Episiotomy

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Medio-lateral episiotomy as baby crowns.

An episiotomy (pronounced /ɛˌpiːziːˈɒtəmiː/) is a surgical incision through the perineum made to enlarge the vagina and assist childbirth. The incision can be midline or at an angle from the posterior end of the vulva, is performed under local anaesthetic (pudendal anesthesia) and is sutured closed after delivery. It is one of the most common medical procedures performed on women, and although its routine use in childbirth has steadily declined in recent decades, it is still widely practiced in Latin America and in Poland and India.

Contents

[edit] Uses

The primary rationale behind an episiotomy is related to the nature rather than the size of the tear. Many physicians use episiotomies because they believe that it will lessen perineal trauma, minimize postpartum pelvic floor dysfunction by reducing anal sphincter muscle damage, reduce the loss of blood at delivery, and protect against neonatal trauma. In many cases though, episiotomies cause all of these problems.[1] Research has shown that natural tears typically are less severe (although this is perhaps not surprising since epistiotomy is designed for when natural tearing will cause significant risks/trauma)

Slow delivery of the head, in between contractions will result in the least perineal damage.[2]

Episiotomy is indicated if:

  • the baby's shoulders are stuck (Shoulder Dystocia) a bony association, though the episiotomy does not resolve this problem, it allows the operator more room to perform maneuvers to free shoulder from the pelvis.
  • There is a serious risk to the mother of second or third degree tearing
  • In some cases where a caesearean is not indicated but delivery is adversely affected
  • 'Natural' tearing will cause an increased risk of maternal disease being vertically transmitted
  • Routine episiotomy is NOT indicated in evidence based practice
  • Large baby
  • rigid perineal muscles
  • When instrumental delivery is indicated
  • When a woman has undergone FGM (female genital mutilation) an anterior and or mediolateral episiotomy may be indicated.
  • Prolonged late decelerations or fetal bradycardia during active pushing

[edit] Controversy about common usage

In various countries, routine episiotomy has been accepted medical practice for many years. Since about the 1960s, routine episiotomies have been rapidly losing popularity among obstetricians and midwives in Europe, Australia and the United States. A nationwide US population study[3] suggested that 31% of women having babies in U.S. hospitals received episiotomies in 1997, compared with 56% in 1979. In Latin America it remains popular, and is performed in 90% of hospital births,[4] in most cases without the mother's consent. There, routine episiotomy is a major cause of infections, some of them fatal.[5]

Recent studies indicate that routine episiotomies should not be performed, as they increase morbidity. This procedure is not helpful for routine patients[6] Having an episiotomy may increase perineal pain in the postpartum period, resulting in trouble defecating, particularly in midline episiotomies [7]. In addition it may complicate sexual intercourse by making it painful [8] and replacing erectile tissues in the vulva with fibrotic tissue.

In cases where an episiotomy is indicated, a mediolateral incision may be preferable to a median (midline) incision as the latter is associated with a higher risk of injury to the anal sphincter and the rectum[9].

[edit] Impacts on sexual intercourse

Some midwives compare routine episiotomy to female circumcision.[10] One study found that women who underwent episiotomy reported more painful intercourse and insufficient lubrication 12-18 months after birth, but did not find any problems with orgasm or arousal.[11]

[edit] Avoidance

Controlled delivery of the head that allows slow gradual stretching of the perineal tissue can help in minimising damage to the perineum.

Perineal massage beginning around the 34th week has been shown to reduce perineal damage by 6%[12].

A perineal dilator can be used to stretch the perineal tissue gradually and train it in preparation for first births. The "Epi-no Birth Trainer" consists of a small inflatable silicone balloon pumped with the same pump as a sphygmomanometer. The Epi-no device has been shown to reduce perineal damage by 50% at first births[13].

[edit] References

  1. ^ Thacker, S.B., and H.D. Banta. 1983. "Benefits and risks of episiotomy: an interpretative review of the English language literature, 1860-1980." Obstet Gynecol Surv 38(6): 322-38.
  2. ^ Albers, L.L., et al. 2006. "Factors Related to Genital Tract Trauma in Normal Spontaneous Vaginal Births." Birth 33(2): 94-100.
  3. ^ Weber AM, Meyn L (2002). "Episiotomy use in the United States, 1979-1997" ([dead link] – Scholar search). Obstet Gynecol 100 (6): 1177–82. doi:10.1016/S0029-7844(02)02449-3. PMID 12468160. http://www.greenjournal.org/cgi/pmidlookup?view=long&pmid=12468160. 
  4. ^ Althabe F, Belizán JM, Bergel E (2002). "Episiotomy rates in primiparous women in Latin America: hospital based descriptive study". BMJ 324 (7343): 945–6. doi:10.1136/bmj.324.7343.945. PMID 11964339. http://bmj.com/cgi/pmidlookup?view=long&pmid=11964339. 
  5. ^ Obstetric Myths Versus Research Realities: episiotomy abstracts 1-18
  6. ^ Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J, Lohr KN (2005). "Outcomes of routine episiotomy: a systematic review". JAMA 293 (17): 2141–8. doi:10.1001/jama.293.17.2141. PMID 15870418. http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=15870418. 
  7. ^ Signorello LB, Harlow BL, Chekos AK, Repke JT (2000). "Midline episiotomy and anal incontinence: retrospective cohort study". BMJ 320 (7227): 86–90. doi:10.1136/bmj.320.7227.86. PMID 10625261. http://bmj.com/cgi/pmidlookup?view=long&pmid=10625261. 
  8. ^ Total Health For Women Painful Intercourse
  9. ^ "ACOG Practice Bulletin. Episiotomy. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 71, April 2006" ([dead link] – Scholar search). Obstet Gynecol 107 (4): 957–62. 2006. PMID 16582142. http://www.greenjournal.org/cgi/pmidlookup?view=long&pmid=16582142. 
  10. ^ [1] Joan Cameron, Karen Rawlings-Anderson, "Female circumcision and episiotomy: both mutilation?" British Journal of Midwifery, Vol. 9, Iss. 3, 01 Mar 2001, pp 137 - 142.
  11. ^ [2] Hanna Ejegård, Elsa Lena Ryding, Berit Sjögren, "Sexuality after Delivery with Episiotomy: A Long-Term Follow-Up", Gynecologic and Obstetric Investigation, Vol. 66, No. 1, 2008.
  12. ^ Shipman MK, Boniface DR, Tefft ME, McCloghry F (1997). "Antenatal perineal massage and subsequent perineal outcomes: a randomised controlled trial". Br J Obstet Gynaecol 104 (7): 787–91. PMID 9236642. 
  13. ^ Cohain JS (2004) (PDF). Perineal Outcomes after practicing with a Perineal Dilator. journal=MIDIRS Midwifery Digest. pp. 37–41. http://www.epi-no.com/pdf_downloads/experience_judy_slome.pdf. 
v • d • e
Obstetrical surgery and other procedures (ICD-9-CM V3 72-75)
Delivery
Diagnostic
Intervention
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