An episiotomy is a surgical procedure that involves making a small incision in the perineum (the area between the vaginal opening and anus) to widen the opening of the vagina while giving birth.
It is done to help with the delivery of the baby or to avoid extensive vaginal tearing and trauma.
Episiotomy can be classified into four types:
- The incision is made to the right or left side from the midpoint of the fourchette (a thin fold of skin at the back of the vulva).
- It runs diagonally in a straight line about 2.5 cm away from the anus.
- The incision begins in the center of the fourchette (a thin fold of skin at the back of the vulva) and extends for 2.5 cm on the posterior side along the midline.
- The incision begins about a centimeter away from the center of the fourchette (a thin fold of skin at the back of the vulva) and extends laterally.
- Because of the risk of injury to the Bartholin's duct (secretes fluid that helps lubricate the vagina), some practitioners strongly advise against lateral incisions.
- The incision begins in the center of the fourchette (a thin fold of skin at the back of the vulva) and is directed posteriorly along the midline for about 1.5 cm before being directed downward and outward along the 5 or 7 o'clock position to avoid the internal and external anal sphincters.
- This procedure is not widely used.
Degrees of an episiotomy is used to document the type of birth cut a woman received to deliver a baby. The degree is determined by the tissues that were lacerated. This assists in guiding management and possible long-term symptoms and outcomes.
- First-degree episiotomy: This cut only penetrates the vaginal epithelium (the tissue lining the vagina).
- Second-degree episiotomy: This episiotomy goes through the perineum muscles but bypasses the anal sphincter.
- Third-degree episiotomy: Only the skin and muscle of the perineum are invaded during an episiotomy. However, in third-degree episiotomy, this can occasionally progress to third or fourth-degree laceration. The tear in this case passes through the perineal muscles and external anal sphincter.
- Fourth-degree episiotomy: This is when laceration passes through the perineal muscles, external anal sphincter, and inner rectum lining.
One of the reasons for the decrease in episiotomy placement is to avoid these extensions and the damage they cause.
What occurs during an episiotomy?
The type of episiotomy and procedure itself may differ depending on the mother’s condition, but an episiotomy generally follow the process outlined below:
- The episiotomy is best done at crowning (when the fetal head pushes against the perineum and is visible). This puts pressure on the perineal nerve and numbs the area; thus, anesthesia is not needed for the cut.
- The doctor cuts with episiotomy scissors.
- After the episiotomy, the baby will be delivered through the enlarged vaginal opening.
- After that, the placenta (afterbirth) will be delivered.
- The doctor will then inspect the incision to look for any additional tearing that may have occurred during the birth.
- The incision to the perineal tissue and muscle is then repaired in layers with dissolvable stitches (sutures)—inner soft tissue, muscle, and skin are sutured separately.
Complications that can occur due to an episiotomy include:
- A second tear in the incision, may extend to the rectum and affect the anal sphincter muscle that controls stool passage
- Blood loss due to the incision and blood collection in the perineal tissues
- Risk of infection in the cut
- Painful sex for a few months after giving birth
Despite the risks, an episiotomy may be necessary in some cases for safe delivery.
Discuss episiotomy with your doctor before giving birth to ensure that you are both comfortable and informed.
How is the recovery period after an episiotomy?
Recovery from an episiotomy can be uncomfortable, if not painful. The degree of pain will be determined by the length and depth of the incision.
- Pain is most noticeable when you walk or sit, but it can interfere with urination and bowel movements for at least a week.
- The first bowel movement after an episiotomy can be excruciatingly painful for some women.
- Pain from an episiotomy can last for several weeks, whereas tenderness from a large incision or tear can last much longer.
- Stitches that were used to close the episiotomy will dissolve on their own.
To aid in your recovery, your doctor may recommend over-the-counter or prescription medications that may include:
- Stool softeners
- Anesthetic spray
Although episiotomy was once a routine part of normal childbirth, with advances in knowledge, it is now only recommended in certain cases. As a result, episiotomy rates have dropped significantly in recent years worldwide.
The episiotomy rate is difficult to determine although some studies have reported that it may range between 53 and 77 percent but can be as high as 92 percent in private hospital deliveries. Doctors no longer advise episiotomy regularly.
If the baby needs to be delivered quickly, your doctor may advise you to have an episiotomy.
They may also advise an episiotomy under the following circumstances:
- The Baby’s shoulder is stuck behind the pelvic bone (shoulder dystocia)
- Baby has an abnormal heart rate pattern during your delivery
- Mothers may sometimes need an operative vaginal delivery (using forceps or vacuum)
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Classification of episiotomy: towards a standardisation of terminology: https://obgyn.onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2011.03268.x
Episiotomy and Repair Technique: https://emedicine.medscape.com/article/2047173-technique
Episiotomy: Techniques and Indications: https://collections.lib.utah.edu/dl_files/fd/2a/fd2a4f9f7b46976e17792e4ab5ee78ff1d2c6a48.pdf
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