An episiotomy is a surgical incision made in the area between the vagina and anus (perineum). This is done during the last stages of labor and delivery to expand the opening of the vagina to prevent tearing during the delivery of the baby.
Description
An episiotomy is a surgical incision, usually made with sterile scissors, in the perineum as the baby's head is being delivered. This procedure may be used if the tissue around the vaginal opening begins tearing or does not seem to be stretching enough to allow the baby to be delivered.
In most cases, the physician makes a midline incision along a straight line from the lowest edge of the vaginal opening to toward the anus. In other cases, the episiotomy is performed by making a diagonal incision across the midline between the vagina and anus. This method is used much less often, may be more painful, and may require more healing time than the midline incision. After the baby is delivered through the extended vaginal opening, the incision is closed with stitches. A local anesthetic agent may be applied or injected to numb the area before it is sewn up (sutured).
Several reasons are cited for performing episiotomies. Some experts believe that an episiotomy speeds up the birthing process, making it easier for the baby to be delivered. This can be important if there is any sign of distress that may harm the mother or baby. Because tissues in this area may tear during the delivery, another reason for performing an episiotomy is that a clean incision is easier to repair than a jagged tear and may heal faster. Although the use of episiotomy is sometimes described as protecting the pelvic muscles and possibly preventing future problems with urinary incontinence, it is not clear that the procedure actually helps.
The use of episiotomy during the birthing process is fairly widespread in the United States. Estimates of episiotomy use in hospitals range from 65–95% of deliveries, depending on how many times the mother has given birth previously. This routine use of episiotomy is being reexamined in many hospitals and health care settings. However, an episiotomy is always necessary during a forceps delivery because of the size of the forceps.
Many expectant mothers and other alt-clickers were interested to read early in May 2005 that:
"Routine use of episiotomy for uncomplicated vaginal births does not provide immediate or longer term benefits for the mother, according to a review of scientific evidence sponsored by HHS' Agency for Healthcare Research and Quality. Episiotomy is the surgical cutting of the perineum -- the skin between the vaginal opening and the anus -- and is a common procedure used in an estimated one-third of vaginal deliveries to hasten birth or prevent tearing of the skin during delivery."
Who Performs the Procedure and Where Is It Performed?
An episiotomy is performed by the health care provider attending to a woman's labor and delivery, typically an obstetrician/gynecologist or midwife. An obstetrician/gynecologist is a medical doctor who has completed specialized training in the areas of women's general health, pregnancy, labor and childbirth, prenatal testing, and genetics. A midwife is a person who has been trained to provide care, support, and supervision to women in all stages of pregnancy, labor, delivery, and the postpartum period. The procedure is performed at the site of labor and delivery, most often a hospital or birth center.
Questions to Ask the Doctor
What is your episiotomy rate?
For what reasons would you perform an episiotomy?
What are my alternatives to having an episiotomy?
How should I care for my episiotomy when I return home?
Definition
An episiotomy is a surgical incision made in the perineum, the area between the vagina and anus. Episiotomies are done during the second stage of labor to expand the opening of the vagina to prevent tearing of the area during the delivery of the baby.
Purpose
An episiotomy is usually done during the birthing process in order to deliver a baby without tearing the perineum and surrounding tissue. Reasons for an episiotomy include:
Evidence of maternal or fetal distress (i.e. no time to allow perineum to stretch).
The baby is premature or in breech position, and his/her head could be damaged by a tight perineum.
The baby is too large to be delivered without causing extensive tearing.
Some experts believe that an episiotomy speeds up the birthing process, making it easier for the baby to be delivered. Speed can be important if there is any sign of distress that may harm the mother or baby. Because tissues in this area may tear during the delivery, another reason for performing an episiotomy is that a clean incision is easier to repair than a jagged tear and may heal faster. Although episiotomies are sometimes described as protecting the pelvic muscles and possibly preventing future problems with urinary incontinence, it is not clear that the procedure actually helps.
Demographics
In 2000, one study calculated the percentage of episiotomies performed in the United States out of all vaginal deliveries to be 19.4%. This was a dramatic reduction from the 1983 rate of 69.4%. Episiotomy rates were higher among white women (32.1%) than African American women (11.2%). Similar differences have been reported in other obstetric procedures (e.g. cesarean section and epidural use).
Episiotomy rates differ according to care provider—patients of midwives have lower rates than patients of medical doctors. One study comparing perineal outcomes for women being cared for by midwives or medical doctors found the episiotomy rate among midwives at 25% and 40% among medical doctors. Younger doctors are also less likely to perform an episiotomy than older doctors; one study found the rate of episiotomies performed by residents to be 17%, while the rate among doctors in private practice was 66%.
Description
An episiotomy is a surgical incision, usually made with sterile scissors, in the perineum as the baby's head is being delivered. This procedure may be used if the tissue around the vaginal opening begins to tear or does not seem to be stretching enough to allow the baby to be delivered.
In most cases, the physician makes a midline incision along a straight line from the lowest edge of the vaginal opening toward the anus. In other cases, the episiotomy is performed by making a diagonal incision across the midline between the vagina and anus (called a mediolateral incision). This method is used much less often, may be more painful, and may require more healing time than the midline incision. After the baby is delivered through the extended vaginal opening, the incision is closed with stitches. A local anesthetic may be applied or injected to numb the area before it is sewn up (sutured).
Episiotomies are classified according to the depth of the incision:
A first-degree episiotomy cuts through skin only (vaginal/lierineal).
A second-degree episiotomy involves skin and muscle and extends midway between the vagina and the anus.
A third-degree episiotomy cuts through skin, muscle, and the rectal sphincter.
During childbirth, the area called the perineum is often cut to facilitate delivery (A). First, a local anesthetic may be given (B). The perineum is cut on an angle with scissors (C). After delivery, the layers of muscle and skin are repaired (D and E). (Illustration by GGS Inc.)
A fourth-degree episiotomy extends through the rectum and cuts through skin, muscle, the rectal sphincter, and anal wall.
Diagnosis/Preparation
Although there are some reasons for anticipating an episiotomy before labor has begun (e.g. breech presentation of the baby), the decision to perform an episiotomy is generally not made until the second stage of labor, when delivery of the baby is imminent.
Aftercare
The area of the episiotomy may be uncomfortable or even painful for several days. Several practices can relieve some of the pain. Cold packs can be applied to the perineal area to reduce swelling and discomfort. Use of a sitz bath can ease the discomfort. This unit circulates warm water over the area. A squirt bottle with water can be used to clean the area after urination or defecation rather than wiping with tissue. Also, the area should be patted dry rather than wiped. Cleansing pads soaked in witch hazel (such as the brand Tucks) are very effective for soothing and cleaning the perineum.
Risks
Several side effects of episiotomy have been reported, including infection (in 0.3% of cases), increased pain, increased bleeding, prolonged healing time, and increased discomfort once sexual intercourse is resumed. There is also the risk that the incision will be deeper or longer than is necessary to permit the birth of the infant. An incision that is too long or deep may extend into the rectum, causing more bleeding and an increased risk of infection. Additional tearing or tissue damage may occur beyond the episiotomy itself.
Normal Results
In a normal and well-managed delivery, an episiotomy may be avoided altogether. If an episiotomy is considered necessary, a simple midline incision will be made to extend the vaginal opening without additional tearing or extensive trauma to the perineal area. Although there may be some pain associated with the healing of the incision, relief can usually be provided with mild pain relievers and supportive measures, such as the application of cold packs.
Morbidity and Mortality Rates
Studies have found that the rates of urinary/fecal incontinence, postpartum perineal pain, and sexual dysfunction are generally the same between women who have had an episiotomy and those who had a spontaneous tear of the perineum. There does appear to be a higher risk of more extensive perineal trauma when an episiotomy is performed (20.9% experienced third- or fourth-degree lacerations) then when it is not (3.1% experienced major perineal damage).
Alternatives
It may be possible to avoid the need for an episiotomy. Pregnant women may want to talk with their care providers about the use of episiotomy during the delivery. Kegel exercises are often recommended during the pregnancy to help strengthen the pelvic floor muscles. Prenatal perineal massage may help to stretch and relax the tissue around the vaginal opening. During the delivery process, warm compresses can be applied to the area along with the use of perineal massage. Coaching and support are also important during the delivery process. Slowed, spontaneous pushing during the second stage of labor (when the mother gets the urge to push) may allow the tissues to stretch rather than tear. Also, an upright birthing position (rather than one where the mother is lying down) may decrease the need for an episiotomy.
Resources
Books
Enkin, Murray, Marc Keirse, James Neilson, et al. A guide to effective care in pregnancy and childbirth. Third edition. Oxford: Oxford University Press, 2000.
Periodicals
Carroli, G., and J. Belizan. "Episiotomy for vaginal birth." TheCochrane Library (2000).
Goldberg, Jay, David Holtz, Terry Hyslop, and Jorge Tolosa. "Has the Use of Routine Episiotomy Decreased? Examination of Episiotomy Rates From 1983 to 2000." Obstetrics and Gynecology 99 (March 2002): 395–400.
Kane-Low, Lisa, Julia Seng, Terri Murtland, and Deborah Oakley. "Clinician-specific episiotomy rates: Impact on perineal outcomes." Journal of Midwifery and Women's Health 45 (March 2000): 87–93.
Klein, M. C., R. J. Gauthier, J. Kaczorowski, et al. "Relationship of Episiotomy to Perineal Trauma and Morbidity, Sexual Dysfunction, and Pelvic Floor Relaxation." American Journal of Obstetrics and Gynecology 171 (1994): 591–8.
McCandlish, Rona. "Perineal Trauma: Prevention and Treatment." Journal of Midwifery and Women's Health 46 (November 2001): 396–401.
Roberts, Joyce E. "The 'Push' for Evidence: Management of the Second Stage." Journal of Midwifery and Women's Health 47 (January 2002): 2–15.
Yokoe, Deborah, Cindy Christiansen, Ruth Johnson, et al. "Epidemiology of and Surveillance for Postpartum Infections." Emerging Infectious Diseases 7 (2001).
Organizations
American College of Nurse-Midwives. 818 Connecticut Ave., NW, Suite 900, Washington, DC 20006. (202) 728-9860. http://www.midwife.org.
American College of Obstetricians and Gynecologists. 409 12th St., SW, PO Box 96920, Washington, DC 20090-6920. http://www.acog.org.
Midwives Alliance of North America. 4805 Lawrenceville Highway, Suite 116-279, Lilburn, GA 30047. (888) 923-MANA. http://www.mana.org.
Once memorably described as ‘the unkindest cut of all’, episiotomy is a surgical cut in the perineum that is effected by knife or scissors shortly before delivery of a baby. The procedure has undoubted merit when there are signs of distress in the baby, or a need for forceps delivery, or where there is a risk of serious and extensive tearing of tissues. However, episiotomy has been applied, in some countries, to an extent that is almost routine; thus hence the controversial nature of this procedure. The wound is stitched immediately after delivery.
An episiotomy (pronounced /ɛˌpiːziːˈɒtəmiː/) is a surgical incision through the perineum made to enlarge the vagina and assist childbirth. The incision can be midline or at an angle from the posterior end of the vulva, is performed under local anaesthetic (pudendal anesthesia) and is sutured closed after delivery. It is one of the most common medical procedures performed on women, and although its routine use in childbirth has steadily declined in recent decades, it is still widely practiced in Latin America, Poland, Bulgaria and India.
The primary rationale behind an episiotomy is related to the nature rather than the size of the tear. Many physicians use episiotomies because they believe that it will lessen perinealtrauma, minimize postpartum pelvic floor dysfunction by reducing anal sphincter muscle damage, reduce the loss of blood at delivery, and protect against neonatal trauma. In many cases though, episiotomies cause all of these problems.[1] Research has shown that natural tears typically are less severe (although this is perhaps not surprising since episiotomy is designed for when natural tearing will cause significant risks/trauma). Slow delivery of the head in between contractions will result in the least perineal damage.[2]
Episiotomy is indicated if:
The baby's shoulders are stuck (Shoulder Dystocia) a bony association, though the episiotomy does not resolve this problem, it allows the operator more room to perform maneuvers to free shoulder from the pelvis.
There is a serious risk to the mother of second or third degree tearing
In some cases where a caesearean is not indicated but delivery is adversely affected
'Natural' tearing will cause an increased risk of maternal disease being vertically transmitted
The baby is very large
Rigid perineal muscles
When instrumental delivery is indicated
When a woman has undergone FGM (female genital mutilation) an anterior and or mediolateral episiotomy may be indicated.
Prolonged late decelerations or fetal bradycardia during active pushing
Controversy about common usage
In various countries, routine episiotomy has been accepted medical practice for many years. Since about the 1960s, routine episiotomies have been rapidly losing popularity among obstetricians and midwives in Europe, Australia and the United States. A nationwide US population study[3] suggested that 31% of women having babies in U.S. hospitals received episiotomies in 1997, compared with 56% in 1979. In Latin America it remains popular, and is performed in 90% of hospital births,[4] in most cases without the mother's consent. This procedure is not helpful for routine patients[5] Having an episiotomy may increase perineal pain in the postpartum period, resulting in trouble defecating, particularly in midline episiotomies [6]. In addition it may complicate sexual intercourse by making it painful [7] and replacing erectile tissues in the vulva with fibrotic tissue.
In cases where an episiotomy is indicated, a mediolateral incision may be preferable to a median (midline) incision as the latter is associated with a higher risk of injury to the anal sphincter and the rectum[8].
Impacts on sexual intercourse
Some midwives compare routine episiotomy to female circumcision.[9] One study found that women who underwent episiotomy reported more painful intercourse and insufficient lubrication 12–18 months after birth, but did not find any problems with orgasm or arousal.[10]
Avoidance
Controlled delivery of the head that allows slow gradual stretching of the perineal tissue can help in minimising damage to the perineum.
Perineal massage beginning around the 34th week has been shown to reduce perineal damage by 6%[11].
A perineal dilator can be used to stretch the perineal tissue gradually and train it in preparation for first births. The "Epi-no Birth Trainer" consists of a small inflatable silicone balloon pumped with the same pump as a sphygmomanometer. The Epi-no device has been shown to reduce perineal damage by 50% at first births[12]. Where episiotomy is never practiced, the sutured tear rates for first birth were documented to be about 30%. ( Albers LL, Sedler KD, Bedrick EJ, et al. Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: a randomized trial. J Midwifery Womens Health 2005;50(5):365-372.). Among 104 consecutive primiparous women who practiced with an Epi-No birth trainer before birth and had normal vaginal births, 10% had sutured perineums. Neither group suffered any third- or fourth-degree tears. The average birthweight was 3,400 g. This 10% rate of sutured perineums among first births who used EPINO birth trainer is the lowest reported for healthy primiparous women to date. (10% Primipara Sutured Tear rate in the absence of episiotomy. Birth 2008;35(2):167.)
^ Thacker, S.B., and H.D. Banta. 1983. "Benefits and risks of episiotomy: An interpretative review of the English language literature, 1860-1980." Obstet Gynecol Surv 38(6): 322-38.
^ Albers, L.L., et al. 2006. "Factors Related to Genital Tract Trauma in Normal Spontaneous Vaginal Births." Birth 33(2): 94-100.
^[1] Joan Cameron, Karen Rawlings-Anderson, "Female circumcision and episiotomy: both mutilation?" British Journal of Midwifery, Vol. 9, Iss. 3, 01 Mar 2001, pp 137 - 142.
^[2] Hanna Ejegård, Elsa Lena Ryding, Berit Sjögren, "Sexuality after Delivery with Episiotomy: A Long-Term Follow-Up", Gynecologic and Obstetric Investigation, Vol. 66, No. 1, 2008.
^Shipman MK, Boniface DR, Tefft ME, McCloghry F (1997). "Antenatal perineal massage and subsequent perineal outcomes: a randomised controlled trial". Br J Obstet Gynaecol104 (7): 787–91. PMID9236642.
