that procedure. Like any procedure.

SPEAKER_01 5:39

And say no, yeah, absolutely. Yeah, you can definitely say no as long as you know why we might be recommending it and why we think it's a good idea and what the risks or chances of other things happening if it's not done would be. If you're fully informed, then of course you can say no anytime, like any other procedure, as you said. Exactly. But it is important to understand, I think, beforehand, which is why this episode is useful. Absolutely. Because of course, at the time when that head is crowning, even if you have good pain relief like an epidural, it's a really intense time. It is, it is. So having that conversation with someone about potentially having a cut can be quite confronting and and it's difficult to make those decisions.

SPEAKER_02 6:23

Yeah. Women aren't supposed to be in a headspace to make challenging decisions like that. So um at that time. So yeah, having that knowledge beforehand is really powerful.

SPEAKER_01 6:31

Yeah. What actually do we do during nipisiotomy?

SPEAKER_02 6:36

Yeah, so once we assess that the need for it and we have consent's been gained, it's important that we're making that cut at the right time. So we're wanting to make sure that that baby's head's up as high as it can possibly be without bursting through that perineum and making sure that the perineum's as stretched as it can be before it starts to tear. That's going to help block any blood vessels from continuing to supply blood so that when the cut's made, there's a less chance of it bleeding. But also that reduces pain as well because the nerve endings in that area are going to be compressed as well, so women are less likely to feel it when it happens. In saying that, though, it's important that we're giving women pain relief prior to that cut. So that would be in the form of an injection in that area where the cut's going to be made and having time for that to actually take effect before the cut's been made as well. And then once that's all set up, the midwife or the doctor will place a pair of scissors inside the vagina at an angle of between 45 and 60 degrees. That's the most optimal angle because we want to obviously avoid cutting too close to that sphincter muscle, because that's the whole point. We're trying to predict it. And it will be cut at the time of a contraction, so when the woman's pushing. So that's to help keep the stretch on that perineum, but also to help, again, I think a little bit of if the woman's got something to focus on, um, while that cut's being made, they're less likely to feel any discomfort during that time as well. There might be a second midwife or doctor that might help support that perineum once it's been cut as well, so that as the baby's head is progressing forward, the perineum isn't tearing any further. So keeping pressure on that area. And if it does start to bleed, keeping pressure on the area. So we're reducing the bleeding as well.

SPEAKER_01 8:19

Yeah, really important. I think the other thing that we do when we're cutting the epesiotomy is making sure that we're not injuring the baby. Absolutely. Absolutely. I think that's the most important part. Yeah, it's a fair concern when people imagine scissors in that area when the baby's head is coming out. We make sure that the baby's head is protected by putting our hand in between the scissors and the baby's head where we're where we're cutting so the baby's protected. Yes. And a common question is does it hurt more or less than a natural tear?

SPEAKER_02 8:52

It's gonna hurt more. When we're inducing a cut or a tear, I guess, to that perineum, it's going to be a lot more uncomfortable than a spontaneous tear. It's just the way the fibres are torn with a spontaneous tear because the perineum is stretched as as far as it can go before it tears. So it's really, really thin. Episiotomy is even when we wait for that perineum to be as stretched as much as possible, the tissue is still a lot thicker. And so repairing it is a lot more challenging. There's a high risk of infection. Um, and just that healing phase can take a lot longer as well. So important to maintain a lot of pain relief during that time is really important so that recovery can can continue and you can care for your baby how you normally would without having to worry about too much pain.

SPEAKER_01 9:37

Yeah, yeah. That is important to note. I suppose I would say the repair of an episiotomy can be challenging because the the muscles involved can be potentially more than a second degree. Yeah. But it is often also slightly less challenging in a way to bring those muscles together when there's been a clean cut like an episiotomy, than potentially like a complicated second degree tear where there's been multiple tears and you're not quite sure how the muscles might best come together. That's a good point, actually. So there are some advantages in a way if you have a clean cut that's controlled versus a difficult tear where you haven't been able to control the extent of tearing.

SPEAKER_02 10:21

Yeah, that's a really good point. Being able to actually identify where those muscles come back together is a lot easier in a pisiotomy, but usually a bit more tension on the stitches to try and bring that back together as opposed to a second. So there's there's pros and cons to both of repairing both of those injuries. Yeah.

SPEAKER_01 10:35

Yeah, but but the way we repair, similar to a second degree, is with the stitches.

SPEAKER_02 10:39

Absolutely. Yeah, yeah.

SPEAKER_01 11:00

Similar to tears, how long can episiotomies take to heal?

SPEAKER_02 11:05

So any kind of tears to heal is often affected by the woman's own body, like in in response to healing. So there's not always like a standard two weeks, four weeks, six weeks, but episiotomies do generally take that slightly little bit longer to heal. So you can expect, yeah, a couple more weeks of a little bit more discomfort in that area than if you were to have a spontaneous second degree tear. Yeah, okay.

SPEAKER_01 11:29

What helps with healing?

SPEAKER_02 11:31

So rest, ice, pain relief, loose garments as well. So not having anything too tight around your body. A large pad can be really helpful though. So even if you're not bleeding too much, if you get a really, really big pad, having that pressure up against that wound can actually be quite helpful. Um, and you can always put an ice pack in between that as well. But trying to keep the pressure off it as much as possible is really important.

SPEAKER_01 11:58

And some of the things similar to when you have a tear that we recommend you keep an eye out for and seek advice if you notice is increasing pain, redness, abnormal discharge, or if you feel like there's been a change in the way the stitches are sitting or the wound is is opening up. Yeah. Then we we need to have a look at it, don't we?

SPEAKER_02 12:20

Absolutely, absolutely. And and don't wait. It's not going to get better on its own. It'll probably get slightly worse. So really important that you get in touch with your care provider. Yeah. And we we would prefer you get in touch with us sooner rather than later. Absolutely.

SPEAKER_01 12:34

Yeah, 100%. We know that perennial massage can reduce the risk of tearing. Can they also help with the episiotomy?

SPEAKER_02 12:42

It definitely can because if you think about a reason as to why an episiotomy might be necessary if that the tissue and the skin is just at its capacity and that baby's head is it's almost preventing that baby's head from moving further up, that's going to be because of the the elasticity of the tissue. So perineal massage can definitely help reduce that risk of requiring an episiotomy for that specific purpose. Um, same as your birth positions as well. So lying on your side or kneeling can also reduce the risk or the need for an episiotomy for the purpose of that stretching of the perineum.

SPEAKER_01 13:15

And I suppose similar also to the setting of your birth and the team that you have around you. Absolutely. How you're feeling, all of that stuff. All of those factors. Yes. Yeah. Do you know some of the stats, Mel, on how many women actually need an episiotomy in Australia?

SPEAKER_02 13:31

So the World Health Organization recommends an episiotomy rate of up to 10%. So that is higher in Australia than the World what the World Health Organization recommends. On average, it's around 20%. And this statistic has fluctuated over years. One of the biggest goals globally is to try and reduce or essentially eliminate our third and fourth degree tears, those severe perineal tears. And episiotomy constantly comes up as one of those procedures that we can do to try and reduce that risk. But what we're finding is that it's really not making much of a difference in that number. So that's why information and informed consent is so important because we don't want to continue to see our episiotomy rates go up when it's not actually changing any of our birth outcomes for the better. Are our episiotomy rates going up? Yes. Really? Yeah. So in 2018 they were around 18%, and now in 2023, they're about 22%. So they are slightly going up. Um if you look at it back from 2004, they were even less than that. So it is changing. Our populations are changing as well, though. So there are a lot of other factors. And when you look at certain ethnicities who have higher risks of, again, our severe perineal tears, then you would look at the statistics of the number of their episiotomy rate for that particular population, and that's probably going to be higher than, say, women who don't have that risk factor. Um what are some of those ethnicities? Yeah, so South Asian ethnicity is probably the most common in saying that though Asian ethnicity encompasses a very large scale of the world. Um so our Indian, Pakistani, Chinese, they're sort of the those population groups that are a lot more likely to be at risk of sustaining severe perineal tears than your white Caucasian or even black population groups.

SPEAKER_01 15:22

I think that that is interesting and and I know that we have found that I think historically we've thought that that's because the connective tissue in those ethnicities is quite strong. Yes. Which is a good thing in general, but difficult when we have stretching of that perineal skin. We want it to be stretching nicely for the head to come out and it might not stretch well because it's so strong.

SPEAKER_02 15:45

Yeah, and that's why birth positions, particularly for this population, are really important, because we want to try and find every other way that we can to support them to reduce that risk of tearing or that need for a pisiotomy.

SPEAKER_01 15:56

Another factor, I think, with some of those ethnicities is that the distance between the opening of the vagina and the bottom or the perineal area can be a bit smaller because women of those ethnicities in general can be a bit smaller in size.

SPEAKER_02 16:11

Yeah, yeah, and we know that that can be a factor again, that women can run that slightly higher risk of severe perineal tears if their the actual size of the length of the perineum is a little bit shorter, but again, they shouldn't be factors that we take into account in isolation. They we need to look at the the whole picture as well.

SPEAKER_01 16:26

Yeah, that's right, because those ethnicities also tend to have smaller babies.

SPEAKER_02 16:30

So exactly, and I've seen some perineums where I've I've looked at them and thought, oh my gosh, this is the tiniest perineum I've ever seen. And they stretch to like 10 centimetres, so yeah, they're amazing. So it's hard to know. It's hard to know what that elastic tissue is going to do until birth really occurs. So then that's why as clinicians we can only do so much because we're sort of restricted and often it's waiting until those moments to then be able to make that decision.

SPEAKER_01 16:54

Yeah, but it's all about trying to prepare yourself with that knowledge that it could be possible and what might be involved so that even when your clinicians having those discussions with you, it's not new information and too confronting and that you can make an as informed decision as possible.

SPEAKER_02 17:11

Absolutely. So important. Fantastic.

SPEAKER_01 17:15

I suppose we've covered a lot about episiotomy and we have talked a little bit about some of the common myths and concerns, but one of the most common myths that you mentioned before is that everyone, particularly first-time mums, would need an episiotomy, and that's just not true, is it?

SPEAKER_02 17:31

No, that's not true at all. Um that's a very old school mentality. If your care provider is telling you that that has to happen, then that's it's not evidence-based at all. So we know that going into your birth for the first time, we don't know what your birth outcome is exactly going to be like. We can do everything we can and you can do things to reduce your risk of tears, but it doesn't warrant a prophylactic episiotomy. Yeah. Um and at the end of the day, you might have not teared at all. Yeah. And yeah, and yet now you've ended up with a tear anyway. Yeah.

SPEAKER_01 17:57

Yeah. Exactly. So it's always important to assess at the time. Absolutely. I know we mentioned that an episiotomy can hurt a little bit more than a tear, but I think it's it's also a common myth that an episiotomy is always worse than a tear in general, because as we were saying, you sometimes having a bad tear that is not controlled can be worse than a small controlled episiotomy to make that space. Yeah. So it's easier to repair. So it can go either way.

SPEAKER_02 18:28

Yeah, absolutely. And again, I think we can keep reiterating the same point that as long as it's informed and there's a as a good reason to do it, then yes, you're definitely reducing that risk of having a worse outcome than what an episiotomy would otherwise be. Yeah.

SPEAKER_01 18:42

And a couple of other myths, you know, if you've had one before, you will definitely need one again.

SPEAKER_02 18:48

Absolutely not. You you do run a slightly higher risk than if you were to have a spontaneous tear the first time and then needing an episiotomy the second time. Like you you probably wouldn't, um, as opposed to if you had one the first time, yeah. But it it doesn't increase your risk of needing one, that's for sure.

SPEAKER_01 19:04

And you can't always avoid one if you prepare enough, although it does help.

SPEAKER_02 19:09

It does help, but yeah, as we said, there's some situations where it would be for the benefit of yourself or for your baby to have one. Awesome. Thank you. That's okay.

SPEAKER_01 19:20

So I suppose to summarize, Mel, what would you say would be the three things you would want people to take away about episiotomies?

SPEAKER_02 19:28

So understanding that it's not routine, so you don't need to worry about that. Ensuring that you have all the information to go forward, if your midwife or doctor suggested an episiotomy, you can make an informed choice around that at the time and know that you can decline. You can say no. You can say no, 100% you can say no. And thirdly, in terms of recovery, it's really not much different than any other tear to recover from. So rest, pain relief, and monitoring any ongoing symptoms to ensure that you get the best care that you need if things do start to get a little bit worse. Fantastic.

SPEAKER_01 20:05

And just like any other tear and birth in general, pelvic floor physiotherapy is really important.

SPEAKER_02 20:11

Do your pelvic floor exercise.

SPEAKER_01 20:14

Key takeaway from everything. Fantastic. Thank you so much, Mel. We really appreciate you coming on to talk about this important topic that everyone, I think, is birthing should know about.

SPEAKER_00 20:26

Thank you so much. Thanks again. Thank you. Every pregnancy is unique. The information provided in today's podcast is for educational and general purposes only. It is not intended to be a substitute for professional medical advice. It is important that you always seek the guidance of qualified health professionals with any questions you may have regarding your health, pregnancy, or any medical conditions.