Why Are We Still Cutting Women's Vaginas During Childbirth?

Just as Rachel was about to start pushing out her first baby, her OB-GYN told a medical student who was shadowing her she was going to cut an episiotomy.

“She said, basically, ‘We know it’s going to be a big baby, so we’re not going to take any chances with it getting stuck,’” recalled Rachel, who asked HuffPost to use a pseudonym for privacy reasons. “I was like, ‘Wait, what?’”

The doctor made a cut in Rachel’s vaginal wall, while she screamed in pain and confusion. She felt everything. By that point, the epidural she’d gotten hours before had worn off.

After Rachel delivered her daughter, her OB-GYN stitched her back up. Rachel didn’t notice the pain as much then, distracted by the new 9 pound, 5 ounce baby trying to latch onto her breast.

But in the following days and weeks she felt it constantly. Peeing burned so much Rachel cried and doused her vagina in Dermoplast pain spray. Sitting was excruciating. After five months, things started to feel relatively normal again. But sex with her husband hurt for a full year. 

“It was miserable,” Rachel told HuffPost. 

For decades, OB-GYNS performed episiotomies as a routine part of childbirth, snipping the tissue between the vaginal opening and anus to give emerging babies more room. Doctors believed that proactively cutting laboring women saved them from developing more serious, less manageable tears and helped with delivery. By exercising some level of control over the tearing, they also believed they were giving women’s pelvic floors a better shot at making a full recovery.

But none of that was really true. Although episiotomy can serve an important purpose in cases when a baby’s shoulder is stuck behind a woman’s pelvic bone, for example, or when a baby must be helped out with a vacuum or forceps (a circumstance that arises in about 3 percent of deliveries in the United States), doctors eventually realized there was no evidence to suggest it helped in most deliveries. Women’s bodies are, by and large, pretty adept at getting babies out and most of the time cutting their vaginal walls isn’t required to help the process along. 

So about 15 years ago, the American College of Obstetricians and Gynecologists (ACOG) updated its guidelines saying for the first time that routine episiotomy was not recommended.

Since then, the best available data suggests episiotomy rates have dropped by a lot. In 2000, 33 percent of vaginal births in this country involved episiotomy. By 2012, it was closer to 12 percent . But there is significant variation in who gets the procedure. A 2015 study found , for example, that white women are more likely to get an episiotomy than black women, and that women with commercial insurance have higher rates than those on Medicaid. This May, The Leapfrog Group, a patient safety organization that directly compares hospitals, released new data  putting the rate at hospitals it tracked at around 7 percent in 2018.

But the data isn’t great. Most of those numbers come from administrative data that relies on coding in hospital records, rather than clinical charts. “What we know from administrative data sets is that there can be a lot of errors,” Dr. Barbara Levy, ACOG’s vice president of health policy, told HuffPost. “If you don’t have clinical knowledge, it can be difficult to tell the difference between a tear and a purposeful cut.”

The overall (though still somewhat murky) picture that emerges is that episiotomy in this country is certainly less common than it was decades ago, but still happening. Too often? About right? With somewhat thin data and no agreed-upon “ideal” rates, no one can really say. As is the case with obstetric care so often this country, a woman’s experience may be entirely shaped by the provider she sees and the institution where she delivers.

Stories like Rachel’s suggest, however, that there are OB-GYNs who continue to perform episiotomies routinely. Although Levy with ACOG declined to comment on the specifics of that case and whether an episiotomy was appropriate, she conceded that practice recommendations from groups like ACOG can take a long time to filter down. 

In the meantime, the onus often falls on women to have conversations with their providers about their episiotomy practices — a challenge because it is, understandably, not something many women have even heard of. 

“As a patient, you want to be having frank conversations with your provider group,” Levy said. “You want to know, what are the circumstances where you might perform an episiotomy? Will I have a chance to make that decision with you? Under what circumstances would it be considered an emergency situation where that would happen without my decision?” Women should ask their providers for information on their episiotomy rates, she said, in the same way they’d ask about C-section rates. 

Because this is not a simple case of episiotomy bad, letting women tear naturally good.

In some instances, an episiotomy with a forceps delivery might prevent a C-section delivery, and that might be a decision a woman and her doctor make together in the moment based on her particular circumstances and wishes, Levy said. Other times — like if a baby’s shoulder is stuck — a doctor might make the decision to perform an episiotomy right away without input. It would not, as Levy put it, be a “discussion item” in the heat of the moment. 

“These are things that should be talked about in advance, and why it is important for women to have a trusting relationship with their provider,” Levy said. 

Because as Rachel found, recovery can be hard. The wound takes time to heal and, like all cuts, runs the risk of infection. Research also now shows that episiotomy can increase a woman’s risk of anal incontinence. 

“That’s the biggest concern,” said Dr. Amy Rosenman, an OB-GYN and expert in female pelvic medicine with the David Geffen School of Medicine at UCLA. “Women can develop sphincter incompetence and begin leaking stool. And unfortunately there is no good solution for that. It is a life-long issue.” 

Rosenman emphasized that the far more common outcome is that women’s bodies slowly recover over a period of several weeks and months. But even that best-case scenario adds an additional layer of pain and complication to the postpartum period, which is already wildly intense.

At a postpartum check-up with her OB-GYN, Rachel brought up her episiotomy and how painful she was finding the recovery to be. 

“She was basically like, ‘You’ll live and it will heal,’ Rachel said. “And she wasn’t wrong. I did live, and it did heal. But it was traumatic.”