Medio-lateral episiotomy as baby crowns.
An episiotomy (// or //), also known as perineotomy, is a planned, surgical incision on the perineum and the posterior vaginal wall during second stage of labor. The incision, which can be done at a 90 degree angle from the vulva towards the anus or at an angle from the posterior end of the vulva (medio-lateral episiotomy), is performed under local anesthetic (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 many parts of the world including Latin America, Poland, Bulgaria, India and Qatar.
Episiotomy is done as prophylaxis against soft-tissue trauma. Vaginal tears can occur during childbirth, most often at the vaginal opening as the baby's head passes through, especially if the baby descends quickly. Tears can involve the perineal skin or extend to the muscles and the anal sphincter and anus. The midwife or obstetrician may decide to make a surgical cut to the perineum with scissors or a scalpel to make the baby's birth easier and prevent severe tears that can be difficult to repair. The cut is repaired with stitches (sutures). Some childbirth facilities have a policy of routine episiotomy.
Though indications on the need for episiotomy vary, and may even be controversial (see discussion below), where the technique is applied, there are two main variations. Both are depicted in the above image. In one variation, the midline episiotomy, the line of incision is central over the anus. This technique bifurcates the perineal body, which is essential for the integrity of the pelvic floor. Precipitous birth can also sever—and more severely sever—the perineal body, leading to undesired birth sequelae such as incontinence. Therefore, the oblique technique is often applied (also pictured above). In the oblique technique, the perineal body is avoided, cutting only the vagina epithelium, skin, and muscles (transversalius and bulbospongiosus). This technique aids in avoiding trauma to the perineal body by either surgical or traumatic means.
In 2009, a Cochrane meta-analysis based on studies with over 5,000 women concluded that: "Restrictive episiotomy policies appear to have a number of benefits compared to policies based on routine episiotomy. There is less posterior perineal trauma, less suturing and fewer complications, no difference for most pain measures and severe vaginal or perineal trauma, but there was an increased risk of anterior perineal trauma with restrictive episiotomy". The authors were unable to find quality studies that compared mediolateral versus midline episiotomy.
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- There is a serious risk to the mother of second- or third-degree tearing
- In cases where a natural delivery is adversely affected, but a Caesarean section is not indicated
- "Natural" tearing will cause an increased risk of maternal disease being vertically transmitted
- The baby is very large
- When perineal muscles are excessively rigid
- When instrumental delivery is indicated
- When a woman has undergone FGM (female genital mutilation), indicating the need for an anterior and or mediolateral episiotomy
- Prolonged late decelerations or fetal bradycardia during active pushing
- The baby's shoulders are stuck (shoulder dystocia), or a bony association (Note that the episiotomy does not directly resolve this problem, but it is indicated to allow the operator more room to perform maneuvers to free shoulders from the pelvis)
There are four main types of episiotomy:
- Medio-lateral: The incision is made downward and outward from midpoint of fourchette either to right or left. It is directed diagonally in straight line which runs about 2.5 cm away from the anus (midpoint between anus and ischial tuberosity).
- Median: The incision commences from centre of the fourchette and extends on posterior side along midline for 2.5 cm.
- Lateral: The incision starts from about 1 cm away from the centre of fourchette and extends laterally. Drawback include chance of injury to Bartholin's duct; thus some practitioners have totally condemned it.
- J-shaped: The incision begins in the centre of the fourchette and is directed posteriorly along midline for about 1.5 cm and then directed downwards and outwards along 5 or 7 o'clock position to avoid the anal sphincter. This is also not done widely.
Controversy about common usage and history of the technique
Traditionally, physicians have used episiotomies in an effort to lessen perineal trauma, minimize postpartum pelvic floor dysfunction by reducing anal sphincter muscle damage, reduce the loss of blood during delivery, and protect against neonatal trauma. While episiotomy is employed to obviate issues such as post-partum pain, incontinence, and sexual dysfunction, some studies suggest that episiotomy surgery itself can actually cause all of these problems. Research has shown that natural tears typically are less severe (although this is perhaps not surprising since an episiotomy is designed for when natural tearing will cause significant risks or trauma). Slow delivery of the head in between contractions will result in the least perineal damage. Studies in 2010 based on interviews with postpartum women have concluded that limiting perineal trauma during birth is conducive to continued sexual function after birth. At least one study has recommended that routine episiotomy be abandoned for this reason.
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 almost all countries in Europe (except for Poland and Bulgaria), Australia, Canada, and the United States. A nationwide U.S. population study 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.
Having an episiotomy may increase perineal pain during postpartum recovery, resulting in trouble defecating, particularly in midline episiotomies. In addition it may complicate sexual intercourse by making it painful 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. Damage to anal sphincter caused by episiotomy can result in faecal incontinence (loss of control over defecation). Conversely, one of the reasons episiotomy is performed is to prevent tearing of the anal sphincter, which is also associated with faecal incontinence. Damage to the anal sphincters is more common, especially during prolonged or difficult childbirth, or where forceps are used, than has been traditionally acknowledged. Whether episiotomy reduces, or indeed increases, the chances of faecal incontinence is difficult to say.
Impacts on sexual intercourse
Some midwives compare routine episiotomy to female circumcision. 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.
Lessening the need for episiotomy
Controlled delivery of the head that allows slow gradual stretching of the perineal tissue can help in minimizing damage to the perineum.
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. Where episiotomy is never practised, the sutured tear rates for first birth were documented to be about 30%. Among 104 consecutive primiparous women who practiced with an Epi-No birth trainer before birth and had normal vaginal births, 10% had sutured perineums. Neither group suffered any third- or fourth-degree tears. The average birthweight was 3,400 g. This 10% rate of sutured perineums among first births who used Epi-No birth trainer is the lowest reported for healthy primiparous women to date.
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