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An Incisive Question

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I have always understood an episiotomy to be an incision made to the side of the vagina, so that any tearing will be directed along its line toward the relatively harmless area of the mother's thigh. But several times in the last decade--most recently in Noah Berlatsky's review of Jennifer Block's new book Pushed ["The Obstetric-Industrial Complex," June 29]--I have heard it described as an incision made along the perineum at the back of the vagina--a procedure increasing the very risks that it was designed to forestall.

Since these reports have usually been written by male journalists, it's possible that they have fallen prey to a bit of locker-room folklore. Or have obstetricians truly abandoned a preventative measure to instead exacerbate the already dangerous conditions associated with childbirth?

Mary Shen Barnidge

Lakeview

Noah Berlatsky replies:

The sources I've seen describe episiotomy as an incision of the perineum. Block discusses the history of the procedure, and nowhere does she indicate that it was ever a cut toward the mother's thigh. Certified nurse midwife Sarah Simmons, who has a home-birth practice in Chicago, told me that episiotomies used to be more mediolateral--in the middle toward the back and going out to the side at an angle. However, research showed that the mediolateral cuts made bigger tears, so now they tend to be done straight back.

Originally, obstetricians argued that episiotomies did exactly what you say--that is, that they reduced the chance of a dangerous tear by using a preemptive, safe, "clean" cut." However, when the first scientific studies of episiotomies were done in the 80s, they revealed that they caused many more dangerous tears than would have resulted if the perineum were left alone. The American College of Obstetricians and Gynecologists acknowledged as much in 2006, when it recommended against routine use of episiotomy. Yet still today one-third of first-time mothers are subjected to this unnecessary and dangerous treatment. Simmons notes that "No matter how episiotomies are cut--once you make an incision you are risking a tear. The only real reason to do an episiotomy is if the baby is in distress and you feel it needs to get out right away. In 450 babies delivered, I have never had to cut an episiotomy."

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