Episiotomy

An episiotomy is a surgical procedure that enlarges the vaginal opening during labor by cutting the perineum, the skin and muscles between the vulva and anus.

Episiotomy is the most commonly performed surgery in the United States. Between 50 and 90% of women giving birth to their first child undergo this procedure. For decades, episiotomies have been performed on a routine basis to help speed delivery during the second stage of labor; as well as to prevent tears to the mother's vagina, especially serious tears that may stretch to the anus. The procedure also lessens trauma to the baby and protects the mother's vaginal muscles.

Episiotomies May Be Useful Under The Following Conditions:

• Labor is too fast. If you are unable to stop pushing and slow your labor, a clean cut may help prevent a serious tear.
• Labor is too slow. If you are unable to speed delivery, widening the vaginal opening may help increase the pace.
• Fetal or maternal distress. An episiotomy may speed delivery if you or your baby are experiencing complications.
• Extremely large or breech baby. An episiotomy may help ensure a safe delivery by widening the vaginal opening.

Currently, there is disagreement in the medical field about the routine performance of an episiotomy. The World Health Organization, among other dissenters, believes the surgery is more painful and takes longer to heal than a natural tear. Talk to your health-care provider if you have any concerns.

What Will Happen?

figure 1

Just before your baby is born, as the head is about to crown, your obstetrician will inject a local anesthetic in the bottom of your vaginal opening and make an incision.

There are two types of incisions: median and medio-lateral (fig. 1). The median incision goes straight down the vagina toward the anus; the medio-lateral incision is made at an angle from the vagina to the anus. The medio-lateral is considered less likely to tear through to the anus, but is more difficult to repair and takes longer to heal than the median. Your obstetrician delivers the baby through the enlarged opening, followed by the placenta. The incision is stitched closed immediately after delivery.

Aftercare

For most women healing is uncomplicated, although it may take several weeks. You can help speed the process by asking nurses to apply ice packs immediately following the birth.

To Continue The Healing Process Over The Next Few Weeks You Should:

• Use sitz bath a few times a day, change your pads frequently, and try a heat lamp to keep the area around the stitches clean and dry.
• Take stool softeners and eat lots of fiber to prevent constipation.
• Perform Kegel exercises. Squeeze the muscles that you use to hold in urine for five minutes, 10 times a day, during your regular activities.

To Help Relieve Your Pain And Discomfort You Should:

• Take a warm bath, but not before 24 hours postpartum.
• Apply warm compresses, ice packs, or witch hazel to the affected area.
• Use over-the-counter topical anesthetics such as sprays or creams.

Your stitches do not need to be removed since your body will absorb them. Normal activities, such as light office work or housecleaning, can be resumed within a week after giving birth. Tampon use, intercourse, or any activity that might rupture the stitches, can be resumed in about a month. Talk to your health-care provider if you have any concerns.

What Are The Risks?

There are several complications, including:

• Large tears. After an episiotomy, large tears may form from the incision that can go all the way through to the anus. In one study, as many as 14% of the women undergoing episiotomies had these types of tears.
• Blood loss. An episiotomy cuts through all the layers of tissue and muscle and can lead to excessive bleeding.
• Infection. The incision and stitches are prone to bacterial infections.
• Painful intercourse. Recent studies show that an episiotomy may increase discomfort during intercourse in the first few months following birth.

Frequently Asked Questions

Q: Will I definitely tear if I do not have an episiotomy?

A: Studies show that tears are common during birth, but a large percentage of women who do not have episiotomies get through the birth process with an intact perineum. Many factors influence whether or not you will tear during labor: the number of deliveries you have had, the duration of second (pushing) stage labor and the size and position of the baby.

Q: Won't an episiotomy heal better than a tear?

A: Studies show that episiotomies don't heal or repair better than tears. They often take longer to heal since the incision is usually deeper than a natural tear. In both cases, the vaginal opening must be stitched and properly cared for postpartum.

Q: What can I do to help avoid an episiotomy?

A: An episiotomy cannot always be avoided. Your obstetrician will decide if you should have the procedure based on the conditions of your labor. There are, however, activities you can do to strengthen the perineum and lower your chances of undergoing the procedure. Practice Kegel exercises during your pregnancy; perform prenatal perineal massage (massaging the perineum for four to six weeks before birth makes it stronger); and learn how to control the timing of your labor process before going into delivery.

Review Date: June 29, 2001
Reviewed By: Peter Chen, M.D., Obstetrics and Gynecology, University of Pennsylvania School of Medicine. Review provided by VeriMed Healthcare Network.


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