In the last stage of labour, some women find they have a problem getting the baby’s head out. Christine Hill on whether it’s better to have an episiotomy rather than tear

When a baby is born, the head has to be pushed through the birth canal and out through the entrance of the vagina. The baby’s head will stretch the opening of the vagina in a similar way to a sweater with a tight neck when you pull it on over your head. The muscles around the vaginal opening may not be able to stretch quite enough, so they tear slightly. This is normal and occurs in about three-quarters of births.

In order to stop uncontrolled and severe tearing, or to allow a baby to be born quickly, the midwife or obstetrician can make a small cut to the side of the vaginal opening, widening it to allow the baby’s head to pass through. This is called an episiotomy.

Why the fuss?

Twenty years or so ago, nearly all women had an episiotomy, sometimes in a hurry and without enough pain relief. Then people began to question their necessity, especially as small tears were found to heal more quickly than episiotomies. As the pendulum of opinion swung to the other extreme, some women came to regard the cut as a physical attack by male obstetricians on vulnerable women and some hospitals even said they never did episiotomies.

A more balanced approach has been to list the occasions when an episiotomy is helpful to baby and mother.

The most common situations would be:

• The baby is in a slightly awkward position, with the wide part of his head presenting first or with his arm up by his head.
• The baby is tired (a euphemism for not getting enough oxygen) and needs to be delivered quickly.
• The baby needs an assisted delivery by forceps or when a Ventouse extraction is performed.
• The woman’s pelvic floor muscles are less elastic than usual, so that it’s clear they can’t stretch enough to allow the baby to pass through and a serious tear backwards is likely.

How much does it hurt?

You shouldn’t feel anything. If you need an episiotomy, you should be given a local anaesthetic or your epidural will be topped up. Incredible as it may sound, most women who have just given birth don’t know whether they have had a tear, an episiotomy or have an intact perineum.

And afterwards?

Most women will need a few stitches after they have given birth, whether they have torn or had an episiotomy. The stitching is performed by the person who delivered the baby, so it might be a midwife or an obstetrician. The mother is given a local anaesthetic. If she’s already had an epidural, it will be topped up as necessary. The mother will lie on her back with her legs up in stirrups, so the person who is stitching can see what they are doing. The stitches don’t have to be taken out later; they dissolve of their own accord over the next couple of weeks.

They can sometimes be pretty uncomfortable, but they shouldn’t be a major problem. Luckily, the pelvic floor muscles have an extremely good blood supply, so everything heals very quickly. It helps the healing if you do the pelvic floor exercises that you were taught in your antenatal classes. The good news is that 97% of women are able to have sex six weeks later. Whether they want to is another story.

So what’s worse, a tear or an episiotomy?

In my experience there isn’t much in it, as long as a tear back into the rectum (a third degree tear) is avoided.

Is there any way of avoiding either?

Some people advocate massaging the perineum with almond oil during pregnancy but, as far as I know, there is no hard evidence to show that this does much. Unfair as life is, some women are born with less elastic pelvic floor muscles and there isn’t anything you can do to change this.

Neither has any study shown that the position you adopt when you deliver your baby makes a difference. Nothing you do when you are pregnant is going to have an effect on the position of your baby’s head at birth, the shape of your pelvis or the amount of elasticity in your skin and muscles around your vaginal entrance.