Episiotomy 

Episiotomy is a surgical incision made in the perineum during childbirth. Despite being a longstanding practice in obstetrics, its routine use has been increasingly questioned. In the United States, the episiotomy rate has declined significantly. According to the American College of Obstetricians and Gynecologists (ACOG), the episiotomy rate decreased from 33.5% of vaginal deliveries in 2000 to 10.4% in 2018. This decline reflects a shift towards more selective use of episiotomy, with healthcare providers now reserving the procedure for situations where it is medically necessary. This change in practice aims to reduce unnecessary interventions and promote a more natural childbirth experience.

This informative blog will delve into episiotomy in a more detailed way to help you make informed decisions. 

What is Episiotomy?

An episiotomy is a surgical incision made in the perineum, the area between the vagina and anus, during childbirth. The incision is typically made during the second stage of labor, just before the baby's head is delivered, and is intended to widen the vaginal opening and facilitate a smoother delivery. 

What Are the Types of Episiotomy?

Here are the main types of episiotomy:

• Median Episiotomy: A vertical incision made directly downward from the back of the vagina. This type of episiotomy is less common due to the increased risk of complications.
• Mediolateral Episiotomy: An incision made at an angle, usually 45 degrees, from the back of the vagina. This type of episiotomy is more common and considered safer than median episiotomy.
• J-Shaped Episiotomy: A curved incision made from the back of the vagina, resembling the shape of the letter "J." This type of episiotomy is less common and usually performed in specific situations.
• Lateral Episiotomy: A horizontal incision made from the side of the vagina. This type of episiotomy is rarely performed due to the increased risk of complications.
• Selective Episiotomy: An episiotomy is performed only when medically necessary, such as when the baby is in distress, or the mother is experiencing severe perineal trauma.

When is Episiotomy Necessary?

Here are some scenarios where episiotomy may be necessary:

Fetal Distress

• Fetal heart rate abnormalities: If the baby's heart rate is abnormal or shows signs of distress, an episiotomy may be performed to expedite delivery.
• Umbilical cord prolapse: If the umbilical cord prolapses (falls out) before the baby, an episiotomy may be necessary to facilitate a rapid delivery.

Maternal Indications

• Severe perineal trauma: If the mother's perineum is severely torn or at risk of severe tearing, an episiotomy may be performed to prevent further damage.
• Prolonged second stage of labor: If the mother is experiencing a prolonged second stage of labor, an episiotomy may be necessary to assist with delivery.
• Instrumental delivery: If the mother requires an instrumental delivery (e.g., forceps or vacuum extraction), an episiotomy may be performed to facilitate the procedure.

Other Indications

• Multiple gestations: Women carrying multiple babies (e.g., twins) may require an episiotomy to ensure a safe and controlled delivery.
• Previous traumatic delivery: Women who have experienced a previous traumatic delivery may be candidates for an episiotomy to minimize the risk of further trauma.

How Do You Prepare Before Episiotomy?

Preparing before an episiotomy can help reduce anxiety, promote healing, and minimize complications. Here's a comprehensive checklist to help you prepare:

Physical Preparation

• Kegel exercises: Perform Kegel exercises to strengthen your pelvic floor muscles, which can help reduce the risk of severe perineal trauma.
• Perineal massage: Massage your perineum regularly to increase blood flow and reduce the risk of tearing.
• Maintain a healthy weight: Excess weight can increase the risk of complications during delivery.

Practical Preparation

• Pack a hospital bag: Prepare a hospital bag with essentials, such as comfortable clothing, toiletries, and insurance cards.
• Arrange for post-delivery support: Plan support after delivery, including help with household chores, childcare, and meal preparation.
• Plan for pain management: Discuss pain management options with your healthcare provider, including epidurals, breathing techniques, and natural methods.

Medical Preparation

• Attend prenatal appointments: Regular appointments will help your healthcare provider monitor your health and the baby's development.
• Discuss medical conditions: Inform your healthcare provider about any pre-existing medical conditions, allergies, or concerns.
• Review medication and supplements: Share your medication and supplement list with your healthcare provider to ensure safe use during delivery.

How is Episiotomy Performed?

Here's a detailed explanation of the episiotomy procedure:

Preparation

• Positioning: The woman is positioned in a lithotomy position, with her legs supported in stirrups. This position allows for easy access to the perineal area.
• Cleaning and draping: To minimize the risk of infection, the perineal area is cleaned with an antiseptic solution and draped with sterile sheets.
• Anesthesia: Local anesthesia, such as lidocaine or benzocaine, may be administered to numb the perineal area. This helps to reduce discomfort and pain during the procedure.

The Procedure

• Assessment: The healthcare provider assesses the perineum to determine the best location for the incision. They will look for any signs of tearing or trauma.
• Incision: A small, shallow incision is made in the perineum, usually with scissors or a scalpel. The incision is typically 1-2 cm long.
• Extension of the incision: If necessary, the incision may be extended to facilitate delivery. This is usually done if the baby is large or has complications during delivery.
• Delivery: The baby is delivered, and the episiotomy is allowed to bleed for a short period to help prevent hematoma formation.

Repair

• Repair: The episiotomy is repaired with sutures, usually in layers, to promote healing and minimize scarring.
• Layered closure: The repair is typically done in layers, with the first layer closing the vaginal mucosa, the second layer closing the perineal muscles, and the third layer closing the skin.
• Suture material: The type of suture material used may vary, but it is usually a dissolvable material that will absorb over time.

What to Expect After an Episiotomy?

Here's what to expect after an episiotomy:

Immediate Aftermath

• Pain and discomfort: You may experience pain, discomfort, and swelling in the perineal area.
• Bleeding: Some bleeding is normal, but heavy or clotting may require medical attention.
• Swelling and bruising: The perineal area may be swollen and bruised, but this should resolve within a few days.

Short-Term Recovery

• Pain management: Your healthcare provider may prescribe pain medication or recommend over-the-counter pain relievers.
• Wound care: To promote healing, keep the perineal area clean and dry. You may also be advised to use warm compresses or sitz baths to reduce discomfort.
• Stitches or sutures: If you have stitches or sutures, they will typically dissolve within 1-2 weeks.

Long-Term Recovery

• Healing time: The perineal area may take 2-6 weeks to fully heal.
• Scarring: You may experience some scarring, but this should fade over time.
• Sexual activity: You may need to avoid sexual activity for 4-6 weeks to allow the area to heal.

Follow-Up Care

• Postpartum check-ups: Schedule follow-up appointments with your healthcare provider to monitor the healing process.
• Pelvic floor physical therapy: You may be referred to a pelvic floor physical therapist to help heal and regain strength in the pelvic floor muscles.

By understanding the reasons for episiotomy, the procedure itself, and the potential outcomes, women can make informed decisions about their care during childbirth and take steps to promote healing and recovery after the procedure.