Episiotomy vs. Tearing: Which is Better?

Last Updated: February 13, 2024
Liesel Teen, RN-BSN

By Liesel Teen

BSN, RN, Practicing Labor and Delivery Nurse

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Many new mamas are left overwhelmed and unsure about all of their options regarding childbirth. The decisions sometimes seem incomprehensible, and sometimes it’s not even clear why you should have to decide. Delayed cord clamping? Natural or epidural? Episiotomy vs tearing?

Wait a second…episiotomy? Tearing?? NONE of us want to have to spend time thinking about the cutting or tearing of our vagina. I mean, it’s HORRIFYING to think about.

Here’s a perk: Experts no longer recommend the routine episiotomy – so you can pretty much check this decision off of your list. However, there are still some situations where an episiotomy is the right choice.

Because of this, I wanted to go over getting an episiotomy vs tearing so that you can make a well-informed choice.

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What is an episiotomy?

Simply put, an episiotomy is a small surgical incision made in your perineum (which is that ridge of tissue between your vaginal opening and anus) during childbirth. We’ll discuss the “why” in a little bit. Let’s take a minute to examine the “what”.

When does an episiotomy occur?

  • As your contractions become more intense and frequent, your baby continues to move down the birthing canal and eventually crowns. This is when the head starts to emerge and doesn’t slip back in
  • At this point, your skin is going to stretch. If pushing slows down a little here, your vagina may have a chance to catch up with the pressure and stretch without tearing too much (sometimes not at all)
  • Eventually, you’ll reach a point where your skin may start to feel like it’s burning, which is not-so-fondly called “the ring of fire.” Whoever coined this term was definitely not thinking about Johnny Cash
  • This is the point at which an episiotomy was historically performed. Rather than giving the skin a chance to stretch without tearing (which it sometimes can), or letting it tear naturally – a small incision is made

There were many assumed benefits of this procedure, which we’ll discuss in a minute. As you can probably imagine, something that we can anticipate and mitigate seems like a great idea, but providers of today have changed course on this

Episiotomy Vs Tearing

Why were episiotomies routinely used in the past?

Doctors used to believe that episiotomies were better than natural tearing for a few different reasons:

  • Because it’s a clean surgical cut, the belief among health professionals was that an episiotomy would heal faster and better than a jagged natural tear
  • Medical professionals were also concerned with possible birth trauma resulting from the baby’s head pushing too long against the perineum
  • They thought an episiotomy could help baby make his or her entrance into the world that much sooner

There is a myriad of other reasons most doctors used to perform routine episiotomies, but NONE of these reasons could be scientifically backed up as being better than allowing for natural tearing.

Why don’t we use them routinely anymore?

When it comes to your lady parts, the data has shown one thing time and time again. Naturally tearing is USUALLY the better option – unless there’s a medical emergency that necessitates episiotomy.

Why, you ask? Well, it’s been proven that routine episiotomy typically increases the risk of severe tears, as well as long term damage to the pelvic floor, vagina, perineum, and anal sphincter.

There is no material benefit to mama or baby for a surgical incision in the hinder parts. MOST of the time. With that said, they do have a time and place.

Types of episiotomy

To really get a good understanding of the exceptions, it’s worth considering the facts.

The episiotomy type clarifies how and where the cut in the perineum is made, which helps us understand why they are sometimes used.

There are many different types of episiotomies, but two are performed most often – a median and a mediolateral episiotomy.

Median episiotomy

Median episiotomies used to be more common because medical professionals believed that mediolateral episiotomies were more painful for women to recover from (among other things).

More recent research has shown us that there isn’t a lot of difference in postpartum pain, but median incisions are much more likely to result in 3rd and 4th degree tears (the WORST kind of tears – UP YOUR BUTT).

How it works:

  • Performed vertically from the base of the vaginal opening, directly toward the rectal opening
  • Higher risk of extending into the anal area, which can mean long-term complications like urinary or fecal incontinence 

Mediolateral episiotomy

This is considered to be the safer, more comfortable, and more commonly form of episiotomy. If your provider determines an episiotomy is necessary, this is probably what you’re going to be looking at.

Here’s how this one works:

  • Done at an angle from the base of the vaginal opening, diagonally away from the rectal opening
  • Lower risk of anal muscle tears
  • Possibly more difficult to repair
Birth Plan

Episiotomy degrees

We classify episiotomies by the severity or extent of the surgical cut by rating them on a 1-4 scale. This same classification exists with natural tears.

The worse the cut (or tear), the more likely it is that you may see complications.

  • First degree: This tear is pretty small and involves skin only, so it heals up pretty quickly (sometimes without stitches). I wouldn’t go so far as to say paper cut, unless you regularly find yourself paper cutting your vagina. It’s close, though
  • Second degree: A second degree tear extends through both the vaginal skin and underlying tissue. This tear is most common, and it’ll probably need a few stitches put into it. Luckily, it usually heals within a few weeks. You’ll have enough going on down there that this won’t add a whole lot to the pain and process of recuperation
  • Third degree: With a third degree tear, the vaginal lining, tissue, and part of the anal sphincter will be affected. A sphincter is what? It’s the ring of muscles responsible for drawing closed a circular opening – in this case, these muscles control the closure of your butt hole
  • Fourth degree: This is the worst kind of tear, and includes the vaginal lining, tissue, rectal lining, and anal sphincter

Both a third and fourth degree tear are bad news (surprise! Pretty much a given when a tear extends to your BUTT HOLE) and sometimes require anesthesia to repair.

Recovery from a severe tear usually takes longer and is more complicated. Because – yeah, you tore your bum.

Episiotomy vs tearing: the evidence for natural tearing

We now know that there’s a higher risk of maternal or neonatal injury when a routine episiotomy is done instead of allowing for natural tearing to occur.

ACOG (American College of Obstetricians and Gynecologists) has recommended AGAINST routine episiotomy since 2006. We’ve see a decline in practitioners who use episiotomy vs natural tearing, which means we see fewer injuries too.

Nature, 1; Medical intervention, 0.

Some providers still use episiotomy

Now – there remain some old-school providers who perform episiotomies routinely. I don’t see it a lot, but I do think for some it is more comfortable to keep doing what they’ve always done. 

In fact, some studies have shown a direct correlation between episiotomy rates and the years a practitioner has been practicing…meaning the longer they’ve practiced, the more likely it is they’re still doing episiotomies (but to make it clear – most DO NOT).

It’s not the norm for medical professionals to go against the general recommendation -but that doesn’t mean it never happens.

Ask your medical provider for their episiotomy rate, and don’t be afraid to voice your concerns and switch providers if your current medical professional is resistant to the idea of avoiding it where possible.

If you’re really struggling during that pushing stage of labor, baby’s head is just too big, or your doc is concerned about you or baby’s safety- an episiotomy may be medically necessary.

It goes without saying that this could end with a pretty nasty cut to your booty.

This is why it’s SO important to make sure you have trust established with your provider. You should never feel pressured into something you don’t want to do – and a good relationship with your provider will help with that. Confirm that your doctor will gain your consent before performing an episiotomy, if possible (which they should do anyway).

A few more reasons for episiotomy vs tearing:

  • Fetal distress
  • Large baby
  • Being Preterm
  • Extended pushing stage of labor
  • Shoulder dystocia (when the head has been delivered but the shoulder is trapped)
  • Breech birth
  • Risk of injury to your urethra
  • Other birth complications

I think the most important thing here is to avoid discounting the possibility of an episiotomy. On the other hand, if your medical professional proudly says they perform them routinely for #allthebirths, it may be worth challenging that or switching doctors.

Start the conversation with them. The worst time to find out that your medical professional is slice-happy is when you are three clicks in on your epidural and your partner has already passed out.

Why does tearing occur during childbirth?

This is where you seriously have to look at mother nature and say, “Come on lady, you’re a MOTHER! What the actual heck.”

Unfortunately, tearing during childbirth is relatively common. According to ACOG (American College of Obstetricians and Gynecologists), SOME kind of tearing will occur in 53-79% of women having a vaginal delivery. The bright side of this is more severe tears only happen in around 3% of births.

Hey – at least we don’t carry our babies for up to 18 months, like whales do!

When does natural tearing occur?

The actual tearing usually occurs when baby’s head or shoulders are trying to get through the vaginal opening. Our vaginal openings are pretty elastic, so many of us can get away with none or minimal tearing (second degree being most common).

If your baby’s head can’t make it through your vaginal opening without tearing, you can definitely blame the father. Particularly if they have a big head too. ?

Related Reading: Pain Meds During Labor (Other Than an Epidural)

How to avoid tearing during birth

While there’s no way to prevent tearing during delivery completely (sorry mama!), there are things you can do to minimize how severe the tear will be.

  • Proper nutrition: Healthy food translates to healthier skin, which translates to stretchier skin! Dial in your diet well in advance if it’s not too late
  • Pelvic floor exercises: This can simply involve regularly doing your kegels. But I’m a HUGE advocate for pelvic floor health and exercise during pregnancy and postpartum. It makes such a difference in your recovery
  • Warm compresses: During labor, ask your nurse or birth attendant to place warm compresses onto your perineum area. As a labor & delivery nurse, I do this for many of my patients and it seems to help a lot! It might sound a little too personal and intimate on paper, but I can assure you that’s the least of what we’re doing down there! Labor is all about you, so don’t be shy asking your nurse to support you however they can
  • Push carefully: During the pushing stage of labor (the second of four stages), listen to your provider when they instruct you to speed up or slow down your pushing. If they say slow down – SLOW DOWN! It can be really hard to trust this direction in the moment, but it’s worth a few extra minutes of pressure. This gives your vaginal tissue time to stretch for baby – and it can make ALL the difference
  • Switch birthing position: This is just as important as giving birth to the baby as it is when making the baby. Do what’s comfortable for you. We’ll talk more on birthing positions to prevent tearing later
  • Perineal massage: This is as strange as it sounds – but it might help! While it’s usefulness and safety during labor is questionable, it’s something you can start doing in the third trimester. Talk with your provider for instruction and recommendations on perineal massage

Here’s more (super good) info on preventing tearing during delivery!

Childbirth positions and tearing

While we know that your birthing position can impact how badly you tear, the research is inconclusive regarding the BEST position is to avoid tearing.

I think the best advice I can give you is to do what’s comfortable for you. There’s no surefire way to avoid tearing, so you may as well let yourself be as relaxed as you can.

Let’s look at the research

The best study I’ve found regarding birthing positions and severe tearing is a research article that examined seven different birthing position studies. Like any good medical read, it can get a bit mind-numbing. As an expert in the field, I’ve taken the liberty of summarizing the important bits below.

  • Kneeling/hands + knees: Throughout all seven studies (which ended up being over 20,000 mamas!) the LEAST incidence of tearing happened when the mother was KNEELING. Being on all fours was a close second. If you can’t stand to stay in this position throughout labor (because it’s HARD), switch to it when your baby starts crowning. Remember, this position does not guarantee that you won’t tear; it’s just less likely
  • Sitting, squatting, birthing ball: Studies have shown that these positions tend to result in MORE TEARING than other positions. Keep in mind, this is different for ALL women, and you should do what you’re most comfortable with. If you want to bounce while birthing, that’s totally your call

Does water birth prevent tearing?

Unfortunately, no. The study I cited shows that women who have a water birth are MORE LIKELY to tear than women experiencing a land birth. With that said – many women report a water birth to be less painful, so it’s still worth considering – the reality is that these women might have torn regardless the method they chose.

There is unfortunately no way to know, which is why data is always going to be spotty.

By the way – if you’re looking for some clear instruction on what to expect during labor and delivery, check out my birthing course Birth It Up!

How to avoid an episiotomy?

The best thing you can do to make sure that you don’t end up with an unauthorized episiotomy is to have a discussion with your healthcare provider BEFORE you go into labor (and make sure you trust your provider). Add it to a birth plan, mention it to your nurses, drill it into your partner’s skull.

All that said, please remember to stay flexible in case an emergency arises. If your medical professional insists, don’t let any of this information deter you. You’ve chosen this professional for a reason, so have faith that they have your best interests and those of your baby at heart.

Related Reading: Midwives’ Brew

Risks of episiotomy vs tearing

Episiotomy risks & complications

We know that an episiotomy is no one’s first choice. If you end up needing one anyway, here are some of the common complications I’ve seen with episiotomies:

  • Bleeding
  • Swelling
  • Longer healing time
  • Infection
  • Pain during sex
  • The need for further stitching
  • Possible tearing into the rectal tissues and anal sphincter muscles
  • Fecal incontinence

These are some pretty nasty complications that can end up being something you will deal with for a long time. Keep in mind that some of these complications can happen with natural tearing, which I’ll outline below.

Risks of natural tearing during birth

The risks associated with a natural tear are similar to the risks associated with an episiotomy, but you’re more likely to sustain LESS damage from naturally tearing. Here are some of the risks associated with natural tears during childbirth.

  • Bleeding (usually less than what is associated with an episiotomy)
  • A small risk of third or fourth degree tear
  • A possibility of stitches (although a rather small chance in comparison with an episiotomy)

Related Reading: How to Induce Labor Naturally

Are you less likely to tear with a second baby?

If you did not tear with your first childbirth, you’re a lot less likely to tear with your second child. Unfortunately, if you experienced a 3rd or 4th degree tear with your first child, there’s a higher chance that you’ll experience a severe tear with your next childbirth.

Feeling more educated about episiotomy vs tearing?

As a new mama you have a LOT of hard decisions to make, but the choice of episiotomy vs tearing doesn’t need to be one of them.

Make sure there’s significant trust between you and your doctor, and don’t be afraid of having a conversation with them.  It is my sincerest hope that you feel more empowered to do the right thing for you and your little bundle of joy.

Good luck, mama!

Drop a comment below and let me know if you have any further questions regarding an episiotomy vs natural tearing. I’m happy to help! 

Related: Reading What Happens During Delivery?

Related Reading: Scheduled C-Section: What to Expect

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Liesel Teen, RN-BSN

Liesel Teen

BSN, RN, Practicing Labor and Delivery Nurse

As a labor and delivery nurse, I’ve spent countless hours with women who felt anxious — even fearful — about giving birth. I want you to know it doesn’t have to be that way for you!

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