I get a lot of questions from patients and potential patients about episiotomies (incision in perineal area to enhance opening during vaginal delivery). I would like to talk about why they are used and then why I generally avoid them all together, although there are rare circumstances where they may be necessary. Years ago episiotomy was used on a regular basis by many physicians and some midwives to expedite the delivery of the baby by making the vaginal opening larger. Many felt and some still do probably that a nice clean incision is better than a spontaneous vaginal tear that could be jagged, etc. There are some emergency situations that occasionally warrant an episiotomy. The first being shoulder dystocia. In the event that the head delivers and the shoulders get stuck, if it is really tight fit, the episiotomy can help make room for practitioners hand to reach in and help relieve the dystocia. The other time is if the head is crowning and has been for some time and fetal heart rate is dropping and having the ability to rapidly deliver for the safety of the baby may be a time that episiotomy is useful.
Now for the downfalls, and the reason why I almost never cut episiotomies. There is ample evidence that suggests that cutting an episiotomy even a lateral one increases the risk of third and fourth degree lacerations meaning the tear has extended through the anal sphincter and rectum. Cutting and episiotomy is like cutting material. When you make a cut, subsequent tearing is much easier and generally more severe than had that skin been left intact and only torn slighty naturally or not at all. There are consequences for women with third and fourth degree lacerations besides the pain of healing. These severe types of lacerations increase the risk for anal incontinence as well as other problems such as having fecal matter in the vagina if they are not repaired correctly. So, this is the reason why episiotomies are frowned upon generally. Plus, a little patience and allowing the perineal skin to stretch on it's own almost always leads to a safe delivery, less tearing, and better recovery for the mother.
Hope this answers any questions about episiotomy!!