EBB 206 – Evidence on Perineal Tears and the Importance of Avoiding Episiotomy with EBB Founder, Dr. Rebecca Dekker

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• Cheyney M, Bovbjerg M, Everson C, et al. (2014). Outcomes of care for 16,924 planned home births in the United States: the Midwives Alliance of North America Statistics Project, 2004 to 2009. J Midwifery Womens Health 59(1):17-27.
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• Simic M, Cnattingius S, Petersson G, et al. (2017). Duration of second stage of labor and instrumental delivery as risk factors for severe perineal lacerations: population-based study. BMC Pregnancy Childbirth 21;17(1):72.
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• Crookall, R., Fowler, G., Wood, C, et al. (2018). A systematic mixed studies review of women’s experiences of perineal trauma sustained during childbirth. J Adv Nurs
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• DeLee, J. (1920). The prophylactic forceps operation. Am J Obstet Gynecol 1:34-44.
• Klein MC, Gauthier RJ, Robbins JM, et al. (1994). Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction and pelvic floor relaxation. Am J Obstet Gynecol 171: 591–8.
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Rebecca Dekker: Hi, everyone. On today’s podcast, we’re going to talk about the evidence on perineal tears and the importance of preventing episiotomies during birth.

Welcome to the Evidence Based Birth® podcast. My name is Rebecca Dekker and I’m a nurse with my PhD, and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See EBbirth.com/disclaimer for more details.

Hi everyone, and welcome to today’s episode of the Evidence Based Birth® podcast. My name is Dr. Rebecca Dekker pronouns, she/her and I will be your teacher for today’s episode. Today, I’m so excited to bring some evidence based information to you about perineal tears and the importance of preventing episiotomies in birth. Before we get started, I wanted to let you know that we will be talking about some topics, including tears, severe tears from the vagina to the rectum, and episiotomies, which is an incision or cut of the tissue next to the vagina.

We’ll also be talking about severe health consequences of severe tears and episiotomies. So today’s episode is the first in a series that we’re going to be doing over the next few months that I like to call protecting the perineum. In today’s episode, I’m going to talk with you about what are perineal tears, what are the factors that can increase your risk of having a perineal tear during childbirth, the health consequences of tears, and why it’s important to avoid an episiotomy if at all possible. In future episodes this year, we’ll cover the evidence on other ways you can prevent or lower your risk of perineal tears during birth.

You might be listening to this episode on our podcast, which has surpassed 2.8 million downloads, but I also wanted to let you know that there is a video of this episode on our YouTube channel, where I’ll be demonstrating, some of this content with a few props. So if you’re more of a visual learner, I encourage you to visit the Evidence Based Birth® YouTube channel and consider subscribing.

So, in today’s episode, we’re going to kind of give an overview of about perineal tears and the health consequences and risk factors. And we’ll talk about episiotomies. And then in future episodes later this year, we’re going to cover different interventions or methods for lowering your risk of experiencing severe tears. So, let’s get started.

I remember when I was pregnant with my first baby, I didn’t really think about tearing that much until it actually happened to me. And thankfully I only had a very minor tear that just needed a couple of stitches and it didn’t really have too much health consequences for me. But then later on, as I started working with more and more college students and teaching them about birth, it was really interesting to see how students between the ages of 18 and 20, who had not yet had children of their own yet, were really, really frightened at the thought of tearing during childbirth. There were some 19 and 20 year olds in my classes who were not having children anytime soon, but when we talked about childbirth in the first couple of classes I had with them, some of them would tell me that they were so severely afraid of the thought of tearing during childbirth, that they were even considering not having children just to avoid that risk.

So, as I went on in my career, and as I got more and more involved in childbirth education, I learned that this is a very common fear. The fear, or feeling frightened at the thought of tearing during childbirth, either for yourself or for someone else. Somebody who’s a student in the healthcare field might be afraid at the thought of watching someone tear. A partner who is there to support you also might feel sick or scared at the thought of you tearing during birth, their loved one.

So, what I want to do in this episode and over the next couple of episodes that we’re going to cover in this series, is give you evidence based information so that you feel more empowered to understand the whole concept of perineal tears and what we can do to lower the risk of severe tears occurring. So first off, what is the perineum? Well, the perineum is a diamond shaped area that’s between the thighs, and in birthing people, it’s going to be the area that is between the symphysis pubis, or the front of the pelvis and the rectum. And so when we’re talking about protecting the perineum, we’re talking about protecting that tissue, and in particular, protecting the tissue that is the space between the vagina and the rectum.

Perineal tears, or tears of the perineum that can happen during childbirth can be rated as first, second, third or fourth degree. A first degree would be the least severe, and a fourth degree would be the most severe. And I’ll link in the show notes, too, some images on the Mayo Clinic website that can help you understand the differences between the types of tears.

A first degree tear, as I said, that’s the least severe. It involves the skin around the vaginal opening. A second degree tear involves the muscles between the vagina and the anus or the rectum. And it typically requires stitches. And a third degree tear is an injury to the perineum that involves the muscles around the anus, and this may require repair in the operating room. And a third degree tear can be divided into further subgroups based on its severity. A fourth degree tear is the most severe kind of tear. And that’s where the tear reaches the tissue lining the rectum and the anal epithelium or the lining of the anus.

A third and a fourth degree tear together are also known as obstetric anal sphincter injuries, abbreviated OASI, and sometimes referred to as OASI injuries. So, how often do tears to the perineum occur during childbirth? Well, about half to three-fourths of people experience tears during childbirth with a vaginal birth. Sometimes you’ll also hear it referred to as a laceration. That is a medical term for a skin tear.

The rate of severe tears, so third or fourth degree tears or OASI tears ranges from three to 7%, but your risk can be much lower of experiencing a severe tear, and in some studies you’ll see that the risk will be more like one to 2%. So it really depends on a bunch of factors.

So what are those factors that can increase or decrease your risk of experiencing a severe tear? Again, we have first, second, third and fourth degree tears. First and second can typically be managed, don’t have usually long term critical health consequences, while a third or fourth degree tear can and have severe health consequences. And so that’s why we’re trying to avoid the severe tears especially.

Well, one of the factors that really influences your risk for having a tear is actually the provider or the person who is attending your birth as the healthcare worker. So who you choose as a provider, or who shows up at your birth to help “deliver your baby” is one of the strongest predictors of whether or not you will leave the birth room with an “intact perineum”. An intact perineum is the words we use in research or medical jargon to talk about someone who leaves without the need for stitches.

So, in a Cochran Review on midwife led care versus medical model care with physicians, researchers found that people who are randomly assigned to Midwifes, they don’t choose a midwife, but they just randomly get a midwife are less likely to have forceps and vacuum, which are instruments that assist with the birth. They’re also less likely to have an episiotomy. And so we do know that the midwife model of care leads to fewer interventions. And these interventions: forceps, vacuum, and episiotomy can greatly increase your risk of tears.

Also, it’s important to know that some providers are going to be much better at helping you prevent tears and some providers make it very likely or much more likely that you’ll tear during birth. And most pregnant families don’t understand the importance of their provider on this really basic, but really important health outcome. And that is, whether or not you are a able to avoid a severe tear during birth.

Another factor that can increase or decrease your risk of a severe tear is your birth setting, where you are giving birth to your baby. Remember earlier when I said that rates of severe tears in some settings can range from three to 7%, which seems fairly high? Well in studies on planned home births, tear rates can be much lower, especially for severe tears.

In one important study published by Kopas in 2014 in the Journal of Midwifery and Women’s Health, they found that only 1.2% had a third or fourth degree perineal laceration, and that’s very low compared to some of those other numbers I was quoting you. In that same study, they found that 49% who had a planned home birth left their birth with an intact perineum, 41% had a first or second degree tear, and 1.2% had a third or fourth degree tear. Also, the episiotomy rate in that study was only 1.4%. The episiotomy is when they use scissors to make a surgical incision on the perineum. And we’ll talk more about episiotomies in a little bit.

The review by Kopas, et al, found that overall rates of tears were lower, both in freestanding birth centers and at home births than in hospitals. One of the difficulties I’ve had in researching this subject is that hospitals in the United States where I live do not publicly report their rates of tears or severe tears. Now, they sometimes will report their episiotomy rates, but they don’t usually report their perineal tear rates. So, although birth setting can be really important, it can also be very difficult to find any kind of transparent information about what the tear rates are at your birth setting.

Another factor that can influence your risk of tears is how many babies you’ve had. If you’re giving birth for the first time, that is a risk factor that makes you more likely to experience severe tears. One large study found that third and fourth degree tears occurred in 5.8% of those giving birth for the first time, but only 0.6% of people were having a subsequent birth. So if you’ve had a prior vaginal birth, your risk of tearing when you’re giving birth the next time is going to be much lower. There are also a lot of other risk factors that have been documented in the research for increasing your risk of severe tears.

So, as I said earlier, if your provider has a high tear rate then going to have a higher risk of tears. As I mentioned, you’re giving birth for the first time. Also, if the baby has a higher birth weight, if you experience an instrument assisted delivery with forceps or vacuum use, if you are given an episiotomy, if you experience something called shoulder dystocia, where there’s difficulty with the birth of your baby’s shoulders. Interestingly, if you have a very long or a very short pushing phase, that can also increase your risk for having severe tear. So a prolonged pushing phase where you’re pushing for hours and hours and hours, or if you have a super short pushing phase and you only push for like five to 10 minutes, those can both increase your risk.

Something called occiput posterior fetal position, also known as sunny side up, when the baby’s head is coming out in the largest diameter, because the baby’s head is facing towards your spine, that can increase your risk for severe tears. And then having a family history of severe tears can also mean that you’re at higher risk.

So one of the problems with tears is that they do have potential health consequences. Of those who experience any kind of tear, the rate of needing stitches or surgical repair is about 60 to 70%. So most people who tear do need at least some stitches. Some people who tear though, don’t need stitches. Of those who experience a tear, about 55% will experience moderate to severe pain when they go home from the hospital. And of those who experience a tear, 60% will have pain with sexual intercourse at three months, and the 30% will have pain with sex at six months.

Some other consequences of tears include incontinence. Incontinence is when you have difficulty with urination and urinating when you don’t mean to, or when you have fecal incontinence, which is when you have a bowel movement without meaning to. And there’s very little research on what happens with people with different kind of tears.

What we do know is that 17% of all people who give birth complain of fecal incontinence after giving birth and 47% of all birthing people complain of urinary incontinence after birth. And it’s likely that these incontinence problems increase when you have tears. Also, if you have a tear, it is possible it could become infected. About five to 11% of people who have a tear may experience an infection. And research shows that postpartum depression, stress, and levels of inflammation are significantly higher if you have a second degree or higher tear. Finally, many people are never asked about health consequences from tears. So there’s a lot of under reporting about how big of a problem this is because most people who experience a tear are never followed up on afterwards. A really important study by Crookall et al, was published in 2018 about birthing people’s experiences after they had a tear.

So I was mentioning some statistics or data, which is what we call quantitative research. Now, I want to tell you a little bit about the qualitative research or what are people’s actual described experiences? Well, this study found, they looked at 34 quantitative and qualitative studies, and they found that people who have severe tears are usually given very little info afterwards and they feel abandoned and “let down” by their healthcare team. People also describe that the repair procedures can be traumatic and that the post repair symptoms can range from anything like minor inconvenience, all the way to having a severe impact on sexual and social functioning.

So you can see why this topic is so important because it has health consequences, and when you think about it, not only are you having these health consequences, but most people are having these consequences while they’re also trying to take care of a newborn and adjust to being a parent of a baby. So this is not an easy time to be experiencing these kinds of health consequences. So, really being able to lower the risk of a severe tear in particular is important for birthing people and their families.

Sadly, over the last 100 years, we have seen really high rates of tears and really high rates of severe tears partially due to the popularity of a procedure that started gaining prominence in the 1920s. And that is an episiotomy with scissors. Dr. Joseph DeLee is actually the physician who popularized the episiotomy in the 1920s. An episiotomy is defined as the surgical enlargement of the vaginal orifice by an incision to the perineum during the last part of the second stage of the labor. It’s still counted as the most widespread surgical technique in the world. And it basically involves an incision with scissors of the tissue between the vagina and the rectum right there, in that very sensitive part of your body. Rates of episiotomy vary based on where you live in the world and even where you live within your part of the world.

Rates are going to be lower in some countries. For example, in Denmark, the rate of episiotomy is less than 5% and it’s going to be higher in other countries. In many countries in Eastern Europe, it’s over 80 to 90%. In China and Thailand, it can over 85%. In Central America, South America, rates can be as high as 90 to 95% for people having vaginal births. This is not because people’s skin or tissue is different in these countries. It’s because doctors are trained differently in different countries. And in some places around the world, doctors are taught that it’s not possible to give birth without cutting that area. And in the United States, it’s less common. The last survey of Listening to Mothers by DeClercq et al, found that the rate of episiotomy was 17% in the United States in terms of vaginal births. And that was from the years 2011 and 2012. And rates have likely gone down more since then.

But what I’ve found is that even within the United States, you can look at from state to state, there’s different episiotomy rates, and you can look at hospitals within cities and see very different episiotomy rates. You could see a rate that’s like 1% at one hospital and 15 to 20% at another hospital. And it’s not because the people giving birth there are different, it’s because the healthcare workers who work there are practicing differently.

Dr. Joseph DeLee was an American physician who is still today known by many obstetricians as “The father of modern obstetrics”. He founded a hospital in Chicago and he was part of the medical school at Northwestern University, and he also worked at the University of Chicago. He was incredibly influential. And one of the things that he popularized was something called the prophylactic forceps operation. I have a copy of his article that he published in 1920, called the Prophylactic Forceps Operation.

And it’s really kind of gross and disturbing to read, but basically Dr. Joseph DeLee believed that people should not be allowed to give birth vaginally on their own. Instead, he believed that everyone should experience an incision, an episiotomy, and forceps to pull out their baby. So you basically have to cut you open at the vagina and pull the baby out with forceps, or kind of like a tong-like medical device. Dr. Joseph de Lee wrote, “If a woman falls on a pitch fork and drives the handle through her perineum, we call that pathologic abnormal. But if a large baby is driven through the pelvic floor, we say that is natural and therefore normal.” In this article, he’s being sarcastic. He’s basically saying like, it’s not normal to give birth to a baby. It’s not natural. It’s not normal to have a baby’s head come through the pelvic floor, and so we have to intervene and cut an incision.

He argued that we could save women’s suffering because you make the second stage of labor shorter by cutting you open. And that we can, he says this in his article, “restore virginal conditions”. And he argued that we could save the brains of babies because their heads would not be resting or pushing against the perineum, all by using the prophylactic episiotomy and forceps operation. And he popularized, wrote about, drew, described these graphic images of what he believed, how we should be cutting these huge incisions through the muscles and the tissues to hasten the birth of the baby, so that you could pull the baby out quickly. Dr. Joseph DeLee had a huge influence on obstetric practice around the world. As everybody began emulating what they started doing in the United States and episiotomies became epidemic around the world.

Countless people were cut on their vagina during the birth of their child. If you go and interview the people in your family have given birth since the 1930s, you’ll probably hear stories about episiotomies. Well, in the late 1980s, early ’90s, a family doctor in Canada was really questioning this whole practice, this whole medical culture of cutting people’s vaginas open during birth. And his name was Dr. Michael Klein. Dr. Klein wanted to challenge this status quo because even though everybody believed in cutting episiotomies, there wasn’t really any research from a randomized trial to back it up. So part of their philosophy, like Dr. DeLee’s philosophy and other people, was that if you cut someone with episiotomy, you make a cleaner incision than a natural tear, which they said was jagged and difficult to sew up. So you make a cleaner cut and you can prevent a severe tear by making a small cut that will then allow the baby to be born. So you won’t have a natural tear.

So they believed that you’re preventing tears by cutting, which just when you think about the logic, it’s like, I want to prevent a tear on you, so I’m going to cut you open instead, was their logic, which does not make sense to me, but it did to them. So Dr. Michael Klein questioned this. So he enrolled 703 low risk women who were pregnant around 30 to 34 weeks and asked them to be in this study about episiotomies. And people were randomly assigned to either routine use of episiotomy, which means everybody gets an episiotomy versus restricted use, which means you’re trying to avoid an episiotomy. So, the doctor would be handed an envelope that would say, try to avoid an episiotomy, which is the restricted use of the episiotomy, or the envelope, they’d open it up, and it would say try to avoid tears in this person, which means liberal use of episiotomy. They’d cut you to avoid a tear. And then they would follow everybody for three months postpartum.

One of the interesting things about this study is that they had trouble getting compliance from the doctors. The doctors who were caring for the women in this study really had difficulty withholding episiotomy. They could not hold themselves back from cutting in the try to avoid an episiotomy group. In fact, 40% of the physicians in this trial used episiotomies almost all the time, regardless of which group their patients were assigned to. So it’s pretty clear that doctors are going to cut episiotomies on whoever they want to in this study. And so it was hard to get them to hold back, but 60% of them did attempt to hold back episiotomies when they were told to. So what Dr. Klein found is that routine use of episiotomy failed to prevent severe tears, and in fact, it caused the opposite.

Episiotomies were the risk factor that caused severe tears. In this randomized trial, only one person had a severe tear without an episiotomy. The other 49 people who had severe tears, we’re talking about third or fourth degree, OASI tears, all of them had been cut with episiotomies first. Dr. Klein found that those with intact perineums had the best outcomes postpartum in terms of the least amount of pain and the least amount of pain with sex. And they recommended, “It is our recommendation that liberal or routine use of episiotomy be abandoned.” And you can Google about Dr. Michael Klein’s episiotomy trial. There’s a fascinating story about how difficult it was to get these results published. All of the major medical journals turned his paper down, because they could not believe that he could possibly find such a result.

It went against all of the common knowledge of obstetricians of that day. Dr. Klein did finally get the paper published in 1992 in a brand new journal that was willing to take a risk on him. And I’ve read through that article several times. It’s fascinating how he did this trial and people did not believe the results, but some people did believe the results. And so gradually there started being a movement against episiotomies in the late 1990s.

Dr. Klein went on to publish a follow up study about his randomized trial. And this is a really important follow up because in the first study they compared episiotomy, the groups who were assigned to routine versus the groups assigned to try to restrict episiotomy, but as I said, the physicians weren’t compliant all of the time. So he went back and looked at the data and compared those who actually got an episiotomy with those who actually did not get an episiotomy. And he found that an episiotomy was a so with a 22 times higher risk of having a severe tear. Again, affirming the earlier results, the best outcomes postpartum were in those who left their births with an intact perineum, where they didn’t tear, or they didn’t have an episiotomy.

He also grouped physicians into those with high episiotomy rates and those with low episiotomy rates. And he found that when you looked at the clients of the physicians with high episiotomy rates, there was a severe tear rate of 21%, which is extremely high, versus 2% in severe tear rate in those who did not use as many episiotomies. He also found an interesting finding with pain, and that was that spontaneous tears, so tearing naturally, that those were less painful than the postpartum pain that clients had with an episiotomy. 20% of participants with episiotomies describe their pain as horrible or excruciating versus 11% of those with spontaneous tears.

So basically what this research is showing us that one of the most important things you can do to lower your risks of experiencing a severe tear is to avoid an episiotomy. This is why it’s so important to have a trusting relationship with your provider and to have a provider who rarely, if ever, cuts episiotomies.

I am really grateful to be able to know a lot of obstetricians and midwives and family doctors who have rarely, if ever, cut episiotomies. They might cut one or two in their entire career, and usually only in extreme emergency situations where the baby needs to be born immediately because of a life threatening condition. On the other hand, I know that there are still some physicians in my community who cut as many episiotomies as they feel like. So one of the things you can do at your birth is to have an advocate with you, either your partner or a doula or someone that you trust, and make sure they know ahead of time, your wishes for avoiding an app episiotomy and to keep their eyes open, especially during the second stage for any scissors that might be lying around, tell them, “Don’t let anyone come near me with scissors.”

Although an episiotomy is a surgeon incision, it can be done without your knowledge. It’s very easy to get distracted during the birth of your baby or perhaps you’re numb from medications and not realize what’s going on. An ethical provider will always ask for consent before doing something like an episiotomy. However, to this day, we still hear stories all the time of doctors who see episiotomies as just a regular part of the birth, and so they don’t even think that they need to ask permission.

To avoid an episiotomy you can also try to give birth in a side-lying or an upright position instead of laying on your back. Those are a couple of evidence based ways to increase your chance of protecting your perineum and avoiding an episiotomy during a birth. Having or planning a water birth can also decrease your risk of having an episiotomy for the obvious reason that you’re underwater, and they can’t see you or get near you to cut you with scissors.

So having a trusting relationship with a provider who rarely cuts episiotomies is important. Having an advocate is important. And then also if you’re able, choosing a setting that will support your desire to avoid an episiotomy. If you’re in the United States, you can go to ratings.leapfroggroup.org, to look up hospitals near you and see if they are publicly reporting their episiotomy rates.

I know some people and healthcare workers might be like, “You are really going to scare people because our hospital never does episiotomies anymore.” And it’s true. Some hospitals have very low episiotomy rates, but that is not every hospital and there’s still plenty of places with lots of room for improvement. So be aware of the episiotomy rates of where you’re giving birth and make sure you’re very clear with your provider that you do not want an episiotomy cut if that is your wish.

I’m really proud of a lot of young people I’ve met today who have educated themselves on this topic and understand the importance of informed consent when it comes to something like having an incision in that part of your body. A lot of the college students I would work with would then go on to interview their parents about their own birth story, or they would interview a family member about what happened when they gave birth. And they would come back to me and report that their parents or their family members who gave birth in the 1990s or the early two thousands even, how many of them said, “Oh yeah, the doctor cut an episiotomy, but you know, I didn’t care.” Or they might say, “The doctor cut an episiotomy and I was traumatized by it.” But it was really interesting to talk with the students about how their loved ones experienced this cultural phenomenon of episiotomies and how they used to be cut on everyone most of the time without consent.

And some of them would say, I feel really disheartened, or I feel really disappointed that my mom didn’t speak up or that my mom was okay with the doctor cutting them without permission. And we had some really interesting conversations about how consent looked different, about the different dynamics of power when you’re giving birth in the hospital in the 1990s or two thousands, about the difference in power dynamics between the physicians and the patients. And I know personally that I also have met women who have been traumatized by being cut without their permission or against their will in the past.

My hope is that by talking about this openly on the podcast about why it’s important to prevent episiotomies, that this information will be empowering, especially for those of you who are still living in parts of the world where episiotomies are common and they’re not thought of as something that you need to ask permission before you do it.

So my heart goes out to our listeners in parts of the world where this is still very much a major human rights violation that’s happening all the time. So in today’s podcast, we covered what are perineal tears? What are the major risk factors? What are the health consequences? And what’s the impact of having an episiotomy or avoiding an episiotomy on your risk of severe tears?

In February, I’m going to do an episode all about warm compresses and whether your provider should have their hands on or their hands off as the baby’s coming out and what effect that has on tears. And then in March, we’ll move on to perineal massage, both during pregnancy and during the birth, and the evidence on whether or not that’s helpful. And then in April, we’ll move on to talk about some assortment of ways to lower the risk of tearing, including water immersion, birthing positions, and listening to the wisdom of midwives who have been passing down their knowledge through countless generations.

I look forward to sharing that information with you in the coming months. If you’d rather go ahead and get started right away about learning some of this information, we do have a long hour plus long class in our Evidence Based Birth® professional membership where I go in depth over all the information on all of these ways to lower the risk of tears. And then in our Evidence Based Birth® Childbirth Class, we do have a video all about protecting the perineum. And this is a topic that our students talk with their instructors about and get mentorship on ways to protect their perineum during the birth.

I love taking a topic that can be kind of scary and overwhelming with this and using evidence to empower us all so that we can improve health outcomes and lower the risk of severe tears happening. Thanks everyone for listening. And we’ll see you next week. Bye.

This podcast episode was brought to you by the book, Babies Are Not Pizzas, They’re Born, Not Delivered. Babies Are Not Pizzas is a memoir that tells the story of how I navigated a broken healthcare system and uncovered how I could still receive evidence based care. In this book, you’ll learn about the history of childbirth and midwifery, the evidence on a variety of birth topics and how we can prevent preventable trauma in childbirth. Babies Are Not Pizzas is available on Amazon as a Kindle paperback, hard cover, and audible book. Get your copy today and make sure to email me after you read it to let me know your thoughts.