Overview of Episiotomy
An episiotomy is a surgical cut made at the end of childbirth, during the second stage of labor, to create more space through the vaginal opening, which aids in the delivery of a baby. Its main purpose is to reduce the pressure on the perineum, the area between the vagina and the anus, and to prevent uncontrolled tearing during childbirth. In essence, it’s often easier to mend a clean-cut incision than a jagged, natural tear.
The basic types of episiotomy are the midline (or median) and the mediolateral. The midline episiotomy starts at the center of the perineum and goes straight down, while the mediolateral type also starts at the center but veers off to the side at a 60-degree angle. Other less commonly used ones involve different cut shapes and directions such as J-shaped, lateral (sideways), anterior (frontward), or radical (extensive).
After the baby is delivered, it’s crucial for doctors to conduct a detailed check of the perineal area and the rectum to identify any injuries that might have occurred during childbirth. For many years, episiotomies were a standard practice in the US. In 2006, the American College of Obstetricians and Gynecologists recommended that they should not be carried out routinely, as once thought. Today, the decision to perform an episiotomy is based on specific medical factors and the judgment of the healthcare professional, as well as the conditions of the mother or baby.
It’s important to note that episiotomies, especially the midline type, are associated with a greater risk of injury to the anal sphincter muscles, which help to control bowel movements. For more information on tears and injuries during childbirth, see the StatPearls guide on “Obstetric Perineal Lacerations”.
Anatomy and Physiology of Episiotomy
The outer parts of a woman’s reproductive system include the mons pubis (a mound of fat tissue covering the pubic area), labia minora and majora (inner and outer folds of skin at the opening of the vagina), clitoris, perineal body, and vaginal vestibule. The perineal body is the area between the buttocks and the vaginal fold. The perineum is the area found inside the lower part of the pelvis. This area is surrounded by bones in your pelvis and includes muscles that are often injured during childbirth.
Cuts or tears in the vaginal area or vulva are usually not deep and often don’t need treatment. However, if there is a cut made during childbirth to widen the birth path (called an episiotomy) or any resulting perineal tears, they might involve multiple parts of the body and are grouped based on the severity of the injury. Unlike vulvar and vaginal tears, perineal tears are ranked according to their severity.
Tears or injuries are generally grouped into four main categories:
- First Degree: a shallow injury to the inner lining of the vagina that may also affect the skin around the perineum.
- Second Degree: This is similar to a first-degree injury, but also affects the perineal body.
- Third Degree: This injury affects both the vaginal lining and the perineal body, and also involves the muscles that control the anus, and can be divided into three more categories based on the extent:
- A: Less than half the muscle that controls the anus is involved.
- B: More than half the muscle that controls the anus is involved.
- C: Both the internal and external muscles that control the anus are torn.
- Fourth Degree: These injuries involve the tearing of the muscles that control the anus and also the inner lining of the rectum.
Severe injuries to the perineum, including third- and fourth-degree injuries, are often referred to as OASIS injuries.
Why do People Need Episiotomy
Episiotomy, a surgical cut made during childbirth to ease delivery and prevent tearing, is no longer routinely recommended. This change in policy is due to the potential unwanted side effects like pain in the area between the vagina and anus (perineal pain), discomfort or pain during sex (dyspareunia), and problems with sexual function.
Previously, episiotomies might have been used when a delivery needed to be sped up due to concerns like the baby being in distress, the shoulder getting stuck during delivery (shoulder dystocia), or a delivery needing instruments like forceps or a vacuum. However, there isn’t strong proof to show that episiotomies are beneficial in these cases.
Studies focusing on the lasting effects of episiotomies have found no significant differences between women who had natural tears and women who had episiotomies when it comes to urinary problems, inability to control bowel movements (anal incontinence), or discomfort during sex. That said, these findings are not conclusive due to limited evidence, and more substantial research is needed.
As of now, the American College of Obstetricians and Gynecologists (ACOG) says that there are no clear cases where episiotomy is definitely needed. Instead, a selective approach is recommended where episiotomies are considered only in certain situations, like when there are concerns about the baby’s heartbeat or when an instrument-assisted delivery is needed. In these situations, studies have shown that a certain type of episiotomy (mediolateral) remarkably reduces the risk of severe tears in the area between the vagina and anus (obstetric anal sphincter injuries).
When a Person Should Avoid Episiotomy
Episiotomy, which is a surgical cut made at the opening of the vagina during childbirth to help a difficult delivery, isn’t usually recommended for all childbirths. Both the World Health Organization and the American College of Obstetricians and Gynecologists (ACOG) suggest its limited use..
In the past, people believed that doing an episiotomy in every birth could prevent severe tears. However, not all women experience significant tearing during normal vaginal birth. So, the use of this procedure in every case can expose women to needless surgery and the potential complications that come with it.
Even when childbirth is complex, like when the baby’s shoulder is stuck (shoulder dystocia) or when special tools are needed to help the baby out (instrumental-assisted deliveries), episiotomy isn’t always beneficial. In fact, severe vaginal tears may still take place even when an episiotomy is performed.
Therefore, experts recommend using episiotomy only when needed due to certain medical reasons, rather than making it a consistent practice in all childbirths.
Equipment used for Episiotomy
When a doctor needs to do an episiotomy, which is a surgical cut in the area between the vagina and anus (perineum) during childbirth, and fix it after, they will need certain tools and preparations:
* They’ll need special surgical scissors, which could be straight or angled, to make the episiotomy.
* Good lighting and clear viewing of the tissue are very important. This allows the doctor to thoroughly check and fix the region.
* Depending on the severity of the tissue tears, different types of anesthesia will be needed. If it’s a first or second-degree tear (a tear in the skin and muscle), the doctor will generally inject a local painkiller into the area. For more severe injuries that involve the muscles controlling bowel movements, stronger anesthesia that affects a larger part of the body or puts you to sleep may be needed.
* They’ll clean the perineum area with a disinfectant, like Betadine or chlorhexidine solution, before starting and also after the repair.
The tools and supplies the doctor uses are:
* Surgical glue
* Stitches (sutures)
* Tools to handle the needle and sutures (needle drivers)
* Clamps to hold the tissue (Allis clamps)
* Tweezers-like tools (forceps)
* Sterile gloves
* Sponges
* Scissors for the sutures
* A thin, flexible tube to drain or insert fluid (Foley catheter) for severe (third- and fourth-degree) cuts
The sutures they use will depend on the degree of the cut. They could use different types of sutures like polyglactin or poliglecaprone.
They often prefer to use so-called monofilament sutures which are less likely to cause infections.
If the tear is very severe, they may have to take you to an operating room.
Who is needed to perform Episiotomy?
An episiotomy is a surgical cut made at the opening of the vagina during childbirth to aid a difficult delivery and prevent rupture of tissues. During this procedure, you will interact with various medical professionals. These include Obstetricians and Family Practitioners, who are doctors specialized in pregnancy, childbirth, and postpartum care – the period after the baby’s birth.
The Midwives are professionals trained to help women during childbirth. They can assist in delivering the baby and provide support and care during and after birth.
You’ll also meet Labor and Delivery nurses, who help throughout the childbirth and provide care for you and your newborn baby. An anesthesiologist is the doctor who administers medicine to manage your pain during and after the procedure.
All of these people work together to ensure you and your baby get the safest and best care possible during your child’s birth.
Preparing for Episiotomy
There are essential steps that need to be taken to make sure you’re safe and comfortable before having an episiotomy (a surgical cut made at the opening of the vagina during childbirth to aid a difficult delivery) and its repair. Firstly, it’s important to have good lighting in the room. Before the process begins, all the tools like surgical instruments, sponges, and stitches are counted and properly arranged. Also, your vaginal area might be cleaned with a special solution, povidone-iodine or chlorhexidine, to help prevent infections after the procedure.
Healthcare professionals are responsible for explaining why an episiotomy is needed and making sure that you give your consent to have the procedure and its repair. During delivery, as you push, the healthcare team will check the perineum (the area between the vagina and anus). This check will help them decide on the best technique to use for the episiotomy. It’s essential to also make sure you’re not feeling any pain during the procedure. If more pain relief is needed, a local anesthetic, which is a medicine that numbs a small part of your body, can be used on the area where the episiotomy will be performed.
How is Episiotomy performed
An episiotomy is a surgical cut made in the area between the vagina and anus (known as the perineum) to help make the birth of your baby easier. It’s performed as you are pushing during labor with either scissors or a scalpel. There are various types of episiotomies, but the two most common forms are the midline and mediolateral cuts.
The method involves making the cut as your baby’s head is crowning (appearing) when the muscles of the perineum are stretched thin. The doctor supports the perineum and uses scissors to make a quick, deep cut during a contraction. It’s important that you are numb (anesthetized) to ensure you don’t feel any pain during the procedure. The timing and technique used are important to reduce the risk of complications such as pain, infection, blood clots (hematoma), and scarring, which may contribute to long-term issues like painful intercourse.
Different initiatives, such as the OASI Care Bundle in the United Kingdom, have been developed to reduce incidents of severe tears during childbirth via episiotomies. Furthermore, tools like the EPISCISSORS-60 have been created to help maintain the optimal 60-degree incision angle, reducing the risk of serious tears. These methods have been shown to decrease incidents of serious tears and improve the overall experience for clinicians and patients.
Each type of episiotomy is designed with the safety of the mother and child in mind while also trying to minimize complications. These include the midline (or median) episiotomy, which is the most preferred in the U.S., the modified-median, J-shaped, mediolateral, lateral, radical lateral and anterior episiotomies. Each type refers to the specific direction and angle of the cut made to achieve certain goals during childbirth.
After every vaginal delivery, the perineum, vagina, and cervix are carefully examined. In cases of severe tearing, a physical exam of the rectum is also performed to check the strength and integrity of the anal sphincter. Proper closure of all the layers involved in the tear or cut, including the vaginal lining, muscles, and skin, is crucial for successful healing and minimizing complications.
For average perineal tears, stitching up the wound in a continuous or running pattern is preferred over interrupted stitches to reduce postpartum pain and decrease the chances of needing to remove the stitches. Once all three layers are properly stitched, the doctor will finish by stitching up the skin. Before and after the repair, it’s important to conduct a physical exam of the rectum to ensure that the wound has been properly repaired and that there are no misplaced stitches.
If the episiotomy extends into a more severe tear, the appropriate repair should be performed. Additional steps such as placing a Foley catheter (a small tube to drain urine from the bladder) before the repair and giving antibiotics to reduce infection risk may be required. After the surgery, it’s important to count surgical tools, sponges, and stitches to ensure nothing has been left behind inside the body.
Possible Complications of Episiotomy
An episiotomy is a surgical cut made in the area between the vagina and anus (perineum) to create more space for a baby to be born. While this procedure can make the birthing process easier, it can carry potential risks and complications such as pain in the perineal area, discomfort during sex and issues with sexual function. Other concerns can be serious, ranging from bleeding and infection, to extended rips into the muscle controlling the anus (anal sphincter), scarring, and even severe problems like the vagina slipping downward towards or into the vaginal opening (vaginal prolapse) or abnormal connections between parts of the body that usually don’t connect(fistulas).
In some cases, despite having an episiotomy, severe tears can happen in the perineum. This makes some question whether episiotomies really help prevent trauma. Additionally, episiotomies can cause problems during future deliveries.
People who smoke, are overweight, have severe lacerations, require assisted vaginal deliveries or need antibiotics after giving birth are more likely to develop complications. If a woman is more likely to experience harm related to damage in the perineum or disorders involving the muscles that support the bladder, uterus, and rectum (pelvic floor disorders), they would benefit from follow-up care in a specialized clinic.
If there is any sign of the anal sphincter not functioning properly after birth, a special kind of ultrasound should be carried out to assess the degree of damage. If considerable damage or persistent symptoms are found, a corrective surgery for the anal sphincter might be needed.
What Else Should I Know About Episiotomy?
An episiotomy is a surgical cut made at the opening of the vagina during childbirth to enlarge the birth canal and assist in delivery. However, its routine use has been a topic of debate. Studies have shown that it may not necessarily improve problems of the pelvic floor or provide better long-term results. In fact, an episiotomy can sometimes increase the risk of conditions like anal incontinence (inability to control bowel movements) and other complications.
If the cut expands into an injury called an “OASIS” (obstetric anal sphincter injuries), the complications can be particularly severe. Episiotomy should ideally be used selectively during vaginal births because this approach is associated with lower chances of perineal trauma (damage to the area between the vagina and anus), less need for stitches, and fewer problems during the healing process.
It is extremely important for healthcare professionals to thoroughly understand when, how, and why to perform this procedure to ensure the best possible outcome for the patient. Preventive steps, such as perineal massage during the late stages of pregnancy and providing support to the perineal area during labor, can also be adopted as these measures can help reduce the need for an episiotomy.