Routine episiotomy is harmful. Consent is essential.

By Eva Martin, MD

“Don’t cut me!” If you hear these words, you probably assume you are standing in a dark alley as a mugger holds up an innocent victim for their wallet.  You probably don’t imagine a hospital room in the moments before the miracle of birth takes place. However, episiotomy against a woman’s wishes or without her consent is a dark reality of births in the United States. While the vast majority of OBGYNs and midwives are not performing procedures without consent, even once is too much. The Improving Birth project highlights that this unspeakable act happens more often than you might imagine. And, despite ACOG’s 2006 recommendation against routine use of episiotomy, the practice is still commonplace in some hospitals. A report from the California Office of Statewide Health Planning and Development reveals just how common it is.

Decades ago, obstetricians routinely performed a procedure called episiotomy prior to birth. Why? Because they thought it improved outcomes. Episiotomy is a small cut made along the skin and muscles at the base of the vagina before birth. Doctors thought it saved the muscles around the vagina from stretching too much and made healing easier. They thought it reduced the risk of a serious tear, called a third or fourth degree laceration, that extends into the rectum. In the 1970s, doctors performed episiotomies on over 60% of all vaginal deliveries.

However, researchers wanted to know if these assumptions about episiotomy were true. So, they conducted trials. The results were shocking. Episiotomies were linked to more pain during recovery. They heal slower than a natural tear. Episiotomies make serious tears more likely, not less likely. (Imagine a piece of paper. If you start a tear in the paper, it’s easy to continue the tear all the way through the paper. But, if the paper is whole, it’s harder to tear all the way through.) Episiotomies have even been linked to future incontinence and sexual dysfunction. And- they don’t shorten labor or make it easier for mothers.

When is episiotomy helpful? Emergencies. For instance, imagine a scenario in which a baby’s heart rate has been dangerously low for several minutes or the baby’s shoulder is stuck. Imagine that the only thing holding that baby back from being born and taking their first breath is the skin around the vagina. In this case, with consent, an episiotomy may save the infant. However, this scenario is pretty rare.

After ACOG issued their recommendation against routine episiotomy in 2006, the rate of this procedure fell. In 2005, it was performed in 21% of vaginal deliveries in California. In 2014, the California average is down to 12%. I was lucky to train in a hospital system dedicated to evidence-based medicine- Kaiser Permanente- where the episiotomy rate is below 3%. However, some hospitals are still clocking in at the old 1970’s rate of 60%.

Nevertheless, the use of episiotomy is not the only issue here. The more disturbing issue is lack of consent. Ms. Kimberly Turbin, a 29-year-old dental assistant from California, was the victim an episiotomy without consent. In the disturbing video (which has over 430,000 views on YouTube), you can witness her doctor performing an episiotomy against her wishes, as she cries out, “Don’t cut me!” Cases like Kimberly’s are the focus on an organization called Improving Birth, which advocates for women’s rights during birth. Personally, I couldn’t even watch the whole video because it was so heart breaking. Consent is not a luxury; it is a necessity. No woman should be subject to medical procedures against her will. In this case, the fact that the medical procedure is contraindicated only adds to the horror.

For more information on this compelling topic, you can find the NPR report here, and the article with the hospital rates of episiotomy here.