Episiotomy

Introduction to episiotomy

An episiotomy (also called as perineotomy) is a surgical procedure which incises the perineum (muscular space between the labia minora and the rectal wall) towards the rear end of the vagina.

Decades ago, episiotomy was considered to be a common practice which is done on women who will have their first natural delivery. Before, birthing facilities and medical hospitals provide a routine episiotomy policy due to the following medical views:

  • A medical incision heals faster compare to an involuntary vaginal tearing
  • Decreases the chances experiencing fetal birth trauma – like for instance, the newborn’s head is pushing against the posterior vaginal wall
  • Speeds up child labor
  • Prevents severe soft tissue tearing
  • Lower the instances of suffering from posterior perineal and/or neonatal trauma
  • Prevent postpartum pelvic floor dysfunction
  • Avoids the anal sphincter muscles from being damaged
  • Reduces blood loss during the course of delivery

Contrary to that, the cases of performing perineotomies continuously declined through the years when studies began to prove that episiotomy may bring future complications. By which the rate of this routine has plummeted for about 25% of all natural deliveries in 2004 to 11.6% in 2012.

However, this routine is still openly practiced in countries such as in the Latin part of America, Poland, Bulgaria, India, and Qatar.

Different types of episiotomy

Episiotomy is surgically incised in different ways and directions, enlisted are the following below:

Medio – lateral episiotomy

Pregnancy week by week

Medio – lateral is incised in a downward and outward movement from the center of the frenulum of labia minora (fourchette) either left or right. It is cut in a diagonal direction that is about an inch away from the rectal wall (between the anus and ischial tuberosity).

Median episiotomy

In median episiotomy, the incision begins in the center point of the frenulum of labia minora and expands on the rear end along the midline for about an inch.

Midline episiotomy

In midline episiotomy, incision is made on the center of the anus.

Oblique technique

Oblique technique is a surgical cut where the perineal area is avoided, incising only the vaginal skin, muscle, and its epithelium. This type of incising technique aims to avoid the mother from suffering posterior perineal trauma caused by the surgical procedure.

Lateral episiotomy

Later episiotomy begins from about 0.4 inch away from the midpoint of the frenulum of labia minora and expands from the name itself (lateral direction). This type of episiotomy is highly dissuaded to perform since it can damage the Bartholin’s duct.

J – Shaped episiotomy

The J – Shaped episiotomy starts in the center of the frenulum of labia minora towards the rear end along the midline for about 0.59 inch.

This type of surgical incision is not widely performed due to its atypical cut that goes downwards and outwards in a 5 – 7:00 position preventing the anal sphincter region.

When is episiotomy necessary to take?

Even though episiotomies are no longer encouraged to use for first vaginal birth nowadays, there are still some scenarios where this surgery is necessary to take such as the following enlisted below:

  • When the newborn’s size (particularly his head) is large and the vaginal opening is narrow
  • Shoulder dystocia – this scenario is when the newborn’s shoulders are stuck in the birth passage during the course of child labor
  • When the last minute monitoring of his heart rate detects fetal distress, episiotomy is necessary to have a safe delivery
  • When forceps (a medical device which ensembles like that of salad tongs) are required to use
  • Vacuum extraction (abbreviated as VE, also called as vacuum – assisted vaginal delivery or simply Ventouse) – is a medical procedure where a vacuum extractor is attached to the newborn’s head with suction to assist his way out
  • The unborn baby is in a breech presentation (fetus’ buttocks is burrowed down the pelvis)
  • The mother is having a hard time pushing her baby out
  • Childbirth is impending and the perineum has not been flexed yet

Performing an episiotomy

This surgical incision is carefully done by an obstetrician gynecologist and/or midwife during the second phase of child labor to expand the birth passage. Furthermore, below are the following step – by – step procedures on how to perform an episiotomy:

  1. Primarily, a midwife or obstetrician gynecologist will inject a local anesthesia called pudendal anesthesia (also known as pudendal and/or saddle block) before performing the episiotomy. In some cases, a local anesthesia or any pain relief medication is not needed when a mother – to – be is already anesthetized via an epidural; or when her perineum already feels numb and has thinned out from the baby’s crowning, especially when he descends quickly through the birth canal.
  2. Then the medical practitioner will use surgical scissors or a scalpel to make a small incision into the perineal skin right before childbirth (the practitioner may perform any of the aforementioned types of episiotomy cut).
  3. Once the newborn together with his (or her) placenta has been delivered, the practitioner will surgically suture (widely known as stitches) the incised area. The sutures will not be removed since these will dissolve for a few weeks after childbirth.
  4. The newborn mother will likely be injected with pudendal anesthesia again if epidural’s effect has faded.

Tips and preventive measures to reduce the risk of episiotomy

The mere thought of getting one’s perineum incised is frightening especially for first – time mothers. To lower the instances and reduce the risk of ending up in episiotomy, below are the following tips and preventive measures she must consider doing:

Proper nutrition

Having a proper nutrition during gestation keeps the skin healthy thus, making it stretchy.

Kegel exercise

Do some Kegel exercises at the course of gestation. This type of exercise strengthens the pelvic floor muscles.

Protracted second phase of labor

The second phase of labor must be protracted accompanied with controlled pushing. Push with a 5 – 7 second interval to prevent the perineum from suddenly tearing. In line with this, squat or stand and never lay using the back while in the course of pushing.

Warm compress

Place a warm compress on the perineum in the course of child labor. This then allows the skin around the perineum to become soft and stretchy.

Antenatal perineal massage

Do some antenatal perineal massage (also called as birth passage widening) for about 6 – 8 weeks before the estimated due date. This type of massage flexes the perineal and posterior vaginal wall and reduces the instances of using medical instruments.

Gentle counter pressure

Request the midwife or obstetrician to apply a gentle counter pressure to the perineum as the newborn’s head is crowning to avoid involuntary perineal tearing.

The aftermath of episiotomy

After the procedure, some newborn mothers experience a slight pain after a week while others endure the pain for a month or so (most especially if they have a third or fourth – degree incision).

From then and there, a newborn mother now has sutures in a very sensitive muscle. With that being said, a nurse will check her perineum for at least once a day to see any inflammation or if the wound is infected.

A woman must wait for at least 4 – 6 weeks (estimated recovery time for an incised posterior vaginal wall) before she resume on sexual intercourse. If she had a third or fourth – degree cut, a woman must be examined first before she resumes for sex.

Once a woman resumed sex after the surgical incision, expect to feel tenderness and tightness on the area. By the same token, here are the following sex positions she must consider to prevent the sutured area from another spontaneous tearing:

  • Woman on top (also known as cowgirl position)
  • Side – wind her sex position (simply side sex position)

Side effects of perineotomy and spontaneous perineal tearing

Women who end up having a perineotomy during the labor and delivery process are expected to experience the following side effects:

  • Primarily, first – time mothers who underwent episiotomy increases the chances of perineal tearing in the upcoming childbirth
  • Heightens the risk of vaginal infection
  • Bruises in the vaginal posterior
  • Swelling of the vaginal posterior
  • Genital bleeding
  • Longer surgical wound recovery
  • Severe pain during the healing process
  • Painful surgical scar
  • Weakens the pelvic floor muscles
  • Future complications with involuntary urination – bladder control problem
  • Second, third, and even fourth – degree laceration (serious tearing which stretches from the anal sphincter and passes through the rectal wall) which may lead to fecal incontinence – loss of bowel movement and gas control
  • Severe blood loss at the time of child labor
  • They tend to wait longer before they have sex without feeling pain

On the other hand, women who delivered without undergoing surgical incision are likely to experience the following aftermath:

  • Immediate healing process accompanied with less pain
  • Have fewer instances of experiencing urinary incontinence
  • Have lower chances of having second, third, and even fourth – degree laceration which can cause fecal incontinence

Treatment options for postpartum perineal pain

Either a newborn mother underwent episiotomy or delivered naturally, vaginal pain and tearing can still be experienced. With that being said, enlisted below are the following treatment options to ease perineal tearing after birth:

Gel ice pack

Place a gel ice pack on the perineum right after child labor for at least 12 hours to reduce pain, discomfort, and swelling. Aside from that, maxi – pads with built – in cool pads will do as well.

Medicated cooling pads

Place medicated cooling pads on the infected area to relieve burning and itching sensations.

Sitz bath

A Sitz bath (also called as a hip bath) is a type of bath which gently cleanses the perineum. It serves as a daily personal hygiene which alleviates pain, itchiness, and swelling in the perineal and genital area.

It comes with a portable mini tub that is placed over the toilet seat where the female genital up to the hips or buttocks (specifically the perineum) are soaked in warm water or saline solution.

Squirt bottle

After taking a bath, wash using a squirt bottle and pat dry instead of wiping the perineal area and genital tract.

Personal sex lubricant

If she opts to end abstinence and have sexual intercourse, apply a personal sex lubricant on the perineum to avoid infecting the surgical wound.