An episiotomy is a surgical incision made in the perineum, the area between the vagina and anus. Episiotomies are done during the second stage of labor to expand the opening of the vagina to prevent tearing of the area during the delivery of the baby.
An episiotomy is usually done during the birthing process in order to deliver a baby without tearing the perineum and surrounding tissue. Reasons for an episiotomy include:
- Evidence of maternal or fetal distress (i.e. no time to allow perineum to stretch).
- The baby is premature or in breech position, and his/her head could be damaged by a tight perineum.
- The baby is too large to be delivered without causing extensive tearing.
- The delivery is being assisted by forceps.
- The mother is too tired or unable to push.
- Existing trauma to the perineum.
Some experts believe that an episiotomy speeds up the birthing process, making it easier for the baby to be delivered. Speed can be important if there is any sign of distress that may harm the mother or baby. Because tissues in this area may tear during the delivery, another reason for performing an episiotomy is that a clean incision is easier to repair than a jagged tear and may heal faster. Although episiotomies are sometimes described as protecting the pelvic muscles and possibly preventing future problems with urinary incontinence, it is not clear that the procedure actually helps.
In 2000, one study calculated the percentage of episiotomies performed in the United States out of all vaginal deliveries to be 19.4%. This was a dramatic reduction from the 1983 rate of 69.4%. Episiotomy rates were higher among white women (32.1%) than African American women (11.2%). Similar differences have been reported in other obstetric procedures (e.g. cesarean section and epidural use).
Episiotomy rates differ according to care provider—patients of midwives have lower rates than patients of medical doctors. One study comparing perineal outcomes for women being cared for by midwives or medical doctors found the episiotomy rate among midwives at 25% and 40% among medical doctors. Younger doctors are also less likely to perform an episiotomy than older doctors; one study found the rate of episiotomies performed by residents to be 17%, while the rate among doctors in private practice was 66%.
An episiotomy is a surgical incision, usually made with sterile scissors, in the perineum as the baby's head is being delivered. This procedure may be used if the tissue around the vaginal opening begins to tear or does not seem to be stretching enough to allow the baby to be delivered.
In most cases, the physician makes a midline incision along a straight line from the lowest edge of the vaginal opening toward the anus. In other cases, the episiotomy is performed by making a diagonal incision across the midline between the vagina and anus (called a mediolateral incision). This method is used much less often, may be more painful, and may require more healing time than the midline incision. After the baby is delivered through the extended vaginal opening, the incision is closed with stitches. A local anesthetic may be applied or injected to numb the area before it is sewn up (sutured).
Episiotomies are classified according to the depth of the incision:
- A first-degree episiotomy cuts through skin only (vaginal/lierineal).
- A second-degree episiotomy involves skin and muscle and extends midway between the vagina and the anus.
- A third-degree episiotomy cuts through skin, muscle, and the rectal sphincter.
- A fourth-degree episiotomy extends through the rectum and cuts through skin, muscle, the rectal sphincter, and anal wall.
Although there are some reasons for anticipating an episiotomy before labor has begun (e.g. breech presentation of the baby), the decision to perform an episiotomy is generally not made until the second stage of labor, when delivery of the baby is imminent.
The area of the episiotomy may be uncomfortable or even painful for several days. Several practices can relieve some of the pain. Cold packs can be applied to the perineal area to reduce swelling and discomfort. Use of a sitz bath can ease the discomfort. This unit circulates warm water over the area. A squirt bottle with water can be used to clean the area after urination or defecation rather than wiping with tissue. Also, the area should be patted dry rather than wiped. Cleansing pads soaked in witch hazel (such as the brand Tucks) are very effective for soothing and cleaning the perineum.
Several side effects of episiotomy have been reported, including infection (in 0.3% of cases), increased pain, increased bleeding, prolonged healing time, and increased discomfort once sexual intercourse is resumed. There is also the risk that the incision will be deeper or longer than is necessary to permit the birth of the infant. An incision that is too long or deep may extend into the rectum, causing more bleeding and an increased risk of infection. Additional tearing or tissue damage may occur beyond the episiotomy itself.
In a normal and well-managed delivery, an episiotomy may be avoided altogether. If an episiotomy is considered necessary, a simple midline incision will be made to extend the vaginal opening without additional tearing or extensive trauma to the perineal area. Although there may be some pain associated with the healing of the incision, relief can usually be provided with mild pain relievers and supportive measures, such as the application of cold packs.
Morbidity and mortality rates
Studies have found that the rates of urinary/fecal incontinence, postpartum perineal pain, and sexual dysfunction are generally the same between women who have had an episiotomy and those who had a spontaneous tear of the perineum. There does appear to be a higher risk of more extensive perineal trauma when an episiotomy is performed (20.9% experienced third- or fourth-degree lacerations) then when it is not (3.1% experienced major perineal damage).
It may be possible to avoid the need for an episiotomy. Pregnant women may want to talk with their care providers about the use of episiotomy during the delivery. Kegel exercises are often recommended during the pregnancy to help strengthen the pelvic floor muscles. Prenatal perineal massage may help to stretch and relax the tissue around the vaginal opening. During the delivery process, warm compresses can be applied to the area along with the use of perineal massage. Coaching and support are also important during the delivery process. Slowed, spontaneous pushing during the second stage of labor (when the mother gets the urge to push) may allow the tissues to stretch rather than tear. Also, an upright birthing position (rather than one where the mother is lying down) may decrease the need for an episiotomy.
Enkin, Murray, Marc Keirse, James Neilson, et al. A guide to effective care in pregnancy and childbirth . Third edition. Oxford: Oxford University Press, 2000.
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Goldberg, Jay, David Holtz, Terry Hyslop, and Jorge Tolosa. "Has the Use of Routine Episiotomy Decreased? Examination of Episiotomy Rates From 1983 to 2000." Obstetrics and Gynecology 99 (March 2002): 395–400.
Kane-Low, Lisa, Julia Seng, Terri Murtland, and Deborah Oakley. "Clinician-specific episiotomy rates: Impact on perineal outcomes." Journal of Midwifery and Women's Health 45 (March 2000): 87–93.
Klein, M. C., R. J. Gauthier, J. Kaczorowski, et al. "Relationship of Episiotomy to Perineal Trauma and Morbidity, Sexual Dysfunction, and Pelvic Floor Relaxation." American Journal of Obstetrics and Gynecology 171 (1994): 591–8.
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Yokoe, Deborah, Cindy Christiansen, Ruth Johnson, et al. "Epidemiology of and Surveillance for Postpartum Infections." Emerging Infectious Diseases 7 (2001).
American College of Nurse-Midwives. 818 Connecticut Ave., NW, Suite 900, Washington, DC 20006. (202) 728-9860. http://www.midwife.org .
American College of Obstetricians and Gynecologists. 409 12th St., SW, PO Box 96920, Washington, DC 20090-6920. http://www.acog.org .
Midwives Alliance of North America. 4805 Lawrenceville Highway, Suite 116-279, Lilburn, GA 30047. (888) 923-MANA. http://www.mana.org .
"Episiotomy FAQ Sheet." Perinatal Education Associates, Inc. 2002 [cited February 25, 2003]. <http://www.birthsource.com/proarticlefile/proarticle98.html 03E; .
Marcus, Adam. "Episiotomy Rates Dropping in U.S." Healthfinder. May 7, 2002 [cited February 25, 2003]. <http://www.healthfinder.gov/news/newsstory.asp?docID=507067 03E; .
Altha Roberts Edgren Stephanie Dionne Sherk
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
An episiotomy is performed by the health care provider attending to a woman's labor and delivery, typically an obstetrician/gynecologist or midwife. An obstetrician/gynecologist is a medical doctor who has completed specialized training in the areas of women's general health, pregnancy, labor and childbirth, prenatal testing, and genetics. A midwife is a person who has been trained to provide care, support, and supervision to women in all stages of pregnancy, labor, delivery, and the postpartum period. The procedure is performed at the site of labor and delivery, most often a hospital or birth center.
QUESTIONS TO ASK THE DOCTOR
- What is your episiotomy rate?
- For what reasons would you perform an episiotomy?
- What are my alternatives to having an episiotomy?
- How should I care for my episiotomy when I return home?