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Episiotomy

Reviewed by
Dr. Milroy J Samuel

Episiotomy (pronounced, uh-peez-ee-OT-oh-mee) is a procedure in which an incision is made in the vaginal wall and perineum (the space between the anus and the vaginal opening). This is done to widen the vaginal opening in order to try to prevent injury to the vagina and perineum, and to make a difficult childbirth easier. While episiotomy is still performed, it is no longer routine, and there are concerns that it can sometimes cause more harm than it prevents.

Reasons for Episiotomy

The vagina is remarkably elastic, and in most cases it stretches enough to accommodate the baby that must pass through it. This stretching can be extremely painful, but it generally does no permanent harm. The doctor uses his or her hands—and in some cases forceps and/or suction—to guide the baby through the birthing process, but the mother does most of the work herself, and the process follows a natural course laid out millions of years before the medical profession existed.

In some cases, however, the vagina cannot stretch enough, and there is a danger that the passage of the infant through the vaginal opening can tear the vaginal tissue, possibly even rupturing the wall that separates the vagina from the rectum. In these instances, an episiotomy is necessary to enlarge the opening prior to the delivery.

Some of the reasons an episiotomy may be called for include:

  • Unusually large baby
  • Baby develops shoulder dystocia (the head has been delivered but the shoulders and the rest of the body remain trapped)
  • Fetal distress that may require doctors to shorten the “pushing” stage of labor
  • Evidence of spontaneous vaginal tearing that occurs during the pushing stage
  • Other unexpected emergency situations

Two Types of Episiotomy

There are actually four types of episiotomy, but only two are commonly done. The difference lies in the placement and direction of the cut.

In a midline or median episiotomy, the incision begins at the vaginal opening and runs straight down, toward the anus. This type of incision heals better than others, but there is a risk that the incision may tear when the baby comes through, and that the tear may extend to the rectum.

There is more than one way to perform a standard midline episiotomy. Some doctors direct the incision more inside the vagina in an upward direction and less in the downward or peri-anal direction. This allows more room for the baby’s head with less chance of extension into the rectum or anus.

A mediolateral episiotomy is made at a 45-degree angle to the midline (to help yourself picture the difference, imagine a midline  incision at six o’ clock, and a mediolateral incision at four or eight o’ clock). The risk of tearing is smaller with this type of incision, but there may be greater blood loss, and in the long term these types of episiotomies are associated with longer healing times and a higher incidence of persistent pain compared to a midline episiotomy.

There are also lateral or J-shaped episiotomies, which involve, respectively, incisions that run at a 90-degree angle to the median line, or that run down the line but deviate away from the anus at a five- or seven o’ clock angle.  These operations are not widely performed, however, and the lateral episiotomy in particular carries additional injury risks that have led some doctors to condemn it as unsafe.

What to Expect During and After an Episiotomy

Before childbirth begins, you may be asked to sign a consent form indicating that you have authorized your medical team to perform an episiotomy if it should become necessary. Once childbirth is underway, if you are not given general anesthesia, a local anesthetic may be administered via injection into the perineum. After the second stage of labor begins—the pushing stage—the incision is usually made just when the baby’s head is crowning—i.e., close to delivery. This helps minimize blood loss by timing the episiotomy to as close to the birth as possible. If a midline episiotomy is performed, the baby is often born in the next few minutes

After the baby has been born, the doctor will examine the vulva, vagina, and perineum to determine whether any additional tearing has occurred. The incision, and any tears if present, will then be closed with dissolvable sutures. This normally takes place right after the placenta has delivered.

After childbirth is completed, the healing process begins. The nurse generally places an ice pack and a large, soft absorbable pad against the perineum. Your doctor will prescribe whatever pain medication is deemed appropriate (this may include an oral medication, as well as an anesthetic spray to be applied directly to the perineum), and you will be instructed to refrain from using tampons or having sex until your doctor says it is safe to resume these activities. You may experience some pain during bowel movements, in which case a stool softener will be prescribed. If you experience pain while urinating, use a plastic cup to pour warm water on yourself while you’re going.

Be sure to notify your doctor immediately if you experience any of the following while you are healing:

  • Severe pain in your perineal area
  • Fresh, red bleeding at the site of the episiotomy
  • Foul smelling vaginal discharge
  • Fever or chills (these, like discharge, may be signs of infection)

Risks of Episiotomy

While episiotomy is still performed when necessary, it has fallen into some degree of disfavor in the medical community. The American College of Obstetricians and Gynecologists and Britain’s Royal College of Obstetricians and Gynaecologists agree that episiotomy should not be routine, but should be reserved for the kinds of medically urgent circumstances described above. Many doctors now believe that episiotomy can sometimes cause the very conditions it is meant to prevent. An episiotomy incision does not necessarily heal faster or better than a natural tear, and may even take longer to heal because of the depth of the incision. Risks of this procedure include:

  • Pain in the perineum during and following childbirth
  • Bleeding
  • Infection
  • Damage to the vagina resulting in subsequent pain and sexual dysfunction

Risks of Not Having an Episiotomy

Allowing natural tearing to occur is not risk-free. Sometimes when a birth occurs without an episiotomy there are significant vaginal lacerations. These can occur near the urethra, the clitoris, or the labia minora (inner lips) of the vagina. Sometimes the repair of spontaneous vaginal lacerations is more difficult, and takes longer than the repair of a standard episiotomy.

To Avoid an Episiotomy

Your doctor or labor nurse may massage the perineum and apply warm compresses to it during the birth in order to soften the tissue and make it more elastic. Mineral oil is liberally used as well to help reduce friction in the area while pushing.

Talking to Your Doctor

Here are some questions to ask your doctor about episiotomy:

  • Do you think it is likely that I will need an episiotomy?
  • What are the alternatives?
  • If I do need to have an episiotomy, will it be painful? If so, how long will the pain be expected to last?
  • How long will it be before I can resume having sex?
  • How soon will I be able to resume using tampons?
  • Would a C-section delivery be a viable alternative to episiotomy?

Medical References:

    http://www.womenshealth.gov/pregnancy/childbirth-beyond/labor-birth.htmlD. C. Dutta, Textbook of Obstetrics, 7th edition, 2011.Planned Parenthood http://www.plannedparenthood.org/health-topics/glossary-4338.htm?__utma=1.1540100363.1395793202.1397863699.1399490879.9&__utmb=1.6.10.1399490879&__utmc=1&__utmx=-&__utmz=1.1399490879.9.6.utmcsr=google|utmccn=%28organic%29|utmcmd=organic|utmctr=%28not%20provided%29&__utmv=-&__utmk=55220523#eJohn Hopkins http://www.hopkinsmedicine.org/healthlibrary/test_procedures/gynecology/episiotomy_92,P07775/The Mayo Clinic http://www.mayoclinic.org/healthy-living/labor-and-delivery/in-depth/episiotomy/art-20047282?pg=2The National Institutes of Health/Medicine Plus http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000482.htmThe Royal College of Obstetricians and Gynaecologists http://www.rcog.org.uk/womens-health/clinical-guidance/incontinence-women-study-group-statement http://www.rcog.org.uk/womens-health/clinical-guidance/management-early-breakdown-episiotomy-or-tear-repairs-query-bank http://www.rcog.org.uk/womens-health/clinical-guidance/episiotomy http://www.rcog.org.uk/womens-health/clinical-guidance/maternal-morbidity-and-mortality-study-group-statement
[Page updated June 2017]