Episiotomy

Vilma Ruddock
Episiotomy

The purpose of an episiotomy is to make the vaginal opening wider so it easier to deliver a baby. The procedure used to be a routine part of childbirth, but it is now recommended only when felt necessary for a safer vaginal delivery.

Why an Episiotomy?

Widening the vaginal opening, or introitus, can make the baby's delivery quicker and less traumatic for baby and mother. Therefore, an episiotomy became routine because OB providers felt it prevented random tearing of vaginal and adjacent tissue layers.

The procedure is now considered for selective reasons when the benefits appear to outweigh the risks in the following circumstances:

  • When it appears there is not enough room to deliver the baby safely through the vaginal opening.
  • The baby is in distress and needs to be delivered soon before it can progressively stretch and ease the vaginal and perineal tissues during more pushing.
  • The baby is known to be large, and there might be problems getting the head or shoulders out.
  • The baby is breech (bottom or feet coming out first) and can be more safely delivered through a wider vaginal opening.
  • It is necessary to deliver the baby by a forceps or vacuum extraction.

Declining Routine Use

The routine use of episiotomies has been decreasing over the last few decades in the United States and elsewhere. There is no evidence it improves the risk of short-term and long-term complications, compared to a tear during delivery, according to a 2005 Journal of the American Medical Association (JAMA) review. Talk to your OB specialists during your prenatal care about their perspective on the procedure.

ACOG Practice Recommendation

Based on the evidence, in an April, 2006 Practice Bulletin the American College of Obstetricians and Gynecologists (ACOG) recommended restriction on the routine use of episiotomies. A summary of the ACOG Practice Bulletin is accessible in a December, 2006 American Family Physicians (AFP) article.

ACOG also recommends steps to decrease vaginal and perineal tears and the chance of needing an episiotomy. During the second (pushing) stage of labor, techniques such as massage and application of warm compresses to the perineum can decrease the risk for significant tears.

Performing an Episiotomy

Your OB doctor or midwife will perform an episiotomy just at the point the baby (most often head first) is about to appear through your vaginal opening. To perform the procedure:

  • Unless you have an working epidural or you are under general anesthesia, your OB specialist injects a local anesthesia solution along the line on the perineum he/she is going to cut.
  • Your OB provider makes a cut with scissors at the posterior entrance of the vagina and extends it downwards to make one of the two types of episiotomy:
    • Medial: The medial, or median, incision is made in the midline between vaginal entrance and anus. It is the more common type used in the United States and is usually easier to repair.
    • Mediolateral: This cut goes sideways at about a 45 degree angle, usually towards the patient's right buttock. It has a lower risk of extending into anal or rectal tissues.

The incision includes skin and the fatty (subcutaneous) tissue underneath it. You might briefly feel pressure or burning from the local anesthesia injection, but you should not feel when the cut is made.

Repair of the Incision

An episiotomy is a controlled cut but might sometimes be harder to repair than a small superficial tear. The meticulous repair starts soon after the baby is delivered and the placenta is out:

  1. First, the vagina, perineum, anus, and lower rectal areas are inspected to see how far and deep the incision went or if there are other tears that need stitches.
  2. Next, the incision is closed in layers making sure to line up the vaginal ring and repairing any torn vaginal tissues, rectal/anal inner lining, anal sphincter, and pelvic floor muscles.
  3. Finally, the subcutaneous fat is closed and perineal skin, from vaginal ring downwards, is the last to be sutured.

The stitches are dissolvable and buried under the skin so no suture removal is needed later.

After-Procedure Care and Healing

Right after the repair is complete, the care and healing of the episiotomy incision begins:

  • Your bottom end will start to hurt as soon as the anesthesia wears off so you will be given pain medicine.
  • A nurse also applies ice packs to your perineum, and you will continue to do this until pain and swelling decreases.
  • You may be given a peri-bottle to squirt water on your perineal area after urinating or passing your stool to keep yourself clean.
  • It is important to avoid constipation to decrease pain and so your stitches can heal well. You might get a stool softener to take by mouth, but you should also drink a lot of fluids and make sure you include fiber in your diet when you go home.
  • At discharge from the hospital, you will get instructions to take sitz baths once or twice a day to decrease swelling.
  • You might get a prescription pain medicine to take at home for a few days or advised to take ibuprofen depending on the level of your pain.
  • Sit on a donut-shaped cushion or a pillow to ease your discomfort.
  • Strictly avoid douching, tampons, or intercourse until after your six-week post-delivery check-up.

The process of healing is similar for both the midline and mediolateral procedures and takes about two to three weeks. Some women may have a thicker scar than others, which might cause prolonged discomfort. This problem is more common in women with darker skin because of the difference in wound healing.

Risks of the Procedure

Despite the controlled cut compared to a jagged vaginal and perineal tear, an episiotomy also has its risks. This has to be weighed against the benefits for your baby and you. According to MedlinePlus, the risks of the procedure include:

  • The doctor or midwife might cut too deeply and extend the incision into the muscle layer of the perineum.
  • The OB specialists might also mistakenly cut into the anal sphincter or open the lining of the anus or rectum. This is more common with a midline incision.
  • The incision can also tear deeper or longer into the vagina and perineum as the baby is delivered.
  • As with any surgical incision, the wound can get infected after delivery.
  • There might be significant bleeding from the incision because of the amount of blood supply to the area.
  • Prolonged pain and discomfort during intercourse can occur.
  • Constipation or difficulty passing stool is not uncommon.

Potential Long-Term Complications

Potential long-term complications of the procedure after healing include:

  • Defect or weakening of the pelvic floor muscles that support the urethra, bladder, vagina, and rectum
  • Anal incontinence (leaking of stool) because of injury to the sphincter, especially with a midline cut
  • Fistula (connecting hole) between the vagina and rectum, which can result in leaking stool through the vagina

When to Call for Help

After you go home with your baby, pay attention to any signs and symptoms of infection and poor healing. Call your OB provider if you notice bleeding from the procedure site, a foul-smelling discharge, fever/chills, or perineal or rectal/anal pain that is not improving.

Episiotomy