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Episiotomy

by Karen Schroeder, MS, RD

Anatomy and Physiology
During pregnancy, the fetus grows inside the uterus, or womb, and is nourished by the placenta. When the baby is ready to be born, labor begins. Signs of labor include: a feeling that the baby has "dropped", discharge of a mucus plug and/or watery fluid from the vagina, a regular pattern of cramps.

During labor, the uterus squeezes or contracts to push the baby through the open cervix and into the vagina, which expands to allow the baby to pass through and be born. Within 30 minutes after the baby's birth, the placenta is delivered.

Reasons for Procedure
During some deliveries, your doctor will perform an episiotomy to enlarge the vaginal opening. To do so, he or she will make a 1-3 inch incision in the perineum, which separates the vagina and the anus. Enlarging the vaginal opening can sometimes speed up the birth process, and may help reduce the risk of spontaneous tearing as the baby is delivered.

An episiotomy may be done in an effort to avoid tearing if: The baby is large or in the breech position, labor is going too quickly, instruments, such as forceps or vacuum extraction, are needed to remove the baby from the birth canal.

In other cases, an episiotomy may be done to help speed up delivery if: labor is going too slowly, the mother or baby are in distress, an episiotomy may also be done for a premature or otherwise fragile baby in order to relieve pressure on the baby as it moves through the vaginal opening.

Treatments
Some women, who deliver their babies without an episiotomy, tear their perineum naturally. The chance of tearing is affected by the number of babies you have had, how long you push during labor, and the size and position of the baby.

Episiotomy was once a routine procedure during childbirth. Recently, though, the routine use of this procedure has been questioned. Some authorities believe that an episiotomy may increase the risk of larger and deeper tears involving the anus and/or anal sphincter. These types of lacerations are more painful and may take longer to heal. Incisions and tears must both be stitched up and cared for after delivery.

Even though routine episiomities may no longer be indicated for every delivery, your doctor may decide to perform the procedure in response to certain conditions previously discussed. During your prenatal visits, be sure to ask your doctor about the appropriate use of episiotomy.

Procedure
As your labor progresses and the baby's head begins to stretch the vaginal opening, your doctor will perform an episiotomy if he or she deems it necessary. If you have not already received anesthesia, your doctor will inject medication to numb your perineum and vaginal opening.

Using surgical scissors, your doctor will make an incision in the perineum to widen the vaginal opening. There are two types of incisions: midline and mediolateral. A midline incision extends straight down from the vagina toward the anus. A mediolateral incision is made on an angle from the vagina in the direction of the anus. The benefit of this type of cut is that it is less likely to tear through to the anus. The downside, however, is that it can also be more painful and take longer to heal.

Once the baby and the placenta have been delivered, your doctor will close the episiotomy incision with stitches. These stitches will be absorbed by your body and do not need to be removed.

Risks and Benefits
The potential risks of an episiotomy include the following: pain during the procedure, large tears, which form at the incision and extend to the anus, blood loss, wound infection, painful intercourse, which may last for a few months after delivery.

The potential benefits of an episiotomy may include the following: decreased chance of tears to the vagina, especially severe tears that may extend to the anus, shortened labor, decreased risk to the baby during a difficult delivery.

While the decision to perform an episiotomy is almost always made at the time of the procedure, you and your doctor must carefully weigh its risks and benefits before you go into labor to decide whether it's the most appropriate treatment choice for you.

After the Procedure
An episiotomy usually heals without complications, although it may take several weeks. Within the first 24 hours, your nurse will likely help you apply ice packs to the stitches.

Other steps that can reduce discomfort or promote healing include: keeping the area clean by bathing and using a spray bottle after going to the bathroom, soaking in a sitz bath several times a day, taking a stool softener to avoid constipation, performing Kegel exercises, applying warm compresses, ice packs, or witch hazel to the area, taking pain medications, but be sure to discuss with your doctor which medications are safe to take, especially if you are nursing.

Refrain from sexual intercourse, douching, and the use of tampons for 4-6 weeks, or until the wound is completely healed. You may resume other activities as you feel able.

You should feel better and have less pain each day. Call your doctor if you experience any of the following: pain that increases or fails to improve, redness, swelling, excessive bleeding, or discharge from the incision site, signs of infection, such as fever and chills, incontinence of urine or feces, foul-smelling vaginal discharge.

Sources:

  • National Library of Medicine. Episiotomy. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/002920.htm. Accessed August 16, 2004.
  • University of Michigan Health System. Episiotomy. Available at: http://www.med.umich.edu/obgyn/smartmoms/labor/episiotomy.htm. Accessed August 16, 2004.
  • University of Michigan Health System. How to tell when labor begins. Available at: http://www.med.umich.edu/obgyn/smartmoms/labor/beginning.htm. Accessed August 17, 2004.
  • University of Pennsylvania Health System. Episiotomy. Available at: http://www.pennhealth.com/health_info/pregnancy/labordelivery/articles/episiotomy.html. Accessed August 16, 2004.


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