Overview of Episiotomy
An episiotomy is a surgical incision through the perineum (a region in the pelvis, situated between the legs) to enlarge the vaginal opening in order to provide sufficient space during the delivery. It is done to prevent laceration of the perineum and rectum. An incision is made into the perineum (skin and muscles between the vaginal opening and anus) to facilitate the birthing under local anesthesia. Additionally, it alleviates the risk of spontaneous tearing of the perineum and fetal trauma during delivery..
What are the types of episiotomy?
There are three types of episiotomies, depending on the placement of incision:
● Midline (median) episiotomy: A vertical incision is made from the middle of the vaginal opening towards the anus.
● Medio-lateral episiotomy: The incision is directed in the mid of the vaginal opening that extends down to the buttock area with an angle of 45 degrees. It also lowers the risk of an anal muscle tear.
● Lateral episiotomy: Very rarely done due to the risk of injuring the underlying muscle. The incision starts 1 cm from the fourchette region.
What could have been the possible benefits of episiotomy?
The main purpose of episiotomy is to prevent multiple and irregular muscle tears, which may occur if you are pushing too fast or harder. An episiotomy is most commonly done in the first pregnancy when the perineum is not so elastic and unable to stretch rather than in the second or subsequent pregnancies. It was believed that episiotomy:
● Could prevent incontinence (inability to control bowel or urinary movements).
● Protect the pelvic region.
● Reduce the risk of trauma to the child.
What are the situations where episiotomy becomes an absolute necessity?
Decreased fetal heart rate stresses the baby , necessitating an emergency delivery. Fetal distress is a condition where the baby’s heart rate may be too fast or slow. This may lead to decreased oxygen supply to the baby, causing complications . To prevent this, an episiotomy is carried out. However, some other conditions include the following:
● The baby is big.
● If forceps delivery is necessary, to make space, an episiotomy may be done.
● Chances of perineum tear.
● Short perineum.
● Shoulder dystocia (when one or both the shoulders of the baby get stuck).
Is episiotomy an absolute necessity in every pregnancy?
After evaluating many reports and cases, it can be concluded that there is a wide variation of episiotomy incidence, and the decision to make it is usually linked to the actual clinical situation. An experienced obstetrician will be able to take a call based on the patient’s need. It will not be necessary in every delivery.
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What are the complications of episiotomy?
● Bleeding and infection: Infection in episiotomy can be an acute infection or can be chronic, leading to necrotizing fasciitis or muscle necrosis. Acute infection may include only the skin and subcutaneous tissue. The signs are edema and exudation at the point of incision. In necrotizing fasciitis, there could be edema, erythema, blue or brown skin, and gangrene(death of the tissue) . When bleeding is not entirely stopped during the recovery time, it might lead to a hematoma.
● Perineal lacerations: The incidence of sphincter damage increases significantly when associated with a perineal tear. It also increases the chances of obstetric lacerations in subsequent pregnancies.
● Urinary incontinence: Due to damage to the pelvic floor, the risk of urinary incontinence may occur.
● Rectal incontinence: Frequent incontinence of flatus (gas discharge) is common.
● Dyspareunia and sexual dysfunction: Dyspareunia (painful intercourse) and sexual dysfunction are common side-effects after episiotomy.
When to see the doctor after an episiotomy?
The discomfort and pain are relieved gradually. In case you develop fever or a pustular wound, abnormal discharge from the wound, or urine incontinence it is advised to contact your doctor immediately as this could be the sign of an infection.
How to avoid an episiotomy?
Here are some techniques that you can try to increase the elasticity of your perineum and reduce the need for an episiotomy:
● Perineal massage during the last few weeks of pregnancy has shown to increase the elasticity of the perineum. You should check with your health care provider before beginning the perineal massage.
● In addition to the above, practice certain breathing exercises and pelvic floor exercises.
● Kegel exercise is one exercise one must do religiously throughout your pregnancy. Make Kegel exercise a part of your routine. It can make labor and post-birth recovery easy. Kegel exercise strengthens your pelvic muscles, making labour and delivery more comfortable and far less painful. To do the Kegel exercise , squeeze and hold the vaginal muscles as to stop urine flow for approximately 10 seconds. Repeat this several times during the day.
● When you are in labor, the perineal massages can be continued along with a warm vaginal compress to relax the vaginal muscles.
● You can also try different labor positions. Kneeling on all fours helps you ease out and deliver without the need for an episiotomy. Some deep squatting positions can increase the chances of tearing.
The need for an episiotomy depends on your clinical situation. But you should not hesitate to discuss the risks related to episiotomy with your doctor. Ensure you have cleared all your doubts and get through your labor with an open and calm mind.
Frequently Asked Questions (FAQs)
- How long does it take for an episiotomy stitch to heal?
Complete wound healing will take about a month after birth. The pain will last for around 2-3 weeks, but the stitches take several months to completely disappear.
- What can I do to heal faster after an episiotomy?
a. Take warm water baths after birth to increase circulation and decrease pain. Also, apply ice on the area to prevent swelling.
b. Kegels is one exercise that can help prevent episiotomy and help heal after an episiotomy. Kegel increases circulation decreases swelling and helps in healing. Kegels strengthen the perineal muscles like a hammock.
c. Take the prescription medications or over the counter pain reliever and stool softener.
- Will I need an episiotomy in my subsequent pregnancies?
In most cases, no repeat episiotomy will not be needed, but again it depends on the clinical situation in the next pregnancy. It will be examined based on the needs and necessity during delivery. A few women may have scars from the previous pregnancy, which will not stretch; then a repeat episiotomy may become necessary.
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