Few women delivering in hospitals today escape a ‘cut’ somewhere on their body – be it a caesarean cut or a perineal cut (episiotomy). And today, 80% of first-time mothers can expect to have an episiotomy. So what exactly does it entail?
What is an episiotomy?
An episiotomy is a surgical cut made into the perineum(area between the vagina and anus) to enlarge the opening before the birth of the baby’s head. It helps to ease the birth of the baby when the mother is having difficulty getting her baby out.
Although episiotomy is one of the most common surgical procedures carried out on women, the medical value of episiotomy is still open to debate.
History of episiotomy
Episiotomies in Europe
Episiotomies were first developed in Europe in the 18th century. An Irish doctor discussed the advantages of episiotomy in 1742 for women experiencing difficult births. Once local analgesia and suturing material became available, episiotomies became very popular in Europe.
Episiotomies in the United States of America
Episiotomy was introduced to the United States of America in 1851. In the 1920’s Dr Delee was the first person to advocate the practice of routine episiotomy with forceps delivery. Episiotomy then became a widespread practice throughout the world, with some authorities even advocating the use of routine (you get it even if you don’t need it) episiotomy for all first-time mothers. There are some obstetricians who still continue to hold this opinion today.
Recent studies show that episiotomies are often performed unnecessarily
As women become more informed about labour and birth and are more involved in the decisions regarding their care, the necessity for routine episiotomy is being questioned.
Recent studies show that episiotomies are often performed unnecessarily and therefore the indications for doing them are being reviewed. Studies show that routine episiotomy is not required for most births. There is also controversy over whether an episiotomy is preferable to a tear.
When is it necessary?
Many experts agree that the following are valid reasons for giving a woman an episiotomy. If the baby:
- Is in the breech position (bottom first instead of the usual head first position) and is born vaginally,
- Is premature and cannot tolerate prolonged pushing against a perineum,
- Is in distress and needs to be born quickly (an episiotomy can reduce the length of the second stage of labour by 5 to 15 minutes),
- Is very large (this is assessed by scan),
- Needs easing out by forceps (forceps are large curved tongs inserted into the vagina to assist delivery).
When is it not necessary?
Debatable reasons for doing an episiotomy are when the doctor or midwife feels that the perineum (the skin and tissues between the vagina and anus) is likely to tear as the baby’s head is born.
Studies have shown that when a tear occurs, it may be less painful and heal faster than an episiotomy, and not the other way around. Women with tears have also been found to resume sex sooner and with less pain than women who’ve had an episiotomy.
Episiotomies were thought to prevent some degree of relaxation or damage to the pelvic floor
Episiotomies were also thought to prevent some degree of relaxation or damage to the pelvic floor, with a further possible complication of a cystocele (a fistula or opening between the vagina and the urethra – causing incontinence), a rectocele (opening between the vagina and the rectum) and the possible prolapse of the uterus. Recent studies on pelvic floor relaxation show no correlation between poor perineal function and the presence or absence of episiotomy.
Exercise could help strengthen the pelvic floor after childbirth
One British study strongly suggested that exercise, not episiotomy, is the most common factor in restoring a woman’s normal pelvic floor strength after childbirth.
Some think that an episiotomy should only be used to relieve foetal or maternal distress
Numerous studies by Sleep, Roberts and Chalmers (1990) state that “the most common cause of perineal damage is episiotomy and episiotomy should only be used to relieve foetal or maternal distress, or to achieve adequate progress when it is the perineum that is responsible for the lack of progress”.
Ways to reduce the need for an episiotomy
During the birth of a baby, in which the mother is encouraged to ease the baby’s head out slowly, using a position which is aided by gravity, and the perineum is supported, it is possible to minimise tearing or the need for episiotomy and thus preserve the integrity of the pelvic floor.
Easing the baby's head out during the birth
Some doctors and midwives try to prevent the need for an episiotomy by easing the baby’s head out during the birth. Some women have tissues that naturally stretch more easily and are more likely to give birth without a tear or an episiotomy.
Give birth in a more upright position
Avoiding sustained pushing and giving birth on your back by being in a more upright position (for example, being raised on pillows into a semi-reclining position is much better than lying almost flat) allows gravity to help you give birth and helps the opening of the vagina to stretch more evenly.
Massaging the perineum
Massaging the perineum with natural oil (grape seed) for 6 weeks before your due date can improve the pliability of the skin and underlying tissues. This massage also helps women become familiar with their anatomy and accustomed to stretching sensations, which are common during the birth.
A warm, moist pad placed against the perineum
A warm, moist padplaced against the perineum during pushing increases the circulation to this area and provides support and comfort whilst these tissues stretch during birth.
Try avoid pushing using sustained breath holding
Try to avoid pushing using sustained breath holding, rather use gentler expulsive, spontaneous pushing, without excessive straining, to ease the baby down through the birth canal and out. By preventing excessive straining during pushing you can reduce the over stretching of the pelvic floor, as well as push your baby out more effectively.
Go to page 2 for information about how an episiotomy is performed
How an episiotomy is performed
How the cut is made
If an episiotomy is needed, the cut is made with scissors, from the vaginal opening into the perineum. This is done once the top of the baby’s head can be seen at the vaginal opening (this is called crowning of the head, and usually means that the birth is imminent).
If there is time, an injection of local anaesthetic is given into the perineum so that this area is numb when the cut is made. The cut can be made either laterally or medio-laterally – towards the side, or down the midline towards the anus.
The type of cut
While women experience less pain after birth from a midline episiotomy compared to a mediolateral episiotomy, there is a greater chance of the midline episiotomy extending into a third-degree tear (a tear that extends into the rectal tissue).
Sewing the wound
Once the baby is born the doctor or midwife sews (sutures) the cut back together again. Dissolving stitches may be used which disappear within 2 weeks.
Do epidurals increase the need for episiotomy?
With a fully effective epidural, theneed for an episiotomy is very likely
With a fully effective epidural, the pelvic floor may be very relaxed and the baby’s head may not completely turn into the birthing position. Sometimes the mother is unable to push effectively to help the baby be born.
When this happens the doctor needs to use forceps to help the baby out. An episiotomy is done to make enough room to put the forceps in position. The likelihood of this happening is reduced in women who have a partial epidural during labour.
Recovering after an episiotomy or tear
Cleanliness and pain relief are the 2 most important issues in the care if the perineal area following birth and once you are back at home. Taking good care of your perineum can prevent infection and discomfort, as well as speed up the healing process.
Cleanliness is critical, so each time you use the toilet:
- Wash hands before and after use and before changing pads.
- Wipe and clean from front to back.
- Cleanse the area with warm soapy water. Use a plastic squeeze bottle to squeeze warm water over the area. Spray this onto your perineum every time you use the toilet, as this will give added protection against infection as it has tremendous cleansing and disinfecting properties.
- Pat dry from front to back.
- Use a clean pad at least every 4 to 6 hours
- Assess the amount and colour of lochia (post partum vaginal discharge) with each pad change.
Relieving pain and discomfort
Try the following:
Apply hot or cold packs
Apply hot or cold packs alternately to decrease swelling and increase circulation. A slush pack gives tremendous relief.
To make a slush pack, just put ice (preferably crushed) and a little water in a bag (a surgical glove works well – its size makes it easier to fit the body) then add several drops of rubbing alcohol. You may want to freeze the glove over a bowl to make it easier to apply to the perineum.
Take a sitz bath
Take a sitz bath (a shallow bath of about 10 centimetres of water) twice a day. Coarse salt mixed with aromatherapy oils dissolved in the bath will speed up healing.
Use direct dry heat
Direct dry heatfrom a heat lamp onto the perineal area for about 15 minutes twice a day. Beware of burning and do not leave on for longer than 15 minutes.
Over-the-counter pain-relieving medication
Use over-the-counter pain-relieving medication or take what your doctor ordered before you left the hospital.
Pelvic floor exercises
Start up with your pelvic floor exercises once again. This will help regain the tone and strength of the pelvic floor and will speed up healing time.
Keep well hydrated
Keep well hydrated (sip 6 to 8 glasses of water a day) and drink fruit juice and eat fresh fruits and vegetables to prevent straining the peri-area due to constipation.
Perineal and vaginal muscle control
The value of perineal and vaginal muscle control after delivery with or without an episiotomy needs to be strongly encouraged by the midwife or doctor to assist mothers to attain good physical and sexual recovery after birth.