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Attention Readers: I am presenting this from a medical standpoint, not necessarily one from a midwife's standpoint. However, I will try to include information and links that may assist with presenting the pros and cons of this controversial procedure. Most midwives I know, including myself, take great pride in our very, very, low episiotomy rates and our ability to assist the mother in giving birth over an intact perineum with few, if any, tears or abrasions. If repairs are necessary, we also take extreme care in making sure that any repairs are performed properly, expertly matching tissues with appropriate tissues, providing sterile techniques to prevent infections, and careful instructions on postpartum care. Even first time mothers are fully capable of birthing their babies without this procedure when allowed enough time and support by a competent birth support provider.
BASIC INFORMATION
DEFINITION
An episiotomy is an incision at the exterior of the vaginal opening to create enlargement.
Obstetricians used to cut episiotomies routinely to speed delivery and to prevent the vagina from tearing, particularly during the first vaginal delivery. Many experts believed that the "clean" incision of an episiotomy would heal more easily than a spontaneous tear. But a great many studies over the last 20 years of so have disproved this theory. Most experts no agree that the procedure should not be done routinely.
Research has shown that women with spontaneous tears generally recover in the same time and often with fewer complications than those with episiotomies. Women who have episiotomies tend to lose ore blood at the time of delivery, have more pain during recovery, and have to wait longer before they have sex without discomfort.
Women who get episiotomies are more likely to end up with serious tears through the anal sphincter or even all the way through the rectum (known as third- or fourth-degree lacerations, respectively) than those who deliver without being cut. These serious tears result in more perineal pain after the birth, require a significantly longer recovery period, and are more likely to affect the strength of the pelvic floor muscles. And tears that disrupt the anal sphincter increase the risk of anal incontinence - trouble controlling bowel movements or gas.
REASONS FOR PROCEDURE
This procedure is Usually performed during childbirth, just before the widest diameter of the baby's head passes through the outlet of the birth canal. This allows easier passage of the baby's head to reduce the potential damage to the mother's vagina, bladder and rectum (however, studies have shown otherwise... this is a medical surgical procedure that has been greatly over-used and over-abused. Midwives have shown that most women can give birth, vaginally, without tearing or needing to have an episiotomy).
This procedure also helps expedite delivery in the case of forceps or vacuum use when there is maternal exhaustion or fetal distress when the baby's heart rate shows that he/she isn't tolerating the last minutes of labor well and needs to be fore as quickly as possible.
Some practitioners will perform an episiotomy when they feel the baby's head is large or may not be molding enough to pass through the vaginal opening or if they feel they need a little extra room to manipulate the baby to get him/her to come out.
Some practitioners will use this procedure if the woman's tissue is starting to bleed or looks like it's about to tear in multiple places as the baby's head begins to crown. The idea here is that being cut in one place is better than tearing in more than one place. However, a few shallow tears may still be preferable to an episiotomy, so your health care provider or midwife will have to make a judgment call.
AVOIDING AN EPISIOTOMY
Talk to your health care provider or midwife early in your prenatal care about your feelings regarding the procedure. Ask him/her how often and under what conditions he/she would perform an episiotomy, and how she might help you to avoid tearing during the delivery. If you are in a group practice, make sure you discuss your concerns with other practitioners in the practice, in case you end up with someone else at your delivery besides your own health care provider. Studies show that, as a group, midwives tend to do far fewer episiotomies than do other health care providers, especially obstetricians, which seem to have the highest rate of surgical intervention.
Perineal Massage: Start doing perineal massage about 5 to 6 weeks before your expected delivery date. A few studies show that perineal massage may make it less likely that you will tear or need an episiotomy. Your midwife should be able to tell you how to do proper perineal massage for the best benefits.
MoonDragon's Pregnancy Information: Episiotomies - What You Should Know
RISK
None expected. However, further tearing may occur beyond the incision which may involve more extensive repair.
DESCRIPTION OF PROCEDURE
An incision is made in the perineum just before the widest part of the baby's head is to be delivered. The size of the incision depends on how large an opening is required for the baby's head to pass through safely.
An injection of local anesthetic may or may not be given prior to the procedure. Sometimes, if your perineum is already numb and thinned out from the pressure of your baby's head, she may be able to do the episiotomy without pain medication. This is sometimes called a pressure episiotomy.
The incision is usually made using surgical scissors to make the small cut. The surgical scissors preferred have a blunt end on one side (this side goes into the vagina) to prevent injury to the vaginal tissue and the baby's head during insertion and cutting.
The baby and placenta are delivered.
After the baby and placenta are delivered, you may get another shot of local anesthesia to be sure you are completely numb before your health care provider or midwife stitches up the cut. Note: if the cut is very small, requiring only a few superficial sutures, local anesthetic may not be necessary and may actually be a hindrance since it can cause tissue swelling and allergic reactions in the mother. The repair of a superficial cut or tear without anesthetic feels like a little "pinch" and can be done. I have had it done on myself and I have repaired a few incisions/tears without using anesthetic. - MoonDragon Midwife
The surgical area is repaired with sutures that will be absorbed by the body. The skill of the practitioner or midwife doing the repair is important. All tissues need to be matched, aligned and repair done properly using sterile technique.
EXPECTED OUTCOME
Expect complete healing without complications. Allow about 6 weeks for recovery from childbirth.
If you have had an episiotomy (or tear), you will have stitches in a very tender area and you will need some time to heal. Your stitches will disintegrate (absorbable sutures usually made from chromic catgut) during the first weeks after delivery and will not need to be removed by your practitioner. Some women feel little pain within a week or two, while other have discomfort for a month or more, particularly if they have a third or fourth degree laceration.
POSSIBLE COMPLICATIONS
Excessive bleeding.
Surgical-wound infection.
Inadvertent injury to sphincter or rectum.
May lead to increased risk of vaginal and/or rectal injury.
Incomplete healing usually caused by poor surgical repair.
Pain of perineum continues after healing.
Inability to resume sexual intercourse after healing. May be caused when the vaginal opening has been sutured too tight or too small for penile penetration.
Possible tearing risks along old scar tissue during later childbirth.
Incontinence of bowel from improper anal sphincter repair.
TREATMENT
GENERAL MEASURES
Bathe and shower as usual. You may wash the incision gently with mild unscented soap.
Take warm baths several times a day as long as you experience discomfort. A warm sitz bath may help relieve discomfort. Comfrey leaf may be added to the sitz bath to help in healing
Use ice packs made of gauze soaked in ice-cold witch hazel to ease discomfort during the 24 hours after delivery will ease the discomfort and prevent or reduce swelling.
MEDICATION
You may use non-prescription drugs, such as acetaminophen or ibuprofen for minor pain.
Stool softener laxative (or lots of prune juice! A much safer and tastier remedy) to prevent constipation if needed.
Antibiotics, if required to fight infection.
ACTIVITY
Follow your midwife's or health care provider's advice on resuming, or beginning, a postpartum exercise program.
Resume driving 10 days after the birth.
Resume sexual relations as directed by your midwife or health care provider or when a follow-up postpartum examination determines that healing is completed (usually 3 to 6 weeks).
SEXUAL ACTIVITY AFTER AN EPISIOTOMY
Your perineum should be completely healed around four to six weeks after delivery, so if your caregiver gives the okay and you're up to it, you can try having sex then. You might feel some initial tenderness and tightness.
Try having a glass of wine, taking a warm bath, and leaving plenty of time for foreplay. You might prefer to be on top so that you can control the degree of penetration, or you may find that lying on your side is most comfortable.
Relaxing as much as possible and using a good water-soluble lubricant will help make sex more comfortable. This may be especially helpful if you're breastfeeding, because lactation lowers your estrogen levels, which reduces the amount of lubrication your vagina can produce. Many women continue to use a lubricant during sex until they stop nursing.
DIET
Eating a high fiber diet will help prevent constipation which is common after childbirth. Increase your fluid intake as you increase your fiber intake.
NOTIFY YOUR MIDWIFE OR HEALTH CARE PROVIDER IF...
Pain, swelling, redness, drainage or bleeding increases in the surgical area.
You develop signs of infections: general ill feeling and fever, headache, muscle aches, dizziness.
You experience nausea, vomiting, constipation or abdominal swelling.
New, unexplained symptoms develop. Drugs used in treatment may produce side effects.
Pass uncontrolled urine through the vagina.
Pass gas (flatus) or stool from the vagina.
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