Episiotomy

EPISIOTOMY
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. The delivery is being assisted by forceps. The mother is too tired or unable to push. Existing trauma to the perineum.
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 providerpatients 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.
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.
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 fourthdegree 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.

Episiotomy

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EPISIOTOMY

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