Episiotomy

An episiotomy is a surgical cut your doctor may make in the muscular area between your vagina and anus just before delivery to enlarge your vaginal opening. Doctors generally perform episiotomies to speed delivery and prevent the vagina from tearing, especially during a first vaginal delivery. Episiotomies used to be a routine part of vaginal deliveries and many experts believed that the clean incision of an episiotomy would heal more easily than a spontaneous tear. However, a large number of studies over the last 20 years have disproved this theory and the number of episiotomies is declining.

An episiotomy may be medically necessary if:

• Your baby’s heart rate shows that he or she isn’t tolerating labor well and needs to be born as quickly as possible.

• If your baby is very large and your doctor needs additional room to manipulate him or her through the birth canal.

• If your doctor needs additional room when using forceps to deliver your baby.

The most common type of episiotomy in the United States and Canada is the midline, second degree episiotomy, which runs in a straight line midway between the vagina and anus. Mediolateral episiotomies, when the cut runs diagonally to one side or the other, are more common in other parts of the world. The most traumatic, and rare, episiotomies are fourth degree and extend through the rectum.

Approximately 40 percent of vaginal deliveries in the United States include an episiotomy. Although between 1980 and 1998 the rate of episiotomies in the United States dropped 39 percent, it is still one of the most frequent surgical procedures performed on women in the United States.

Doctors once thought that an episiotomy would prevent deep, ragged, uncontrolled tears in the perineum. However, research has shown that episiotomies often cause, not prevent, tears. And women with spontaneous tears generally recover in the same or less time and often with less pain and fewer complications than those with episiotomies. Women who get episiotomies are more likely to end up with serious, deep tears that go close to or through the rectum. Tears that go through the rectum result in more perineal pain after delivery, require a significantly longer recovery period, are more likely to weaken the pelvic floor muscles, result in anal incontinence, and cause more discomfort when sex is resumed.

To help prepare your body for delivery, reduce the risk of tearing and the likelihood you’ll need an episiotomy, eat well and try doing daily Kegel exercises and perineal massage starting five to six weeks before delivery. Good nutrition helps keep your tissues healthy and elastic, which will help them stretch to accommodate your baby.

Kegel exercises strengthen the pelvic floor muscles. To do a Kegel, contract your pelvic floor muscles – these are the ones you use to stop the flow of urine – release and repeat. Perform a set of twenty five of these each day to tone the muscles you’ll use during delivery.

To perform perineal massage, wash your hands thoroughly with soap and hot water and make sure your fingernails are trimmed. Sit comfortably with your legs spread apart. Apply K-Y jelly or other lubricant to your thumbs and insert them in your vagina. Press downward toward your rectum, until you feel a gentle stretching. You may feel a slight burning or other discomfort; don’t be worried, this is normal. However, stop immediately if you feel any sharp pain. Repeat the massage daily for about 8 to 10 minutes per session.

If you do have an episiotomy, or you tear during delivery, your doctor will stitch you up and it will take some time to heal. Try the following to speed healing and ease the discomfort.

• Twenty-four hours after delivery, you can start soaking in a warm tub or sitz bath. A sitz bath is a shallow plastic basin you fill with warm water and place on your toilet seat. This is a convenient way to soak your bottom without taking a full bath in the tub.
• Keep the area dry and exposed to air as much as possible. Blow dry the area for a few minutes after bathing (on low heat and keep the dryer at least 12 inches away from the area), and limit the amount of time you spend sitting until the stitches heal.
• Walking and Kegel exercises will stimulate circulation and promote healing. Perform Kegels every day. You may find it more comfortable to perform them when you are getting out of bed or rolling over, so you don’t feel like you are pulling on your stitches.
• Reduce swelling by applying ice packs.
• Special perineal pads are soothing. These pads fit between a sanitary napkin and the wound. Chilled witch hazel pads are also helpful.
• Avoid constipation and don’t strain to move your bowels. The pressure can stretch your tissue and cause pain around the wound.
• Apply a numbing spray to the area. Numbing sprays are usually available at hospitals.
• Sit carefully, and on one cheek if possible. You may find it more comfortable to sit on hard surfaces, since soft surfaces allow your bottom to stretch and pull on the stitches.

If the wound area becomes hot, swollen, and painful or if it produces a pus-like discharge, you may have an infection and should call your doctor immediately.

An episiotomy is a controversial procedure and you should learn all the facts, discuss it with your doctor, and weigh the benefits and risks carefully before you make a decision. Ask your doctor how often and under what circumstances he performs an episiotomy, and how he might help you avoid spontaneous tearing as well. If you choose not to have an unnecessary episiotomy, express your feelings to your doctor well in advance of delivery, and include instructions in your birth plan.