During childbirth, the vagina has to stretch to accommodate a head the size of a grapefruit. This, you may imagine, takes time. So if something goes wrong during labour and delivery has to happen fast, doctors or midwives might speed things along by artificially widening the vaginal opening. With scissors.
The procedure is called an episiotomy, and involves making a slit in the perineum — that tiny space between the vagina and anus — as the baby’s head enters the birth canal. It splits open the skin, fat, muscle, and dense connective tissue next to the vagina, leaving an opening that needs to be repaired with stitches after the baby’s out.
It sounds extreme because it is. Today, episiotomies are rarely performed. But as recently as 1979, four out of five delivering mums were having the flesh between their anus and their genitals snipped during childbirth. What follows is an abridged version of the long, capricious history of the episiotomy.
1740 — 1920: For Use Only In Dire Emergencies
The first instructions for performing an episiotomy appear in Fielding Ould’s 1742 Treatise of Midwifery in Three Parts:
…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..
But Ould makes it clear that the procedure is one of the last things to try in the case of a breech birth, or when the vaginal skin is so tight that the baby’s head can’t push through. In either case, the technique is only warranted if there’s “no Chance for saving either Mother or Child, but by making an Incision.”
Given the state of medicine in the 1740s (no antibiotics, few painkillers, unwashed hands EVERYWHERE), an episiotomy was as likely to give the mother a life-threatening infection as save her. And even as anesthetics and the germ theory (handwashing!) entered the medical lexicon for childbirth during the 1800s, midwives and doctors knew that the potential consequences of an episiotomy were dire, and so the procedure was rarely used.
1920 — 1980: The Episiotomy Becomes A “Logical” Preventative Tool
At the 1920 meeting of the American Gynecological Society, Joseph DeLee, a Northwestern University professor of obstetrics, got up in front of his esteemed colleagues and argued that labour was an abnormal pathology that damaged both mother and child.
Perhaps laceration, prolapse and all the evils soon to be mentioned [infection, exhaustion, skull fractures in the infant] are, in fact, natural to labour and therefore normal, in the same way as the death of the mother salmon and the death of the male bee in copulation, are natural and normal. If you adopt this view, I have no ground to stand on, but, if you believe that a woman after delivery should be as healthy, as well, as anatomically perfect as she was before, and that the child should be undamaged, then you will have to agree with me that labour is pathogenic, because experience has proved such ideal results exceedingly rare.
Since the job of the obstetrician was to actively prevent problems like blood loss, exhaustion in labour, and perineal tears, not to mention head trauma in the infant from bashing against the vaginal walls, DeLee saw the episiotomy as a logical preventative procedure. Although many of his colleagues at the time disagreed, DeLee was influential, and the episiotomy eventually became a routine part of most hospital deliveries. By 1979, 80% of first time vaginal births involved that not-so ‘little snip’.
1980 — Present: Episiotomy Rates Crater as Actual Evidence Disproves “Logic”
In the 1980s, the movement for evidence-based medicine — that is, using scientific and clinical evidence to determine whether medical interventions actually work — turned its attention to the now-routine practice of vaginal-cutting during childbirth. Because, after close to 60 years of widespread use, the episiotomy was racking up some alarming side effects.
Shockingly, one of them was anal sphincter damage. In some cases, instead of redirecting the forces of childbirth to prevent tears in the perineum, episiotomies were concentrating the forces of childbirth and ripping the muscles around the anus apart. Cutting straight down from the vagina towards the anus (the method most common the US) posed the greatest risk for this kind of damage; about half of women on the receiving end of the procedure suffered ongoing gas or faecal incontinence.
Other studies found that routine episiotomies didn’t actually provide the benefits they’d “logically” promised. Doctors started abandoning the procedure, even more so after a systematic review of its effectiveness, published in 2005 in the Journal of the American Medical Association, showed that an episiotomy had no effect on improving incontinence or pelvic floor relaxation, and that women who’d had the procedure suffered more pain during sex later on. Other studies found that an episiotomy had no real effect on the baby’s health, either.
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 per cent, 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.