Episiotomy vs a Natural Tear: Which Is Better?

Is it better to be cut or to tear naturally at delivery? Obviously, the answer is neither, but the majority of patients will tear at delivery, and for a long time it was thought that cutting would result in better healing than tearing, but newer research is showing the opposite. Today we’ll dive into what the studies show and how to talk about this topic with your provider.

First off, let’s go over some definitions:

Natural Tearing: This happens as the baby comes through the birth canal and most often tears the tissue between the vagina and the anus. However, it can also tear up (towards the urethra) or out to the side as the baby comes out.

Nurse Note: It’s important to know that this type of tearing happens at delivery — not during the pushing phase. A good provider helps a patient stretch (as they support) those tissues rather than push hard right at the end which can cause more tearing.

Episiotomy: This is where your provider makes a cut to help baby out — It can be either towards the rectum from the birth canal, but can also be to the sides called a mediolateral episiotomy — where the cut goes towards the thigh. They use scissors to make this cut.

Nurse Note: I am also dying as I type this. This isn’t fun to think about — but an important topic to consider, and I want to emphasize that the majority of birthing patients have some type of tear. So, I’m glad you’re here.

Let me just put a plug in for learning how to manage your care of your life and your bottom postpartum. I recommend this as I think it has a very thorough postpartum section that is missing in most.

Grades of Tears

Now, there isn’t just one type of tear — we grade them as to how close they come towards the anal sphincter and the muscles/tissues involved in it.

Sometimes patients just tear a bit, just the skin — and that is a first degree tear. If it extends further and a bit deeper, that is a second degree tear.

When the tear extends towards the anal sphincter tissues it is a 3rd or 4th degree tear depending on how close it gets to the anus. — and as you can imagine that is much more to heal from than just a first degree tear. We call these Obstetric Anal Sphincter Injuries (OASI) and that is the main thing we’re trying to prevent.

As a provider cuts an episiotomy they are most often not cutting into the anal tissues. They cut what would most often be a second degree and then often the cut extends with a tear beyond that.

If any of you are sewers reading this, I sometimes do think of it how you’ll nick a fabric with your scissors and then pull and the tear in the fabric extends easily as you’ve started it. I do see that sometimes happening. (and yes, typing this paragraph made me 😱🙀).

Stats on Tears at Birth:

• About 85% of women have a tear at birth (meaning only about 15% of an intact perineum after delivery)
• First time moms are more likely to have a tear than subsequent births
• 40% of first time birth tears are 2nd degree tears
• You can also have labial tears where it it extends up towards your labia (these STING when you pee)
• Experienced midwives are less likely to have larger tears at delivery (love me a midwife)

I also want to mention that I am a survivor of a 3-4th degree tear (sort of in the middle of those) and I just want to insert some emojis of how I feel writing this. 😫😭😩😿 But I do want you to know I survived all of this! It is possible, even if it sounds miserable. I wish I had prepared better!

Ok, those are the basics — and I think far too many people stop there — but I think it’s important to know that an episiotomy can be necessary.

When an Episiotomy is Necessary:

These are times in which baby may need to come out quickly, or more manipulation will need to happen in the birth canal.

Shoulder Dystocia – This is where baby’s shoulder is caught behind the pubic bone. Sometimes providers have to reach up into the birth canal to help this. As there is more trauma to the tissues, most believe a cut may be necessary depending on the interventions needed. However, we can often relieve the dystocia without them having to reach up inside, in which case a cut wouldn’t help.

Fetal Heart Rate Decelerations – If baby’s heart rate is going down often they will cut an episiotomy to shorten time to delivery. It can lead to better outcomes for baby.

Forceps or Vacuum Delivery – These are assisted devices (often called an “operative vaginal delivery” to help baby to come out. I have a whole podcast episode on them if you want to learn more. I did learn in this episode that forceps do have a risk of a higher tear — and I think that’s important to know (more doctors use a vacuum lately though).

Other times I’ve seen it that seem valid:

Patient tearing towards urethra – As you can imagine a tear through the urethra is something we want to avoid — if a provider can tell that a patient is tearing up towards their urethra they may cut down to encourage the tear to go that way, rather than up. I don’t hear about this in any studies, but I’ve seen it and personally I think that’s valid!

I will say that sometimes patients get REALLY tired after a LONG pushing time (more info on pushing times here). Sometimes the doctor will ask the patient if they’d like an episiotomy to help speed-up baby’s birth. I think that’s valid. Some patients will be begging to take any more time of pushing away, while other sill prefer to continue to push. My doctor did this for me on one of my kids and I said no episiotomy, and I’m glad I did — but I didn’t mind being given the option.

You’ll notice I didn’t include things like “big baby” — while that can increase your odds for tearing, it doesn’t mean that an episiotomy will make that tear less or heal better.

Want to know more hospital tips — check out these posts:

• Epidural Myths vs. Facts: What Social Media Gets Wrong About Labor Pain Relief
• Lies I Used to Believe about Labor & Birth
• Common Choices During Labor
• How to Push During Labor (What No One Explains)
• Why People Get An Epidural Even When They’re Not Planning On It

Which brings us to:

Selective Episiotomy

So, back in the day they did a routine episiotomy — meaning they cut it on every patient. Early on in my career (remember, I started in 2001) I worked with a few older providers who cut every single patient. This isn’t considered appropriate anymore (frankly, wasn’t great in 2001, and we reported it frequently).

Now, they are encouraging selective use of episiotomy (which means “only if needed”). Obviously, that is up to expertise of your provider and would be for the reasons mentioned above. Most often due to forceps or vacuums (which happen in about 5% of births).

There is a Cochrane review where they compared selective episiotomy vs routine episiotomy. Here are the results:

• Selective Episiotomy reduced severe perineal tearing by 30% (vs routine episiotomies).
• No real difference in infection rates between the two
• Less moderate to severe reports of pain 3 days postpartum
• No changes in baby’s APGAR (shows how well baby is doing after birth) or blood loss between the two groups
• No difference in reports of pain with intercourse (reported at 6 months+ after delivery)
• No changes in reports of urinary incontinence (reported at 6 months+ after delivery)

A few other interesting things I noted in that study:

• No real difference noted between people who had their cut extend towards the anus vs to the side towards their thigh
• None of the studies in this review really dove deep into women’s pain (?) or their satisfaction with their birth {big sigh}
• Hospitals actually save money with less episiotomies (patients stay less time on postpartum when they don’t tear as much)
• The studies didn’t report on fistulas (where there is an opening between the birth canal and the rectum) or fecal incontinence (where you leak stool) — which seem important to note

(BTW, I give full citations of the studies under “sources” at the end of the article)

Benefits of an Episiotomy:

The use of an episiotomy shows less Obstetric Anal Sphincter Injuries also called OASI (meaning a tear that extends to the tissues of the rectum) during an operative vaginal delivery (forceps or vacuums). Study linked here.

Most people seem to think that if you’re doing an operative vaginal delivery you should consider an episiotomy — and that is discussed in the video linked above. You can also listen to the podcast here.

I also wanted to address something that I see a lot online:

Coached Pushing and Episiotomies

This study showed there was a higher incidence of both tearing and episiotomies when coached pushing is used.

FYI, coached pushing is when people usually hold their breath and count to ten as they push.

Nurse Opinion: I’m here to say that’s complicated. For a lot of women un-coached pushing doesn’t provide results. In order to actually get baby to descend they have to hold their breath and push a long time. I just feel like they’re two separate kinds of birth….

I agree that uncoached pushing is the best way, but often it just doesn’t work. Recently, providers have been against “laboring down” (or waiting until the patient has more of an urge to push — or baby is lower), although some studies are walking that back. It’s just complicated, and I want you to understand that with these studies.

I want you to remember that tearing happens at delivery — not the hours of pushing prior to that. To me, this means that coached pushing may be necessary to get that baby to the perineum, and then at that point we use more patient-directed pushing. Most often this happens — you’ll see providers ask for small tiny pushes as the baby’s head descends through that portion. That is very different than the types of pushing we used prior to baby coming out.

Also, that study only had 39 women in it. That may speak to the fact that most people don’t have the “fetal ejection reflex” where they just quickly bear down and baby is born.

💡💡💡 I also have a whole post on how to PREVENT tears that dives into this all a bit more (and a few things you can do like perineal stretching and warm compresses at birth).

Avoid Tearing at Delivery: 3 things you can do.

There are a LOT of people talking about pushing online — and many of them haven’t pushed with a variety of patients at delivery. While the studies can give us information, make sure to listen to experts about what to expect and how to make choices at your delivery.

How does this apply to you?

That’s the big question, right? How do you apply this to your own delivery. Here are a few takeaways for me.

Ask your provider how often they perform episiotomies? Honestly, it’s a good question for any provider. Gives you an idea how respectful they are of your questions. If they brush this off that it is not important, it is! A red flag in my book. If they honestly say they do it about 5% of the time but they truly try to avoid it unless entirely necessary, that’s a good answer.

Also, if a provider says “never” that’s a red flag to me too — these are sometimes necessary, and honesty is really important to me in a provider!

Ask your provider how often they use vacuums or forceps? Most of them are only trained in one or the other. Again — just allows an open conversation between your expert and you. Doesn’t need to be long, but does give an idea of what they would use if they needed to.

Be aware that sometimes a cut is necessary, and have a provider you feel confident in. I see so many people questioning their providers nonstop –but you need a provider you can trust. They could be making life or death calls for you, in addition to smaller, but substantial, calls like this.

Learn how to heal your bottom postpartum. Oh goodness, I wish I’d done better on this with my first baby. I wasn’t prepared to heal at all. I have a whole post on how to take care of your bottom after delivery, but it’s just one part of postpartum.

However that’s just one part of it. Learning to take care of yourself while taking care of someone else you love so very much is very demanding. Learning from an expert (who is honest and open about what to expect after seeing thousands of patients) is your best bet.

So yes, avoiding an episiotomy is good, but having a trained expert you trust is always the key. Plus, learning to make choices for yourself is always a good thing. I’m glad you’re here.

What did you learn or come to think after this post, tell me in the comments!

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Sources:

Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev. 2017 Feb 8;2(2):CD000081. doi: 10.1002/14651858.CD000081.pub3. PMID: 28176333; PMCID: PMC5449575.

Is an episiotomy always necessary during an operative vaginal delivery with vacuum? A longitudinal study — The Journal of Maternal-Fetal & Neonatal Medicine Antonio Ragusa,Fernando Ficarola, Alessandro Svelato, Caterina De Luca, Sara D’Avino, Alis Carabaneanu, Amerigo Ferrari, Gianna Barbara Cundari, Roberto Angioli &Paolo Manella Article: 2244627 | Received 26 May 2022, Accepted 31 Jul 2023, Published online: 08 Aug 2023

Sampselle CM, Hines S. Spontaneous pushing during birth. Relationship to perineal outcomes. J Nurse Midwifery. 1999 Jan-Feb;44(1):36-9. doi: 10.1016/s0091-2182(98)00070-6. PMID: 10063223.