Episiotomy and Sex

The Episiotomy Cut: Debate 2012: In 1935 Aldridge and Watson published their theory that performing an episiotomy, which is a cut in the perineum to widen the vaginal opening for birth, would protect the mother’s pelvic floor, and enable the muscles to stretch less.

In the early 1900s gynecologists and midwives felt that episiotomies would confer protection of various pelvic floor problems, including prevention of prolapsed uterus.

By the 21st century obstetricians were looking at all the factors leading to bladder incontinence and weakness of the pelvic floor muscles, and it was hotly debated as to whether these episiotomy cuts would be helpful or harmful.

Current policies generally recommend avoiding an episotomy.

In one study in Swewden Women who underwent episiotomy experienced a more complicated and emotionally difficult delivery. They reported a higher frequency of dyspareunia and insufficient lubrication than women who had given birth without episiotomy. Arousal, orgasm and satisfaction with sex were not affected. Episiotomy, perineal lacerations, fundal pressure at delivery and a history of dyspareunia were independent risk factors for dyspareunia 12-18 months postpartum.

The subject is complicated by the fact that women have some bladder dysfunction, and prolapse, immediately after delivery that resolves relatively quickly. The dysfunction immediately after delivery probably comes from temporary weakness or paralysis of nerves of this area, secondary to the baby’s head pounding against the pelvic floor and it’s muscles.

In a study published in Obstetrics & Gynecology in 2012 a group of researchers  from the Johns Hopkins School of Medicine looked at women 5 and 10 years after their deliveries to determine how they fared. Specifically, this study was interested in “whether a woman tore” her vaginal area in the process of birthing. And they asked in the subsequent years of a woman had incontinence, overactive bladder, anal weakness and prolapse (dropping) of the bladder. They looked at whether a delivery had forceps or a cut or just had a tear in the process of delivery. And they couldn’t find any association between the pelvic complaints or whether the patient had an episiotomy.

Actually, having delivered by forceps, or if you have had a tear, the pelvic floor is worse. Women with multiple tears were actually worse off, so if you had a tear in one delivery, you need to think about ways to avoid this in other deliveries. Other causes of potential injury are many. Just having a birth through the vagina can lead to more pelvic floor dysfunction. Larger babies and longer times in the second stage can cause problems.

So, ‘bottom line’ is how do we protect the pelvic floor. Birthing isn’t the only issue, you can’t strain too much when having a bowel movement, nor lift heavy objects regularly.  Oddly either choosing to have no children, fewer children, or no vaginal births (elective c-section) do all work to prevent some of these injuries, but aren’t reasonable solutions for moms to be. Good nutrition so that your muscles are well developed and not weak, avoid toxins (caffeine, cigarette smoke), normalize weight gain (so babe is normal sized too!), and protect nerve function by not being diabetic.

There are new technologies, such as the Emsella chair, to improve the way Kegel’s exercises are done, and FDA cleared for the treatment of urinary issues. Whether Emsella can both improve the pelvic floor once you have had a child, and can be preventative technology is not yet known.

Once it comes to birthing, let your obstetrician or midwife decide how to effectively shorten the second stage of labor , and if you need an episiotomy for the baby, it’s not going to harm the pelvic floor.


Suzanne Trupin, MD, Board Certified Obstetrician and Gynecologist and owner of Women's Health Practice, Hada Cosmetic Medicine, and Hatha Yoga and Fitness

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