Episiotomy and when is it needed
What is an Episiotomy?
An episiotomy is an incision through the vaginal wall and the perineum (the area between the thighs, extending from the vaginal opening to the anus) to enlarge the vaginal opening and facilitate childbirth.
During a vaginal birth, the health care provider will assist the fetus’ head and chin out of the vagina when it becomes visible. Once the head is out of the vagina, the shoulders are eased out, followed by the rest of the body.
In some cases, the vaginal opening does not stretch enough to accommodate the fetus. In this case, an episiotomy may be done to help enlarge the opening and deliver the fetus. The episiotomy is usually done when the fetal head has stretched the vaginal opening to several centimeters during a contraction. Although episiotomy was a very common procedure in the past, more recent studies have found that routine or preventive use of episiotomy does not benefit the health of mother or baby. The American College of Obstetricians and Gynecologists (ACOG) no longer recommends performing an episiotomy on a routine basis. Discuss with your health care provider the best treatment option for you and your baby.
Types of Episiotomy
An episiotomy may be classified into two types:
- Midline or median.This refers to a vertical incision that is made from the lower opening of the vagina toward the rectum. This type of episiotomy usually heals well but may be more likely to tear and extend into the rectal area, called a third or fourth degree laceration.
- Mediolateral. This refers to an incision that is made at a 45-degree angle from the lower opening of the vagina to either side. This type of episiotomy does not tend to tear or extend, but is associated with greater blood loss and may not heal as well.
After the delivery of the baby, the mother may be asked to continue to push during the next few uterine contractions to deliver the placenta. Once the placenta is delivered, the episiotomy incision is sutured. If a mother does not have regional anesthesia such as an epidural, a local anesthesia may be injected in the perineum to numb the area for repair of a tear or episiotomy after delivery.
Other related procedures that may be used during labor and birth include cesarean delivery and external and internal fetal monitoring. Please see these procedures for additional information.
Reasons for the procedure
Not all women will require an episiotomy, and assisting the tissues to stretch naturally may help reduce the need for this procedure. If an episiotomy is not done, tearing of the perineal tissues may or may not occur.
An episiotomy may be used to assist in the treatment of the following conditions:
- Birth is imminent and the perineum hasn’t had time to stretch slowly
- The baby’s head is too large for the vaginal opening
- The baby is in distress
- The mother needs a forceps or vacuum assisted delivery
- The baby is in a breech presentation and there is a complication during delivery
- The mother isn’t able to control her pushing
There may be other reasons for your health care provider to recommend an episiotomy.
Risks of the procedure
As with any surgical procedure, complications may occur. Some possible complications of an episiotomy may include, but are not limited to, the following:
- Tearing past the incision into the rectal tissues and anal sphincter
- Perineal pain
- Perineal hematoma (collection of blood in the perineal tissues)
- Pain during sexual intercourse
Peoples who are allergic to or sensitive to medications or latex should notify their health care provider.
If the birth of the baby occurs too rapidly, an episiotomy may not be performed.
There may be other risks depending upon your specific medical condition. Be sure to discuss any concerns with your health care provider prior to the delivery.
During the procedure
An episiotomy may be performed as part of a vaginal birth. The procedure and the type of episiotomy may vary depending on your condition and your health care provider’s practices.
Generally, an episiotomy follows this process:
- You will be positioned on a labor bed, with your feet and legs supported for the birth.
- If you have not been given any labor or delivery anesthesia, a local anesthetic may be injected into the perineal skin and muscle to numb the tissues before the incision. If epidural anesthesia is used, you will have no feeling from your waist down and no additional anesthesia will be needed for the episiotomy.
- During the second stage of labor (pushing stage), as the fetal head stretches the vaginal opening, the physician/midwife will use special scissors or a scalpel to make the episiotomy incision.
- The baby will be delivered.
- The placenta will be delivered.
- The episiotomy incision will be examined for any further tearing.
- A local anesthetic may be injected into the perineal skin and muscle to numb the tissues.
- The perineal tissues and muscle will be repaired using sutures, which will dissolve over time.
After the procedure
After an episiotomy, you may experience incisional pain. An ice pack may be applied immediately after birth to help reduce swelling and pain. During your stay in the hospital and at home after your baby’s birth, sitz baths (warm or cold shallow baths) may relieve soreness and speed healing. Medicated creams or local anesthetic sprays applied to your perineum may also be helpful.
You may take a pain reliever for soreness as recommended by your physician. Be sure to take only recommended medications.
You should keep the incision clean and dry, using the cleansing method recommended by your health care provider after urination and bowel movements. If bowel movements are painful, stool softeners recommended by your health care provider may be helpful.
You should not douche, use tampons, or have intercourse until the time instructed by your physician/midwife. Also, you may have other restrictions on your activity, including no strenuous activity or heavy lifting.
You may resume your normal diet unless your health care provider advises you differently.
Your health care provider will advise you when to return for further treatment or care.
Notify your health care provider if you have any of the following:
- Bleeding from the episiotomy site
- Foul-smelling drainage from the vagina
- Fever and/or chills
- Severe perineal pain
Your health care provider may give you additional or alternate instructions after the procedure, depending on your particular situation.
Going to the toilet
Keep the cut and the surrounding area clean to prevent infection. After going to the toilet, pour warm water over your vaginal area to rinse it.
Pouring warm water over the outer area of your vagina as you pee may also help ease the discomfort.
You may find squatting over the toilet, rather than sitting on it, reduces the stinging sensation when passing urine.
When you’re passing a stool, you may find it useful to place a clean pad at the site of the cut and press gently as you poo. This can help relieve pressure on the cut.
When wiping your bottom, make sure you wipe gently from front to back. This will help prevent bacteria in your anus infecting the cut and surrounding tissue.
If you find passing stools particularly painful, taking laxatives may help. This type of medication is usually used to treat constipation and makes stools softer and easier to pass.
How Can I Prevent the Need To Have An Episiotomy?
The following measures can reduce the need for an episiotomy:
- Good nutrition–healthy skin stretches more easily!
- Kegels (exercise for your pelvic floor muscles)
- A slowed second stage of labor where pushing is controlled
- Warm compresses and support during delivery
- Use of perineum massage techniques
- Avoiding lying on your back while pushing
Talk to Your Doctor
There are few, if any, reasons for episiotomy to be performed on a routine basis. The doctor must make a decision at the time of delivery regarding the need for an episiotomy. Open dialogue between the provider and the patient during prenatal care visits and at the time of delivery is a critical part of the decision making process. There are circumstances when an episiotomy may be very beneficial and may prevent the need for cesarean section or assisted vaginal delivery (with the use of forceps or a vacuum extractor).
Also read – Perineal tear during vaginal birth