Written by : Dr.M.D.Mazumdar, MD
An episiotomy is a surgical incision to enlarge the vaginal opening at the time of childbirth. Also known as a perineotomy, this is a cut made on the perineum (the area between the vaginal opening and the anus) at the time of passage of the fetal head or breech.
In a normal childbirth, a number of tears occur along the vaginal edge as well as inside the vagina. These tears are usually irregular and may occur at any site in the perineum. A tear which is large enough may even tear the perineal body (the perineal body is a small fibromuscular structure in the perinuem connected to the muscles and ligaments of the pelvic floor. A tear in the perineal body can lead to weakenign of the pelvic floor.
It was earlier believed that a surgically made incision would cause better healing with less pain and bleeding.
However, there has been controversies about the importance of episiotomy with many authorities saying that healing, blood loss and pain is similar to that of a naturally occuring perineal tear. Nowadays, episiotomies are not routinely performed in all women in labour.
Types of Episiotomies: Episiotomies can be dividied into four main types, depending on their relation to the lowest part of the vaginal opening (the fourchette) and the anus:
a. Medio-lateral: This is the commonest type of episiotomy. The episiotomy begins at the fourchette and angles away at 45 degrees to one side of the midline of the perineum. The main advantage of this type is that an extension of the incision will not affect the anal sphincter. The disadvantages are that it cuts through muscles along the side of the vagina leading to increased blood loss, slow healing and risks of painful sexual intercourse later on.
b. Midline: In this type of episiotomy, the incision starts at the fourchette and goes down in the midline towards the anus. The main advantages are that it is less painful, there is less blood loss and sexual pain is lesser than the mediolateral episiotomy. The chief disadvantage is that, in case the incision gets extended during childbirth, there may be tearing of the anal sphincter with the risk of later fecal incontinence.
c. Lateral: The lateral episiotomy is an incision line from just above the fourchette extending laterally to the side. This type of episiotomy is not much practiced since it can damage structures like the Bartholin's glands
d. J-shaped: This incision starts at the fourchette and runs down along the midline for about 1-2 cms and then angles away to one side away from the anus. This is also a very uncommon type of episiotomy.
When is an Episiotomy needed:
- An episiotomy may be needed if the baby is very large and there are apprehensions that there may be a tear in the vaginal opening extending to the anus.
- If the baby needs to be born as early as possible due to irregular heartbeat or other signs of fetal diistress, an episiotomy may be done for a faster delivery.
- In a breech delivery, where the baby is born bottom first, a larger vaginal opening may be needed to avoid a large tear.
- If the mother has a medical condition like a heart disease in which it is necessary to decrease the duration of labour.
- An assisted delivery with forceps or vacuum is necessary.
- If the mother is exhausted and is unable to push while the baby is at the vaginal opening.
- Excessive bleeding, either at the time of delivery or while repairing the episiotomy wound.
- Formation of a haematoma or a blood clot in the cut tissues which may need a secondary repair.
- Pain, especially while sitting.
- Difficulty in passing urine or stool due to the pain
- Infection of the wound. S. aureua infection of the wound may occur in unhygienic conditions or due to lowered immune conditions of the mother. Necrotizing fasciitis is a rare but potentially fatal complication of episiotomy.
- Extended healing time from the childbirth.
- Fecal incontinence if the anal sphincter is affected.
- Pain during sex or dyspareunia. Scarring of the perineum during episiotomy are major risk-factors for long-term dyspareunia.
Can an Episiotomy be prevented?
- Massaging the perineum in the later weeks of pregnancy with a good quality lubricant or oil can help the perineum to be supple and stretch easily during childbirth. This can not only prevent tears, but also prevent the need for an episiotomy.
- Controlled delivery of the fetal head can prevent the need for an episiotomy. The fetal head should not be allowed to deliver quickly but slowly with each contraction, allowing good stretching of the perineum.
- A good nutrition during the pregnancy can result in a supple perineal skin and tissues which can then stretch more easily.
- Kegel's exercises can help strengthen the pelvic muscles. Strong pelvic muscles can result in more control during the second stage of childbirth and decrease the need for an episiotomy.
- Delivering in a propped up or sitting position decreases the need for a episiotomy. Delivering while lying down results in more episiotomies.
Procedure of performing an Episiotomy:
An episiotomy is a simple surgical procedure. If an epidural anesthesia has not been given earlier, a local anaesthesia will need to be injected into the skin of the perineum to numb the area. A medio-lateral episiotomy is usually preferred. The incision starts at the lower midpoint of the vaginal opening and in angled away at approximately 45 degrees to one side. After the baby is delivered, the episiotomy is repaired in layers using dissolvable sutures.
Recovering from an Episiotomy:
Recovering from an episiotomy may be quite painful in the first few days. The following few steps may help in decreasing the pain and help in early healing of the wound:
- Pain can be decreased by the use of painkillers like paracetamol. Ibuprofen is best avoided if the baby is born premature or is of low birth weight. Aspirin should also be avoided as it passes in the breastmilk. Diclofenac gel patches applied to the perineum can also ease the pain
- Apply an ice pack to the perineum from time to time. Ice should be wrapped in a cloth and not applied directly to the area.
- Use a doughnut cushion - meaning a cushion with a hole in the middle to sit on. This prevents direct pressure on the episiotomy wound.
- After passing urine or stool, pour warm water over the genital area - this will soothe and also help keep the area clean. Pat yourself dry, don't wipe. Using laxatives to make the stools soft in the first few days may help. This will also avoid pressure on the stitches.
- Sitting in a warm sitz bath also helps. Or you can sit in a large bowl of warm water to which an antiseptic solution like betadine solution has been added. This is not only soothing but also helps clean the wound.
- Avoid sex as long as you have pain. But when you do resume sexual intercourse, use a lubricant to decrease the pain.
- Pelvic floor exercises like Kegel's exercises help strengthen the pelvic muscles and improve blood supply to the area thus helping in the healing process.
- Look out for signs of infection like severe pain not relieved by painkillers, redness and swelling of the surrounding tissues, pus oozing from the cut region, bad smell from the area and fever an chills.
Episiotomy or a Perineal Tear: Which is preferable?
It was generaly believed that an episiotomy helped prevent extensive tears of the perieum during childbirth and that healing was better with a clean surgical incision.
But 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. The tear being a natural one, heals better with less pain. Also, the degree of tear will vary depending on the size of the baby as well as the suppleness of the perineum. There may not even be any tear at all or only a very minimal one even for a large baby. So, there is minimal perineal damage.
But, when a surgical incision is made, the length may be more than is required for the delivery of the baby. And since the connective tissue, muscles and skin are cut in an episiotomy, the strength of the perineum and pelvic floor may be permanently compromised.
With less and less medical personnel advocating episiotomies, the rates of episiotomies has reduced in recent years.