If you've read the blog so far, you’ve become aware of the pelvic floor, an important area of your body that you may not have known before. You’ve learned that it looks a certain way before childbirth and another way afterward. With this new “pelvic perspective” in mind, let’s examine how various obstetrical events and procedures can affect your function afterward, and what to do when things go awry.
INJURIES AND ANATOMIC CHANGES AND THE OBSTETRICAL EVENTS THAT CAN CAUSE THEM
Whether childbirth is easy or difficult, long or short, natural or operative, one fact remains constant: a woman’s body will never be exactly the same after pregnancy, labor, and delivery,
as it was beforehand. The good news? For the vast majority of women, these physical changes are subtle and inconsequential, visible to the doctor during a pelvic exam but creating no problems for the woman herself.
The other side of the story? If you’ve reached this blog, it’s likely that you have noticed
some sort of change, and you’re looking for relief. As the next step, now that you’re familiar with your pelvic area, it’s time to learn about the most common and significant changes that can arise.
PERINEAL INJURIES AND EPISIOTOMIES
Dr. David Chapin, an esteemed vaginal surgeon at Harvard Medical School, has been known to occasionally quip to the resident physicians he’s instructing:
“The obstetrician-gynecologist spends the first half of his career supporting the perineum, and the second half of his career being supported by the perineum.” - Dr. Chapin
Dr. Chapin makes this point with a lighthearted touch, but it has stuck in my mind and always rings true. The same women who keep young obstetricians busy in the labor suite tend to keep them busy again in the operating room years later, reconstructing those pelvic supports that were lost during childbirth. For countless women, the specialty called obstetrics and gynecology could be more accurately dubbed obstetrics, therefore gynecology.
YOUR PERINEUM DURING AND AFTER CHILDBIRTH
During childbirth, as the fetal head or shoulders are delivered, the perineum can tear spontaneously or be cut intentionally with an episiotomy. Perineal tears can be partial, extending only through the vaginal skin; or they can be complete, extending all the way through the perineal muscles and even into the rectum. If the perineum is torn during childbirth and not adequately repaired, any or all of the perineal muscles (including the bulbocavernosus and transverse perineal) can become permanently separated, creating a gaping appearance to the vaginal opening.
When childbirth widens the perineum, you may later begin to notice a bulging sensation near the vagina and rectum, or a loss of sensation or vaginal fullness during intercourse.
When the anal area is involved, it can lead to incontinence of both gas and stool. If, on the other hand, the perineum becomes too tight or scarred, intercourse may be painful. Even with a proper repair, the perineal muscles and tissues may not properly heal.
DID YOU KNOW …?
Even in the absence of an episiotomy, between 35 and 75 percent of women suffer some degree of perineal injury while giving birth. For those who have a perineal injury during their first delivery, the risk of a spontaneous perineal tear during the next delivery is more than tripled.
(Above) Perineal anatomy before delivery. (Below) Common changes after childbirth,
affecting the perineum and nearby structures
EPISIOTOMY: THE “LITTLE CUT”
For some women, the decision over episiotomy—to cut or not to cut—symbolizes
whether her delivery is smooth or traumatic, natural or medicalized, and whether
she considers herself injured or intact afterward. The procedure is performed with
a snip of the perineum, that bridge of tissue between the vaginal and anal open-
ings. By creating more space at the vaginal opening, episiotomies hasten delivery
of the newborn.
Did you know that aside from cutting the umbilical cord, episiotomies are the most common obstetrical operations (1.2 million per year) performed in our country and also across the world?
First utilized in Europe, episiotomies were imported to the United States and brought into widespread use during the early 1900s. For decades thereafter, many doctors performed them routinely, claiming they resulted in a wide variety of benefits: speeding labor, protecting pelvic muscle tone, preserving sexual function, aiding maternal healing, sparing compression of the fetal head, and reducing the risk of anal sphincter injury. To this day, some practitioners argue that it’s better to cut and neatly repair the perineum and vagina than to allow these tissues to spontaneously stretch and lose their virginal tone altogether.
But among the majority of physicians, there has been close to a 180-degree reversal in these beliefs. The strategy of routine episiotomy simply has not withstood the scrutiny of modern research, and it is no longer mainstream.
At least five studies have shown that episiotomies seem not to protect against the development of urinary incontinence. In fact, there is plenty of evidence to suggest that
episiotomies increase the overall risk of harm to your pelvic function.
INJURIES FROM EPISIOTOMIES: ANAL SPHINCTER, PELVIC MUSCLES, HEALING, AND PAIN
It’s unfortunate but perhaps not all that surprising how few high-quality research studies have been performed to understand the physical effects of episiotomy. After all, this procedure involves a highly intimate area of the female body charged with a rich supply of nerve endings, making it a complex area to study and master. Beyond that, episiotomies have always been highly politicized—representing, for many women, a symbol of invasive delivery, and making physicians and patients equally reluctant to test different strategies at the time of birth.
Despite the fact that our understanding of this procedure has evolved at a shamefully slow pace, a fairly clear picture has begun to emerge. It’s perhaps best summarized by the Cochrane Group, a team of analysts that draws scientific conclusions based on the best re-
search for a given topic. Their report concluded that routine episiotomy increases
the overall risk of trauma and complications during vaginal delivery, and therefore
should be used selectively.
But what are the specific benefits of avoiding episiotomy that led to this overarching conclusion?
To improve healing and preserve muscle strength. One study from several years
ago involved more than two thousand Argentinean women who were randomly assigned to receive either routine episiotomy or selective episiotomy based on need—in other words, performed only if their obstetrician felt that a significant perineal injury was about to occur. Overall, pain and healing complications were found to be more common among women who received routine episiotomy. Other studies indicate that over the long term, women who undergo episiotomy tend to be left with weaker vaginal muscle strength than those with an intact perineum after delivery, or those who tear spontaneously.
Eventually, this weakening of vaginal muscle might tip the balance of continence or pelvic support for a good number of women.
To spare lacerations. During first deliveries, episiotomies in general appear to increase the risk of a torn anal sphincter. Midline episiotomy (a straight-down incision from the opening of the vagina toward the anus) in particular has been associated with up to twenty times the usual risk of lacerations involving the rectum; one large Canadian study found that nearly all tears extending into the anal sphincter muscle followed an episiotomy. With second, third, or later deliveries, the overwhelming majority of severe perineal injuries originate with episiotomies. In Sweden, a decline in episiotomy rate from 28 to 10 percent was associated with a slightly decreased rate of anal sphincter injury.
These obstetrical injuries to the anal sphincter increase the risk of anal incontinence during a woman’s post reproductive years.
It’s been reported that just over 40 percent of women with anal sphincter disruption during childbirth will have temporary anal incontinence after delivery, and that 7 percent will experience permanent loss of anal control to some degree.
To safeguard sexual function. What about the bedroom? While the long-term impact of episiotomy on sexual function is unknown, a 1994 study found sexual satisfaction at three months postpartum to be greatest among women without perineal injury. Satisfaction was lowest among women with an episiotomy that had extended, or torn further, during delivery.
Conclusion
The journey of becoming a mother brings incredible changes to your body, some subtle and others more profound. With a deeper understanding of how obstetrical events like perineal injuries and episiotomies impact pelvic health, you’re equipped to take proactive steps toward recovery and long-term well-being. By focusing on informed choices and effective healing, you can navigate the post-childbirth phase with confidence and resilience.
Coming up Next: The Pelvic Floor After Childbirth Pt. 2
You’ve uncovered a new understanding of the pelvic floor, learning how childbirth can reshape it and the lasting impact of perineal injuries and episiotomies. From the risks and benefits of these procedures to the ways they influence your body, you now have valuable insight into what happens during and after delivery.
But what about the recovery process? Episiotomies are often repaired immediately, yet the journey to healing is rarely straightforward. In our next post, we’ll dive into what happens after an episiotomy, explore how these repairs affect long-term pelvic health, and share practical strategies to help you regain strength and confidence. With expert insights from the Altyx founder, Dr. Roger Goldberg, you’ll discover how to navigate recovery and take back ownership of your body. Don’t miss it—your next step to feeling empowered starts here!
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