What Is An Episiotomy?
It is a surgical incision to open the perineum - the tissue between the anus and vagina. It is performed during the second stage of labor when the baby is being pushed through the vagina. The purpose of the procedure is to avoid tearing the delicate perineal tissue. Critics contend that episiotomies are performed too often in hospitals in the United States. In recent years however the practice has significantly declined, especially in leading teaching hospitals. One review found that 64 percent of vaginal deliveries had episiotomies in 1980. This figure shrunk to 39 percent in 1998 and today is only about 2 to 3 percent.
Why Is It Performed?
Originally an episiotomy was performed to prevent perineal tearing - it was thought an incision would heal faster than a natural tear. It was also thought it would help prevent the bladder and rectum protruding into the vagina after birth. However, it was eventually found that it did not prevent these problems, but rather caused more lacerations and complications. Recovery can be more uncomfortable than a natural tear and the incision can become infected. For many women episiotomies caused postpartum pain during sex for months after delivery as well as fecal incontinence.
When Is It Recommended?
An episiotomy may still be warranted, according to The American College of Obstetricians and Gynecologists if:
• Severe vaginal tearing is likely.
• The baby needs delivering quickly. This may be due to fetal distress for example, or because the umbilical cord prolapses into the vagina. Or it may be because the mother has a serious condition such as heart disease during pregnancy and a speedy delivery is recommended.
• The baby is in an abnormal position. For example, in a breech position (head first) and stretching the perineum. This increases the risk of bleeding in the baby's skull (intracranial hemorrhage).
• An episiotomy may be required for a forceps delivery but less likely if the Wrigley forceps is used. With the Kielland's forceps rotation, episiotomy is needed and quite a generous incision needs to be made. If a forceps delivery is necessary, which technique used is determined by hospital practice and type of delivery complication presented.
The baby is premature. Episiotomy is believed to reduce the risk of damage to the baby's skull (prevents the so-called 'champagne cork' effect).
How Is It Performed?
Firstly, you will need to have given consent before delivery for the procedure (should it be required). Consent at the time it is needed is not considered true and informed. An anesthesia in the form of a local injection or nerve block is administered if you have not already had a regional anesthesia (namely, an epidural injection) in the second stage of labor. A typical incision is made straight down (midline tear) and does not cut into the rectum tissue or the rectum itself. If a larger cut is necessary it will swing to one side to avoid the rectum (mediolateral episiotomy). After delivery the tear is stitched (sutured). Every effort will be made to avoid leaving unsutured spaces in which blood could collect and infections begin.
Degrees Of Episiotomies
The extent and severity of a surgical cut or natural vaginal tear is referred to in degrees. The degrees are:
First degree: A small, simple cut that only extends through the vaginal mucosa. It does not cut into the underlying tissue.
Second degree: The most common type of episiotomy. It cuts through the vaginal mucosa, into the submucosal tissue, but not the rectal sphincter muscle.
Third degree: In addition to those tissues cut in the 2nd degree, the anal sphincter muscle is also partly or completely cut.
Fourth degree: The severest type, this also involves cutting the lining of the rectum.
Recovering From Episiotomy
The stitches from the incision dissolve within about 5 days so you do not have to go back to hospital to have them removed. The typical healing time is 4 to 6 weeks depending on the size (degree) of the incision and the type of suture material used in closing the wound. The following tips will also help your recovery:
Pain: It is common to feel mild to moderate pain after the procedure for 2 to 3 weeks. You can use painkillers such as Tylenol if you are breastfeeding and ibuprofen is safe as long as your baby was not born prematurely (before 37 weeks). Aspirin should be avoided as it can be passed through breastmilk. If your tear is particularly painful, place an ice pack (or ice placed in a towel) on the wound. This acts as an effective pain-relief. Don't place the ice directly on the wound.
Bathing: Have a daily sitz bath. Only stay in the water for a few minutes, staying longer will cause the stitches to become soggy, increasing the risk of infection. Outside of bathing keep the wound as dry as possible. Pat dry after bathing and urinating.
Sitting: Sitting on a doughnut-shaped cushion or squeezing your buttocks together when sitting can take the pressure off the wound.
Healing: Lie on the bed without your clothes on for at least 10 minutes a day. Exposing your stitches to air can speed up the healing process.
Toilet: After going to the toilet, pour warm water over the vaginal area to rinse it. This will help prevent infection. Additionally, pouring warm water over the vagina while you pee can help reduce discomfort. Try squatting over the toilet rather than sitting to reduce the stinging sensation while urinating. If you are having a stool movement, place a clean cotton pad on the site of the stitches and gently press as you go. This can help reduce pain. After, wipe your bottom from front to back to help prevent bacteria infecting the cut.
Sexual Intercourse: 90 percent of women who have an episiotomy report that sex is painful for a while. Avoid resuming sexual activities until at least your 6 week postpartum checkup, unless your doctor says otherwise.
Pelvic Floor Exercises: Performing Kegels (pelvic floor exercises) can help speed up recovery.
See: How do you do pelvic floor exercises? and how many pelvic floor exercises should you do a day?
Can It Be Prevented?
A large-scale study in 2000 reported:
• Prenatal perineal massage in the weeks before labor reduces the likelihood not only of episiotomies, but also natural tears.
• Perineal massage by midwives during labor does not seem to be particularly effective.
• Midwives have a high rate of preserving perineums in home deliveries (but it needs to be remembered that high risk pregnancies, which are more likely candidates for episiotomy, are not candidates for home birth). Tears may be avoided if the midwife or birthing attendant gently controls the advancement of the baby's head - only allowing it to emerge between contractions and not during one.
How To Do A Perineal Massage
Studies show that performing a perineal massage on yourself once or twice a day for the last 4 to 6 weeks of your pregnancy will reduce your risk of both natural vaginal tears and the necessity for a surgical tear in childbirth. This massage uses both thumbs to stretch the perineal tissue. It doesn't hurt, is easy to perform and has no known risks.
1. Keep your finger nails short. Before starting, wash your hands. In a private space, relax with your knees bent. You may wish to place a pillow under your back for support.
2. Lubricate your fingers with almond or vitamin E oil, or even vegetable or olive oil that you cook with. You could also use K-Y jelly. Never use petroleum jelly (vaseline), baby oil or mineral oil.
3. Place both thumbs into the entrance of the vagina (about 3 cms in). Press down towards your anus and to the sides until you feel a slightly stretching burning sensation.
4. Hold the position for 1 to 2 minutes.
5. Next, with the thumbs slowly massage the lower half of the vagina using a U-shaped movement. Use the opportunity to practice your slow breathing techniques from birthing class. Massage slowly for 5 to 7 minutes.
6. After a week or two you should notice that the area has become stretchier and there is less burning. If your partner or husband is doing the exercise on you, he should use his index fingers and not his thumbs (but can follow the same instructions).
Perineal trauma, whether a surgical cut or a natural tear, is very painful. It may:
• Interfere with the establishment of breastfeeding and bonding.
• Increase the risk of postpartum depression.
• It is unusual however for post-operative pain to last longer than 3 weeks.
Other Possible Complications:
• Infection, although the risk is still quite low.
• Excessive raised or itchy scar tissue which needs to be surgically removed (Fentons procedure).
• Problems having bowel movements if anal tissues are cut (3rd and 4th degree).
I was given an episiotomy with my first daughter. I was really sore for the first 4 or 5 days and sat on plenty of padding. I had a jug with warm water and a few drops of tea tree oil by the toilet and passed it over my bits every time I urinated. I took Tylenol regularly. The stitches got tight very fast, but that meant it was healing. Within a few weeks the stitches dissolved and I was back to normal by week 6. With my second child I tore naturally and needed stitches. It required stitches and the same recovery procedure. No difference really. I think however that the episiotomy cut is cleaner and might do less damage than a natural tear.
I had an episiotomy with my first boy and tore with the next 2 - my babies are all big! The first was the worst pain but it was also my hardest delivery. I took Tylenol for the first few days in all cases and used a squirt bottle with warm water after using the bathroom. I was back to having sex in all cases by week 6.
It took me at least 3 months to recover from my episiotomy. I had a third degree tear and bad grazing as well.