Episiotomy

An episiotomy (pronounced /ɛˌpiːziːˈɒtəmiː/) is a surgical incision through the perineum made to enlarge the vagina and assist childbirth. The incision can be midline or at an angle from the posterior end of the vulva, is performed under local anaesthetic (pudendal anesthesia) and is sutured closed after delivery. It is one of the most common medical procedures performed on women, and although its routine use in childbirth has steadily declined in recent decades, it is still widely practiced in Latin America.

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Uses

Many physicians use episiotomies because they believe that it will lessen perineal trauma, minimize postpartum pelvic floor dysfunction by reducing anal sphincter muscle damage, reduce the loss of blood at delivery, and protect against neonatal trauma. In many cases though, episiotomies cause all of these problems.{Thacker, S.B., and H.D. Banta. 1983. Benefits and risks of episiotomy: an interpretative review of the English language literature, 1860-1980. Obstet Gynecol Surv 38(6): 322-38.} Research has shown that natural tears typically are less severe.

Slow delivery of the head, in between contractions will result in the least perineal damage. (Albers, L.L., et al. 2006. Factors Related to Genital Tract Trauma in Normal Spontaneous Vaginal Births. Birth 33(2): 94-100.) Episiotomy is indicated if:

• the baby's shoulders are stuck (When a baby's shoulders are stuck they are stuck behind bony pelvis, not soft tissue, so this indication is disputed)

Controversy about common usage

In various countries, routine episiotomy has been accepted medical practice for many years. Various urban legends circulate on the fact that after very rapid natural births, young doctors would still make episiotomies so as not to displease their professors.

Since about the 1960s, routine episiotomies are rapidly losing popularity among obstetricians and midwives in Europe, Australia and the United States. A nationwide US population study ^[1] suggested that 31% of women having babies in U.S. hospitals received episiotomies in 1997, compared with 56% in 1979. In Latin America it's still popular, where it's done on 90% of hospital births ^[2] and in most cases without the mother's consent. There, routine episiotomy is a major cause of infections, some of them fatal ^[3] .

Recent studies indicate that routine episiotomies should not be performed, as they increase morbidity. This procedure is not helpful for routine patients^[4] Having an episiotomy may increase perineal pain in the postpartum period, resulting in trouble defecating, particularly in midline episiotomies ^[5]. In addition it may complicate sexual intercourse by making it painful ^[6] and replacing erectile tissues in the vulva with fibrotic tissue.

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^[7].

Informed consent

Expectant mothers frequently make "birth plans" during their antenatal care, and are generally encouraged to discuss their views on episiotomy with their caregivers, or as early as possible in labor. In the final stages of delivery the midwife or obstetrician may not have time to discuss the benefits, risks and alternatives without endangering the mother or baby. However, staff restrictions or complications in labour often mean that these plans have to be altered in the course of the birth.

Avoidance

Perineal massage beginning around the 34th week has been shown to reduce perineal damage by 6%^[8].

Controlled delivery of the head that allows slow gradual stretching of the perineal tissue can help in minimising damage to the perineum. Episiotomy is almost never required. Natural tears heal quicker, bleed less because they break fewer blood vessels, and are less painful, so a tear is always preferrable to an episiotomy.

There is also a device which is made to stretch the perineal tissue gradually to train it in preparation for first births. The "Epi-no Birth Trainer" consists of a small inflatable silicone balloon pumped with the same pump as a sphygmomanometer. The Epi-no device has been shown to reduce perineal damage by 50% at first births^[9].

References