EPISIOTOMY 411. About the sometimes needful cut

What is an episiotomy?
An episiotomy is an incision performed between the vagina and the rectum with the aim of increasing the size of the opening of the vagina to assist in delivery of a baby.

How common is episiotomy?
An episiotomy is performed in about 40 per cent of vaginal deliveries in the United States (US), but the prevalence of episiotomy has been decreasing in recent years. For example, 1.6 million episiotomies were performed in 1992 and only 716,000 in 2003. Some countries have significantly lower episiotomy rates than the US. In general, episiotomy is less common in Europe than in the US. Local figures are not available but from observation, one in every four deliveries is aided by an episiotomy. Quite often, operative vaginal deliveries that make use of forceps or vacuum require episiotomy. Other cases where episiotomies will be used frequently include breech deliveries and very large babies.

How is an episiotomy done?
The usual cut (incision) for an episiotomy goes down mediolaterally and typically does not involve the muscles around the rectum or the rectum itself. Anaesthesia in the form of nerve blocks or local injections of anaesthetic are given if the patient has not received regional anaesthesia (such as an epidural) for the delivery.

What are the advantages of an episiotomy?
An episiotomy can decrease the amount of pushing the mother must do during delivery. It can also decrease trauma to the vaginal tissues and expedite delivery of the baby when quick delivery is necessary. Doctors who favour episiotomies argue that a surgical incision is easier to repair than a spontaneous irregular or extensive tear. It is also likely to lead to a more favourable outcome with fewer complications.

How is an episiotomy cut repaired?
The repair is straightforward and is fairly simple to perform. The incision is repaired by suturing (sewing) the wound together in two or three layers to restore the anatomy of the perineum.

What are the possible complications of an episiotomy, and should an episiotomy be part of a routine delivery?
Episiotomy can be associated with extensions or tears into the muscle of the rectum or even the rectum itself.
Other complications include:
o bleeding
o infection
o swelling
o defects in wound closure, or complete wound breakdown
o pain
o possible short-term sexual dysfunction.

Studies have shown conflicting results regarding the question of whether performing an episiotomy results in greater postpartum pain than not performing the procedure. However, it is important to note that if the baby needs to be delivered more urgently, then waiting for the mother to push it out without the assistance of an episiotomy may in certain cases cause harm to the foetus.

Also, there are some tears that occur when no incision is made that are very difficult to repair and cause greater blood loss than might otherwise occur. Some babies are very large and should not be subjected to unnecessary stress during delivery. The American College of Obstetricians and Gynaecologists supports the position of restricted, instead of routine, use of episiotomy. Instead, episiotomy should be considered in certain situations when there is a high risk of severe lacerations or the need to facilitate rapid delivery of a foetus.

What is the healing time for an episiotomy?
The typical healing time for an episiotomy is around four to six weeks, depending on the size of the incision and the type of suture material used to close the wound. Sitz baths are very useful and highly recommended. The mother is advised to sit in a basin of warm water twice a day until the incision heals. The usefulness of added salt has been questioned and is no longer routine. Penetrative sex should be avoided for up to six weeks or longer, until the wound heals to prevent pain and possible breakdown of the wound.

END: PG24/43