Birth Prep

What is an Episiotomy?

A look into how episiotomies came to be and why they are becoming less and less frequent…
Dr. Marcy Crouch
Posted on
September 23, 2022
Minute Read

To Cut or Not to Cut

What is an episiotomy?

If you have had a baby or heard birth stories, you may have heard about an “episiotomy.” An episiotomy is a surgical procedure that is historically performed during birth to make the birth easier and less traumatic to the tissues. This incision is usually performed straight down the midline of the perineum, which is the space between the bottom of the vagina and the anus.

The Space Between

The perineum is an essential structure in the pelvic floor, as it is the area where the pelvic floor muscles converge. There are also significant nerves that run through that area that help us maintain continence and give us sensation.

During birth, the perineum and vaginal opening stretch to accommodate the head and shoulders of the baby. Sometimes, tearing of those structures may occur, which can complicate and prolong recovery.

Why were episiotomies invented in the first place?

Episiotomies used to be used routinely, as physicians thought it would prevent more significant tearing and would be easier to heal than a spontaneous tear. Turns out that’s not the case. Episiotomies often cause more damage and long-term problems than smaller spontaneous tears and can contribute to prolonged pelvic pain and dysfunction.

Episiotomies began in the 1740s and were described in Fielding Ould’s 1742 Treatise of Midwifery in Three Parts.

An excerpt from his instructions for episiotomy is below:

“…then the Incision made very leisurely towards the Rectum; this Incision must be proportioned to the present Exigency of Affairs…taking all the Care imaginable not to cut so far as to go through the substance of the Womb to the Rectum..” (excerpt taken from HERE)

However, even back then Ould knew that this procedure should only be used in “dire emergencies” and that using an episiotomy should be the last thing performed in order to save the mother and or child.

However, their reasons for being weary of this procedure were quite different from ours. Back in the 1740s, without sterile environments or antibiotics, it was very likely that making an incision like that would probably kill the mother due to infection. This fear continued through the 1800s and on.

Why did they stick around?

Even though Ould and others recognized that episiotomies weren’t the best route to take, this procedure still made its way into common medical practice.

In 1920, at the meeting of the American Gynecological Society, Joseph DeLee, a Northwestern University professor of obstetrics, stood in front of his esteemed colleagues and argued that labor was an “abnormal pathology” that “damaged both mother and child.”

Hence the idea that birth should be thought of as a “disease which needed to be treated,” so to speak. DeLee thought that the way to “prevent” the “horrors” of birth would be to, in fact, make a large incision in the perineum.

It’s also been said that episiotomies became more widely adopted for the benefit of the physician, making births in the laying down position easier.

Episiotomies became routine, up until the late 1970s, which meant that almost EVERY mother was given the procedure, whether or not she needed and/or consented to it. This is seriously troubling.

Are episiotomies still a thing?

Thankfully, the “routine” use of episiotomies has since declined, and they are reserved for medical emergencies or dire straits. However, even though episiotomies are proven to be damaging, there are many providers that still use them regularly.

Gizmodo says:

“The American Congress of Obstetricians and Gynecologists now recommends that the procedure should only be used in extremely limited situations. Doctors are listening. In 2012, the episiotomy rate in the United States sank to 11.6%, its lowest level in years. According to Katherine Green, an Assistant Clinical Professor of Nursing at UMass Amherst, it’s now used only in the event that a baby’s head or shoulder becomes stuck in the birth canal.

It took the better part of a century for the episiotomy to get a scientifically-supported role in childbirth, but evidence-based medicine has brought it back to its origins as a rarely-used tool for emergencies.”

“I’ve had an episiotomy…What do I do?”

First, don’t panic. Did you know that most of the long-standing issues from having an episiotomy can be treated with physical therapy?

Anal sphincter damage, pelvic pain, sexual dysfunction, and urinary and fecal incontinence are all common pelvic floor problems that can cause a great deal of long-term suffering. Treating these issues with conservative management firsthand, like pelvic physical therapy, is imperative to proper healing and recovery.

Lucky for you, The Down There Doc has a ton of free content and advice on postpartum recovery and birth prep on!

If your concerns are related to an episiotomy, we recommend you start here.

Dr. Marcy Crouch

Known as The Down There Doc on Instagram and TikTok, Dr. Marcy Crouch is a board-certified women’s health physical therapist working to elevate pregnancy and postpartum care for women everywhere.