Once considered a routine and necessary procedure, you may not have even heard of an episiotomy nowadays. If you have heard one, it was probably discussed in hushed, embarrassed, and sometimes even angry tones of voice; however, the likelihood of you encountering this pregnancy boogey man is very slim.
The American College of Obstetrics and Gynecology recommend that they not be performed routinely anymore, dropping the rate of procedures from 25% in 2004 to only 11.6% in 2015.
What is an Episiotomy?
An episiotomy is a surgical procedure performed during labor if the doctor believes it to be necessary. It is a surgical cut in the muscular area between the woman’s vagina and anus, also known as the perineum.
This is done as a way to enlarge the vaginal opening in order to help labor progress. This process was started as a way to help prevent women from tearing naturally during child labor, as well as to make labor progress faster, especially on first time mothers.
Changing attitudes towards episiotomy
Many doctors believed that an episiotomy would be easier to heal from than a natural tear, due to the smooth edges of the incision. They also believed that it would help to prevent further complications post-partum, such as incontinence. It was believed that this procedure would help to keep the support of muscular and connective tissue of the pelvic floor, as loss of this support is what leads to incontinence.
However, many doctors and obstetricians now believe that an episiotomy should not be “routine” by any means and should, in fact, be a last resort. Due to this, the procedure has been used less and less, shrinking to less than 25% of all labors in recent years, compared to over 65% of deliveries in the 70s when this procedure was at its peak.
Types of episiotomy incisions
Should you receive an episiotomy, two main types of incision are most commonly used. The first one is called the Median Episiotomy. This incision is performed by making a straight cut down into the perineal muscles between the vagina and the anus. This style is the easiest to repair, but the procedure has a high risk of extending damage into the anal cavity. The second style, the Mediolateral Episiotomy, is slightly different. This style of incision is an angled cut that is aimed down and away from the anus and vagina, into the perineal muscle. This incision is more difficult to repair, often causes more pain and discomfort, but is less likely to extend into the anal cavity.
An episiotomy often occurs towards the end of labor, as the baby is entering the birth canal or is getting ready to. If you have not already received an epidural or other form of pain medication, the doctor or midwife will give you a pudendal block. This is a local anesthetic administered into the perineum directly to numb the area.
Why might I need an episiotomy?
Despite how out of date this procedure is to most doctors, there might be a few instances in which receiving an episiotomy might be beneficial, or at the least, necessary.
Imminent Birth:
If your labor has progressed too quickly and the baby is already on its way into the birth canal, it is important to evacuate the baby as soon as possible to avoid cord prolapse and other medical emergencies. In this case, it could be better to widen the vaginal opening in order to better facilitate the speed of the delivery.
Distress:
Related to an imminent birth, is whether the baby might be in distress. Should the child’s umbilical cord become crushed (prolapse), or for some reason the child is not receiving oxygen, speed is of the essence.
Too Large:
If the baby’s head is so large that it poses the risk of a deep tissue tear into the anal cavity, an episiotomy might be needed. This will also happen if the doctor needs to assist labor with either a vacuum or forceps; they need more room in order to negotiate the baby’s position.
Breech or Stuck:
If your baby is in breech position, attempts to turn it have not worked, and a C-section is not possible, an episiotomy can be used to help birth the child in a better fashion. This also applies if the child’s shoulders have become stuck in the birth canal, better known as shoulder dystocia.
Pushing:
If you cannot control your pushing during labor the doctor might opt for an episiotomy as well. The desire to constantly push, or having no drive to push, can severely complicate labor; therefore, many doctors will use this procedure in order to speed delivery.
What are the side effects?
The reason this procedure has been on the decline in recent years is due to the side effects often felt by more women who have had to endure it. These problems and side effects include:
-Infection in the incision, most likely due to contact with the anus
-Bruising
-Bleeding
-Intense swelling
-Painful scarring that may prevent enjoyment of sexual intercourse for a period of time ranging from a few weeks to years
-Problems with incontinence
-A long and extended recovery period
Why is it better to tear?
Contrary to what the doctors who routinely practiced episiotomies believed, it is actually much harder for the body to heal the clean edges of a scalpel incision than the natural jaded edges of a vaginal tear.
Research also suggests that women who deliver their child with perineum tearing often recover faster and have fewer complications than women who deliver with an episiotomy.
As mentioned in the last section, women who deliver with an episiotomy often encounter heavy bleeding, bruising and pain, and lose more blood during delivery than a woman undergoing a natural delivery.
Receiving an episiotomy is also linked to an increased risk of tearing if the mother were to become pregnant again. These complications of an episiotomy birth often scare away mothers-to-be as they read about the symptoms.
Tearing naturally often allows the mother to heal faster, heal with less pain, and have minimal or no scarring. Women who tear naturally also do not have the same rates of infection, and often to do not have the same reoccurrence of tearing in their next deliveries.
How do I avoid an unnecessary procedure?
After being presented with the information above, it is logical for you and most other women to want to avoid an episiotomy, especially if you are hoping for a natural birth without the assistance of medication or other surgical procedures. Below are several methods and tips on how to avoid the necessity of an episiotomy:
Talk:
Talk to your physician! Create a birth plan that states that you do not want an episiotomy and that it is not allowed unless absolutely medically necessary. Ask them about how often and under what circumstances they have performed episiotomies, as well as their medical stance on the procedure. You should also consult them for their own tips on how to avoid perineal tearing, and make sure to ask the beliefs of any other practitioners in the office, as they may also deliver your child. If you are choosing a midwife instead of an obstetrician or family physician, they also have been shown in studies to perform far fewer episiotomies.
Good Nutrition:
Maintaining proper nutrition during your pregnancy is vital for many reasons, but one of the lesser-known benefits is its effect on your skin. When your body is properly fed and receiving all of the vitamins and minerals that it needs, your skin becomes more elastic. This means that your skin will stretch more, and stretch more easily, which could help limit the need for an episiotomy.
Non-Recumbent Positioning:
Recumbent laboring is when you lie on your back while pushing. While this is prominently seen in movies and on television, it is a position that often leads to more tearing and makes it more difficult for the baby to slide through the birth canal. Consider, instead, laboring on all fours, while squatting, sitting up, or other positions your practitioner can recommend. These positions are more “natural” for the body, and may ease the delivery process.
Kegels:
Kegels are recommended for many different ailments faced by pregnant women, such as avoiding urine incontinence. Kegel exercises strengthen the pelvic floor muscles and grant you greater control over the pushing process, and helps prevent tearing.
Perineal Massage:
In the weeks leading up to your delivery date, and potentially during delivery as well, you can perform a perineal massage. You should massage the area in between the vagina and the anus, which is the perineum. This massage can help loosen the muscles, making them more flexible and giving.
Warm Compress:
Warm compresses or massage with warm mineral oil is one of the most common practices in order to prevent the need for an episiotomy. While you are pushing, your practitioner will apply a warm compress, or warm mineral oil, to your perineal tissue. This helps, like the massage, to warm up and soften the muscle tissue and helps prevent tears in the skin.
Controlled Pushing:
If you are able, you should practice slow and controlled pushing during the second stage of labor. This means pushing for only 5 to 7 seconds, while bearing down gently. This is more beneficial than the traditional 10 seconds of hard bearing down with no breathing. This helps the baby move more fluidly through the birth canal and does not force them out, which can cause tearing and the need for an episiotomy.
Counter pressure:
When the baby’s head is beginning to crown, you can ask your practitioner to help you relieve the pain and help prevent the need for an episiotomy. This works by having the practitioner apply counter pressure to the perineal muscles, to help keep them from ripping while the head is crowning.
Recovering from an episiotomy
Despite all of your preparation, however, episiotomies are sometimes medically necessary. If this does end up being the case and your health care provider needs to perform the procedure, you will undergo a recovery period. You will have received stitches in a very sensitive area and will probably be in pain or at least feel tender for a few weeks. Recovery can last from a few days to a few months depending on the procedure and on if there was serious tearing. All women who deliver vaginally will experience some perineal pain, but should you have an episiotomy, the pain will often be more intense. In order to relieve the pain, you should use the following tips:
Ice the area:
Applying ice packs and cold compresses to the perineal tissue after delivery, and from time to time in the 12 hours or so after birth is important. This helps prevent swelling and numbs the pain.
Medication:
Medicated pads can help by applying a medicated balm directly to the tissue. You might also want to use ibuprofen or Tylenol to help reduce inflammation and pain, but you should not use aspirin if you are breastfeeding your baby.
Bathroom Aid:
Using the bathroom after an episiotomy can be a painful process. Using a sitz bath, to bathe your tissue in warm water after using the restroom can help. You can also wash yourself with a squirt bottle instead of wiping with tissue, and pat your sensitive areas dry. Pouring warm water over your vulva while you urinate can also help. You might also want a padded ring around your toilet, or modify a pillow so you do not have to sit and stretch over the toilet.
After about four to six weeks, your perineum should be completely healed. In this case, it should be safe to resume sex, but double check with your physician beforehand. For the first time and maybe after that as well, you should use gentle foreplay, warm lubricant, and move slowly to give your body time to adjust.
Episiotomies can be helpful and even lifesaving procedures to ensure that your baby is brought into the world in the safest way possible; however, they do carry considerable risks, and in order to ensure the best possible health care for you and your child, be sure to consult with your health care provider about the procedure.
