Episiotomy

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Episiotomy
Medio-lateral-episiotomy.gif
Medio-lateral episiotomy as baby crowns
Pronunciation /əˌpiːziˈɒtəmi,ˌɛpəsaɪˈ-/
Other namesPerineotomy
Specialty obstetrics
ICD-9-CM 73.6
MeSH D004841
MedlinePlus 002920

Episiotomy, also known as perineotomy, is a surgical incision of the perineum and the posterior vaginal wall generally done by an obstetrician. This is usually performed during the second stage of labor to quickly enlarge the aperture, allowing the baby to pass through. The incision, which can be done from the posterior midline of the vulva straight toward the anus or at an angle to the right or left (medio-lateral episiotomy), is performed under local anesthetic (pudendal anesthesia), and is sutured after delivery.

Contents

Its routine use is no longer recommended, as perineal massage, a form of the plastic surgeon's principle of 'skin tissue expansion' applied to the vaginal cavity, is an alternative painless method of enlarging the orifice for the baby. [1] [2] [3] It is nonetheless one of the most common surgical procedures specific to women. In the United States, as of 2012, it was performed in 12% of vaginal births. [1] It is still widely practiced in many parts of the world, including Korea, Japan, Taiwan, China, and Spain. [4] [5]

Uses

Vaginal tears can occur during childbirth, most often at the introitus as the baby's head passes through, especially if the baby descends quickly. Episiotomies are used in an effort to prevent soft-tissue tearing (perineal tear) which may involve the anal sphincter and rectum. 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 injuries that can be difficult to repair. The cut is repaired with stitches (sutures). Some childbirth facilities have a policy of routine episiotomy. [6]

Specific reasons to do an episiotomy are unclear. [1] 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 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". [6] The authors were unable to find quality studies that compared mediolateral versus midline episiotomy. [6]

Types

Illustration of midline and medio-lateral incision sites for possible episiotomy Blausen 0355 Episiotomy.png
Illustration of midline and medio-lateral incision sites for possible episiotomy
Illustration of infant crowning and midline and medio-lateral incision sites for possible episiotomy during delivery Blausen 0294 Delivery Crowning.png
Illustration of infant crowning and midline and medio-lateral incision sites for possible episiotomy during delivery

There are four main types of episiotomy: [7]

Controversy

Traditionally, physicians have used episiotomies in an effort to deflect the cut in the perineal skin away from the anal sphincter muscle, as control over stool (faeces) is an important function of the anal sphincter, i.e. lessen perineal trauma, minimize postpartum pelvic floor dysfunction, and as muscles have a good blood supply, by avoiding damaging the anal sphincter muscle, 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 cause all of these problems. [8] Research has shown that natural tears typically are less severe (although this is perhaps 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. [9] 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. [10]

In various countries, routine episiotomy has been an 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, 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. [11] In Latin America, it remains popular and is performed in 90% of hospital births. [12]

Discussion

Having an episiotomy may increase perineal pain during postpartum recovery, resulting in trouble defecating, particularly in midline episiotomies. [13] In addition, it may complicate sexual intercourse by making it painful and replacing erectile tissues in the vulva with scar tissue. [14]

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. [15] Damage to the anal sphincter caused by episiotomy can result in fecal 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 fecal incontinence.[ citation needed ]

Impacts on sexual intercourse

Some midwives compare routine episiotomy to female genital mutilation. [16] 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. [17]

Pain management

Perineal pain after episiotomy has immediate and long-term negative effects on women and their babies. These effects can interfere with breastfeeding and the care of the infant. [18] The pain from injection sites and episiotomy is managed by the frequent assessment of the report of pain from the mother. Pain can come from possible lacerations, incisions, uterine contractions and sore nipples. Appropriate medications are usually administered. Nonpharmacologic interventions can also be used: a warm salt bath increases blood flow to the area, decreases local discomfort, and promotes healing. [19] Routine episiotomies have not been found to reduce the level of pain after the birth. [20]

See also

Related Research Articles

<span class="mw-page-title-main">Midwifery</span> Pregnancy and childbirth-related profession

Midwifery is the health science and health profession that deals with pregnancy, childbirth, and the postpartum period, in addition to the sexual and reproductive health of women throughout their lives. In many countries, midwifery is a medical profession. A professional in midwifery is known as a midwife.

<span class="mw-page-title-main">Caesarean section</span> Surgical procedure in which a baby is delivered through an incision in the mothers abdomen

Caesarean section, also known as C-section or caesarean delivery, is the surgical procedure by which one or more babies are delivered through an incision in the mother's abdomen. It is often performed because vaginal delivery would put the mother or child at risk. Reasons for the operation include obstructed labor, twin pregnancy, high blood pressure in the mother, breech birth, shoulder presentation, and problems with the placenta or umbilical cord. A caesarean delivery may be performed based upon the shape of the mother's pelvis or history of a previous C-section. A trial of vaginal birth after C-section may be possible. The World Health Organization recommends that caesarean section be performed only when medically necessary.

<span class="mw-page-title-main">Childbirth</span> Expulsion of a fetus from the pregnant mothers uterus

Childbirth, also known as labour, parturition and delivery, is the completion of pregnancy where one or more babies exits the internal environment of the mother via vaginal delivery or caesarean section. In 2019, there were about 140.11 million human births globally. In the developed countries, most deliveries occur in hospitals, while in the developing countries most are home births.

<span class="mw-page-title-main">Perineum</span> Region of the body between the genitals and anus

The perineum in mammals is the space between the anus and the genitals. The human perineum is between the anus and scrotum in the male or between the anus and vulva in the female. The perineum is the region of the body between the pubic symphysis and the coccyx, including the perineal body and surrounding structures. The perineal raphe is visible and pronounced to varying degrees. The perineum is an erogenous zone. This area is also known as the taint or gooch in American slang.

<span class="mw-page-title-main">Postpartum period</span> Time period beginning after the birth of a child and extending for about one month

The postpartum period begins after childbirth and is typically considered to last for six weeks. However, there are three distinct but continuous phases of the postnatal period; the acute phase, lasting for six to twelve hours after birth; the subacute phase, lasting six weeks; and the delayed phase, lasting up to six months. During the delayed phase, some changes to the genitourinary system take much longer to resolve and may result in conditions such as urinary incontinence. The World Health Organization (WHO) describes the postnatal period as the most critical and yet the most neglected phase in the lives of mothers and babies; most maternal and newborn deaths occur during this period.

<span class="mw-page-title-main">Frenulum of labia minora</span> Anatomical feature

The frenulum of labia minora is a frenulum where the labia minora meet posteriorly.

<span class="mw-page-title-main">Perineal massage</span> Massage of a pregnant womans perineum prior to childbirth

Antenatal perineal massage (APM) or Birth Canal Widening (BCW) is the / massage of a pregnant woman's perineum – the skin and deep tissues around the opening to the vagina or, performed in the 4 to 6 weeks before childbirth, i.e., 34 weeks or sooner and continued weekly until birth. The practice aims to gently mimic the 'massaging' action of a baby's head on the opening to the birth canal (vagina) prior to birth, so works with nature, to achieve the 10 cm diameter opening without using the back of baby's head, i.e., doing some of the hard work of labour (birth) before the start of labour, making birth less stressful on the baby and mother. The intention is also to attempt to: eliminate the need for an episiotomy during an instrument delivery; to prevent tearing of the perineum during birth and in this way avoid infection, helping to keep antibiotics working into the future. This technique uses Plastic Surgeons 'skin tissue expansion' principle, to aid a natural birth.

<span class="mw-page-title-main">Rectocele</span> Bulging of the rectum into the vaginal wall

In gynecology, a rectocele or posterior vaginal wall prolapse results when the rectum bulges (herniates) into the vagina. Two common causes of this defect are childbirth and hysterectomy. Rectocele also tends to occur with other forms of pelvic organ prolapse, such as enterocele, sigmoidocele and cystocele.

<span class="mw-page-title-main">Shoulder dystocia</span> Birthing obstruction complication

Shoulder dystocia is when, after vaginal delivery of the head, the baby's anterior shoulder gets caught above the mother's pubic bone. Signs include retraction of the baby's head back into the vagina, known as "turtle sign". Complications for the baby may include brachial plexus injury, or clavicle fracture. Complications for the mother may include vaginal or perineal tears, postpartum bleeding, or uterine rupture.

<span class="mw-page-title-main">Pelvic examination</span> Physical medical examination

A pelvic examination is the physical examination of the external and internal female pelvic organs. It is frequently used in gynecology for the evaluation of symptoms affecting the female reproductive and urinary tract, such as pain, bleeding, discharge, urinary incontinence, or trauma. It can also be used to assess a woman's anatomy in preparation for procedures. The exam can be done awake in the clinic and emergency department, or under anesthesia in the operating room. The most commonly performed components of the exam are 1) the external exam, to evaluate the vulva 2) the internal exam with palpation to examine the uterus, ovaries, and structures adjacent to the uterus (adnexae) and 3) the internal exam using a speculum to visualize the vaginal walls and cervix. During the pelvic exam, sample of cells and fluids may be collected to screen for sexually transmitted infections or cancer.

An asynclitic birth or asynclitism are terms used in obstetrics to refer to childbirth in which there is malposition of the head of the fetus in the uterus, relative to the birth canal. Asynclitic presentation is different from a shoulder presentation, in which the shoulder is presenting first. Many babies enter the pelvis in an asynclitic presentation, and most asynclitism corrects spontaneously as part of the normal birthing process.

A postpartum disorder or puerperal disorder is a disease or condition which presents primarily during the days and weeks after childbirth called the postpartum period. The postpartum period can be divided into three distinct stages: the initial or acute phase, 6–12 hours after childbirth; subacute postpartum period, which lasts two to six weeks, and the delayed postpartum period, which can last up to six months. In the subacute postpartum period, 87% to 94% of women report at least one health problem. Long term health problems are reported by 31% of women.

Sex after pregnancy is often delayed for several weeks or months, and may be difficult and painful for women. Painful intercourse is the most common sexual activity-related complication after childbirth. Since there are no guidelines on resuming sexual intercourse after childbirth, the postpartum patients are generally advised to resume sex when they feel comfortable to do so. Injury to the perineum or surgical cuts (episiotomy) to the vagina during childbirth can cause sexual dysfunction. Sexual activity in the postpartum period other than sexual intercourse is possible sooner, but some women experience a prolonged loss of sexual desire after giving birth, which may be associated with postnatal depression. Common issues that may last more than a year after birth are greater desire by the man than the woman, and a worsening of the woman's body image.

<span class="mw-page-title-main">Perineoplasty</span>

Perineoplasty denotes the plastic surgery procedures used to correct clinical conditions of the vagina and the anus. Among the vagino-anal conditions resolved by perineoplasty are vaginal looseness, vaginal itching, damaged perineum, fecal incontinence, genital warts, dyspareunia, vaginal stenosis, vaginismus, vulvar vestibulitis, and decreased sexual sensation. Depending upon the vagino-anal condition to be treated, there are two variants of the perineoplasty procedure: the first, to tighten the perineal muscles and the vagina; the second, to loosen the perineal muscles.

<span class="mw-page-title-main">Perineal tear</span> Medical condition

A perineal tear is a laceration of the skin and other soft tissue structures which, in women, separate the vagina from the anus. Perineal tears mainly occur in women as a result of vaginal childbirth, which strains the perineum. It is the most common form of obstetric injury. Tears vary widely in severity. The majority are superficial and may require no treatment, but severe tears can cause significant bleeding, long-term pain or dysfunction. A perineal tear is distinct from an episiotomy, in which the perineum is intentionally incised to facilitate delivery. Episiotomy, a very rapid birth, or large fetal size can lead to more severe tears which may require surgical intervention.

Warren operation is a surgery performed to correct anal incontinence. It is done by disrupting the anterior segment of the anal sphincter, perineal body and rectovaginal septum.

The postpartum physiological changes are those expected changes that occur in the woman's body after childbirth, in the postpartum period. These changes mark the beginning of the return of pre-pregnancy physiology and of breastfeeding. Most of the time these postnatal changes are normal and can be managed with medication and comfort measures, but in a few situations complications may develop. Postpartum physiological changes may be different for women delivering by cesarean section. Other postpartum changes, may indicate developing complications such as, postpartum bleeding, engorged breasts, postpartum infections.

The husband stitch or husband's stitch, also known as the daddy stitch, husband's knot and vaginal tuck, is a medically unnecessary and potentially harmful (FGM) surgical procedure in which one or more additional sutures than necessary are used to repair a woman's perineum after it has been torn or cut during childbirth. The purported purpose is to tighten the opening of the vagina and thereby enhance the pleasure of the patient's male sex partner during penetrative intercourse.

<span class="mw-page-title-main">Operative vaginal delivery</span>

Operative vaginal delivery, also known as assisted or instrumental vaginal delivery, is a vaginal delivery that is assisted by the use of forceps or a vacuum extractor.

References

  1. 1 2 3 American College of Obstetricians Gynecologists' Committee on Practice Bulletins—Obstetrics (July 2016). "Practice Bulletin No. 165: Prevention and Management of Obstetric Lacerations at Vaginal Delivery". Obstetrics and Gynecology. 128 (1): e1–e15. doi:10.1097/AOG.0000000000001523. PMID   27333357. S2CID   20952144.
  2. ↑ Eason E, Labrecque M, Wells G, Feldman P (March 2000). "Preventing perineal trauma during childbirth: a systematic review". Obstetrics and Gynecology. 95 (3): 464–471. doi:10.1016/s0029-7844(99)00560-8. PMID   10711565.
  3. ↑ Beckmann, Michael M.; Stock, Owen M. (30 April 2013). "Antenatal perineal massage for reducing perineal trauma". The Cochrane Database of Systematic Reviews (4): CD005123. doi:10.1002/14651858.CD005123.pub3. ISSN   1469-493X. PMID   23633325.
  4. ↑ Chang SR, Chen KH, Lin HH, Chao YM, Lai YH (April 2011). "Comparison of the effects of episiotomy and no episiotomy on pain, urinary incontinence, and sexual function 3 months postpartum: a prospective follow-up study". International Journal of Nursing Studies. 48 (4): 409–418. doi:10.1016/j.ijnurstu.2010.07.017. PMID   20800840.
  5. ↑ Graham ID, Carroli G, Davies C, Medves JM (September 2005). "Episiotomy rates around the world: an update". Birth. 32 (3): 219–223. doi:10.1111/j.0730-7659.2005.00373.x. PMID   16128977.
  6. 1 2 3 Carroli G, Belizan J (2000). Carroli G (ed.). "Episiotomy for vaginal birth". The Cochrane Database of Systematic Reviews (2): CD000081. doi:10.1002/14651858.CD000081. PMID   10796120.
  7. ↑ Dutta DC (2011). Textbook of Obstetrics (7th ed.).
  8. ↑ Thacker SB, Banta HD (June 1983). "Benefits and risks of episiotomy: an interpretative review of the English language literature, 1860-1980". Obstetrical & Gynecological Survey. 38 (6): 322–338. doi:10.1097/00006254-198306000-00003. PMID   6346168.
  9. ↑ Albers LL, Sedler KD, Bedrick EJ, Teaf D, Peralta P (June 2006). "Factors related to genital tract trauma in normal spontaneous vaginal births". Birth. 33 (2): 94–100. doi:10.1111/j.0730-7659.2006.00085.x. PMID   16732773.
  10. ↑ Rathfisch G, Dikencik BK, Kizilkaya Beji N, Comert N, Tekirdag AI, Kadioglu A (December 2010). "Effects of perineal trauma on postpartum sexual function". Journal of Advanced Nursing. 66 (12): 2640–9. doi: 10.1111/j.1365-2648.2010.05428.x . PMID   20735499.
  11. ↑ Weber AM, Meyn L (December 2002). "Episiotomy use in the United States, 1979-1997". Obstetrics and Gynecology. 100 (6): 1177–1182. doi:10.1016/S0029-7844(02)02449-3. PMID   12468160. S2CID   28134959.
  12. ↑ Althabe F, Belizán JM, Bergel E (April 2002). "Episiotomy rates in primiparous women in Latin America: hospital based descriptive study". The BMJ. 324 (7343): 945–946. doi:10.1136/bmj.324.7343.945. PMC   102327 . PMID   11964339.
  13. ↑ Signorello LB, Harlow BL, Chekos AK, Repke JT (January 2000). "Midline episiotomy and anal incontinence: retrospective cohort study". The BMJ. 320 (7227): 86–90. doi:10.1136/bmj.320.7227.86. PMC   27253 . PMID   10625261.
  14. ↑ "Painful Intercourse". Total Health For Women. Mother Nature, Inc. 2006. Archived from the original on 15 June 2006. Retrieved 6 June 2006.
  15. ↑ American College of Obstetricians-Gynecologists (2006). "ACOG Practice Bulletin. Episiotomy. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 71, April 2006" (PDF). Obstetrics & Gynecology. 107 (4): 956–62. doi:10.1097/00006250-200604000-00049 . Retrieved 16 January 2012. Abstract.
  16. ↑ Cameron J, Rawlings-Anderson K (1 March 2001). "Female circumcision and episiotomy: both mutilation?". British Journal of Midwifery. 9 (3): 137–142. doi:10.12968/bjom.2001.9.3.7997 . Retrieved 16 January 2012.
  17. ↑ Ejegård H, Ryding EL, Sjogren B (17 January 2008). "Sexuality after delivery with episiotomy: a long-term follow-up". Gynecologic and Obstetric Investigation. 66 (1): 1–7. doi:10.1159/000113464. PMID   18204265. S2CID   25348363.
  18. ↑ Shepherd E, Grivell RM (July 2020). "Aspirin (single dose) for perineal pain in the early postpartum period". The Cochrane Database of Systematic Reviews. 2020 (7): CD012129. doi:10.1002/14651858.CD012129.pub3. PMC   7388929 . PMID   32702783.
  19. ↑ Hasegawa J, Leventhal LC (2009). "Pharmacological and non pharmacological treatmente for relief of perineal pain after vaginal delivery". Einstein. 7 (2). São Paulo: 194–200.
  20. ↑ Jiang H, Qian X, Carroli G, Garner P (February 2017). "Selective versus routine use of episiotomy for vaginal birth". The Cochrane Database of Systematic Reviews. 2017 (2): CD000081. doi:10.1002/14651858.CD000081.pub3. PMC   5449575 . PMID   28176333.
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