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Episiotomy
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An episiotomy 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.
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Encyclopedia
An episiotomy 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 and in Poland and India.
Uses
The primary rationale behind an episiotomy is related to the nature rather than the size of the tear. An episiotomy creates a primary intention wound which is easier and less painful to suture, causes less scarring and reduces the risk of infection compared to natural wounds. This is because the natural wounds are typically secondary or tertiary intentions which create poorly related wounds (ragged edges) and shearing between perineal layers slowing healing and increasing the infection risk
Many physicians use episiotomies because they believe that it will lessen perineal trauma, 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. Research has shown that natural tears typically are less severe (although this is perhaps unsurprising since epistiotomy 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.
Episiotomy is indicated if:
- the baby's shoulders are stuck (When a baby's shoulders are stuck they are stuck behind bony pelvis, not soft tissue, so this indication is disputed)
- 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
- Routine episiotomy is NOT indicated in evidence based practice
- Large baby
- rigid perineal muscles
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 suggested that 31% of women having babies in U.S. hospitals received episiotomies in 1997, compared with 56% in 1979. In Latin America it's still popular, where it's done on 90% of hospital births and in most cases without the mother's consent. There, routine episiotomy is a major cause of infections, some of them fatal .
Recent studies indicate that routine episiotomies should not be performed, as they increase morbidity. This procedure is not helpful for routine patients
Having an episiotomy may increase perineal pain in the postpartum period, resulting in trouble defecating, particularly in midline episiotomies . In addition it may complicate sexual intercourse by making it painful 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.
Impacts on sexuality
Some midwives compare routine episiotomy to female circumcision. 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.
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%.
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.
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