Episiotomy: The cruellest cut in pregnancy?

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A cut into the perineum to enlarge the opening of the vagina to help ease the birth.
A cut into the perineum to enlarge the opening of the vagina to help ease the birth.

Although episiotomy is one of the most common surgical procedures carried out, its medical value is open to debate.

There’s also debate over whether an episiotomy is preferable to a natural tear during labour.

An Irish doctor first discussed the advantages of episiotomy in 1742 for difficult births. Once local analgesia and suturing material were available, episiotomy became popular.

History of Episiotomy 

In the 1920s, Dr Delee first advocated the practice of routine episiotomy with forceps delivery.

Episiotomy then became popular worldwide, with some authorities advocating routine episiotomies for all first-time mothers.

Some obstetricians still hold this opinion!

Even though studies show that routine episiotomy isn’t required for most births.

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.

When to have one

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 (most breech babies will be delivered via Caesarean)
  • Is premature and can’t 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) or needs easing out by forceps, due to difficulty pushing or maternal exhaustion.

When not to have one

A 2017 literature review in the British medical research NGO Cochrane found no indications for doing routine episiotomies.

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.

There is the belief that a surgical cut is easier to repair, causes less pain and heals faster than a naturally occurring tear.

A study done in 1987 by Dr Nancy Fleming concluded that "the naturally occurring laceration (tear) appears to be at least as good as an episiotomy statistically and better than one clinically when compared in the areas of sexual function, perineal pain, time of healing and change in perineal muscle function".

This means that medical 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 after birth and with less pain than women who’ve had an episiotomy.

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 prolapse of the bladder wall through the vagina, which can cause 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.

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.

A 1990 study by Sleep, Roberts and Chalmers states 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".

How is it done?

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’s 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 mediolaterally (towards the side) or down the midline (towards the anus).

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 (this is a tear which extends into the rectal tissue).

Once the baby is born the doctor or midwife sews (sutures) the skin back together again. Dissolving stitches are usually used which disappear within two weeks.

Recovery

In any vaginal birth, but especially with an episiotomy, the perineum can be painful afterwards.

How to relieve the discomfort:

An ice pack or cooling gel pad frequently placed on the perineum in the first 24 hours following birth significantly reduces the swelling and bruising.

After that, warmth either from a hot lamp placed near the perineum or from sitting in warm water is very soothing.

It’s important to keep this area as clean and as dry as possible while it is healing.

If you notice any bleeding or pus (which is a sign of infection) oozing from the site of the episiotomy or tear, or if the swelling worsens significantly, you must call your doctor or midwife.

If you still feel pain with sex some months after the birth, or if you experience urinary incontinence, you should see your doctor or midwife.

Whether you have had an episiotomy or a tear, or given birth without any perineal trauma, Kegel exercises will help you regain the support and tone of your pelvic floor.

Steps to avoid it:

Some women have tissues that naturally stretch more easily and are more likely to give birth without tearing or an episiotomy.

During a birth 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 an episiotomy.

Avoid sustained pushing and avoid giving birth on your back. Try a more upright position (being raised on pillows into a semi-reclining position is much better than lying almost flat) and let gravity help you to stretch the vagina open more evenly and slowly.

Massaging the perineum with a natural oil for six 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 birth.

A warm, moist pad placed against the perineum during pushing increases the circulation to this area and provides support and comfort while the tissues stretch during birth.

Try to avoid pushing using sustained breath-holding. Rather use gentler, spontaneous pushing, without excessive straining, to ease the baby down through the birth canal. By preventing excessive straining during pushing you can reduce the overstretching of the pelvic floor and push your baby out more effectively.

Epidurals often increase the need for an episiotomy. In a full 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.

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.

Find out more about the birthing process here

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