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Episiotomy: Procedure, Complications, and Recovery

What is an episiotomy?

An episiotomy is a surgical cut made in the perineum during childbirth. The perineum is the muscular area between the vagina and the anus. After you’re given local anesthesia to numb the area, your doctor makes an incision to enlarge your vaginal opening before you deliver your baby.

An episiotomy used to be a normal part of childbirth, but it has become less common in recent years. In the past, an episiotomy was done to prevent severe vaginal tears during delivery. It was also believed that an episiotomy would heal better than a natural or spontaneous tear.

More recent research, however, suggests that an episiotomy may actually cause more problems than it prevents. The procedure can increase the risk of infection and other complications. Recovery also tends to be lengthy and uncomfortable. For these reasons, today an episiotomy is now only performed under certain circumstances.

Reasons for episiotomy

Sometimes the decision to perform an episiotomy must be made quickly by a doctor or midwife at the time of delivery. Here are common reasons for an episiotomy.

Speed prolonged labor

In cases of fetal distress (changes in the fetal heart rate), maternal exhaustion, or a prolonged second stage of labor, an episiotomy may expedite delivery. After the baby reaches the vaginal opening, the doctor can make extra room for the head to pass by performing an episiotomy. It shortens the time to delivery.

If there’s fetal distress and the only obstruction to delivery is pressure at the vaginal opening, an episiotomy may prevent the need for vacuum extraction or a forceps-assisted vaginal delivery.

Assist with a vaginal delivery

When a vacuum extraction or forceps-assisted vaginal delivery is performed, an episiotomy can make the procedure easier by reducing resistance from the vaginal opening and allowing delivery with less force to the baby's head. The rapid descent of the baby with vacuum or forceps delivery often causes laceration or tearing of the vaginal opening. In these cases, an episiotomy may prevent excessive tearing.

Breech presentation

If a baby is in a breech presentation (the baby's bottom is in position to pass through the cervix before the baby's head), an episiotomy may provide additional room for maneuvering and placement of forceps to aid in delivery of the baby's head.

Delivery of a large baby

Shoulder dystocia is a problem that can occur when delivering large babies. It refers to entrapment of the baby's shoulders within the birth canal. This complication is common in women who have diabetes, but can occur in any woman delivering a large baby. An episiotomy allows more room for the shoulders to pass through. It’s essential for the successful delivery of the baby.

Previous pelvic surgery

Vaginal deliveries may result in long-term complications, including relaxation of the vaginal walls. This can cause the bladder, cervix, uterus, or rectum to bulge through the vaginal wall. Women who undergo reconstructive surgery to repair problems with the vaginal wall shouldn’t attempt another vaginal delivery. There's a risk of injuring or destroying the repair. If an expecting mother insists on a vaginal delivery following pelvic reconstructive surgery, an episiotomy may facilitate the delivery and prevent further damage to repaired areas.

Abnormal position of a baby’s head

Under normal circumstances, the baby descends through the birth canal with its face toward the mother's tailbone. This position, called the occiput anterior presentation, allows the smallest diameter of the head to pass through the vaginal opening and makes for an easier, quicker delivery.

Sometimes the baby's head is in an abnormal position. If the baby's head is tilted slightly to one side (asynclitic presentation), facing toward one of the mother's hips (occiput transverse presentation), or facing toward the mother's bellybutton (occiput posterior presentation), a larger diameter of the baby's head will need to pass through the birth canal.

In cases of occiput posterior presentation, there is more likely to be significant vaginal trauma during the delivery. An episiotomy may be required to enlarge the vaginal opening.

Delivery of twins

During delivery of multiple babies, an episiotomy allows additional room at the vaginal opening for delivering the second twin. In cases where both twins are in a headfirst position, the doctor may slow delivery of the second twin by performing an episiotomy. In a situation where the first twin is delivered normally and the second twin must be delivered from a breech position, episiotomy allows adequate room for the breech delivery.

Episiotomy type

The two most common types of episiotomy are midline episiotomy and mediolateral episiotomy.

Midline episiotomy

In a midline episiotomy, the incision is made in the middle of the vaginal opening, straight down toward the anus. 

The advantages of a midline episiotomy include easy repair and improved healing. This type of episiotomy is also less painful and is less likely to result in long-term tenderness or pain during sexual intercourse. There is often less blood loss with a midline episiotomy as well.

The main disadvantage of a midline episiotomy is the increased risk for tears that extend into or through the anal muscles. This type of injury can result in long-term problems, including fecal incontinence, or the inability to control bowl movements.

Mediolateral episiotomy

In a mediolateral episiotomy, the incision begins in the middle of the vaginal opening and extends down toward the buttocks at a 45-degree angle. 

The primary advantage of a mediolateral episiotomy is that the risk for anal muscle tears is much lower. However, there are many more disadvantages associated with this type of episiotomy, including:

  • increased blood loss
  • more severe pain
  • difficult repair
  • higher risk of long-term discomfort, especially during sexual intercourse 

Episiotomies are classified by degrees that are based on the severity or extent of the tear:

  • First degree: A first-degree episiotomy consists of a small tear that only extends through the lining of the vagina. It doesn’t involve the underlying tissues.
  • Second degree: This is the most common type of episiotomy. It extends through the vaginal lining as well as the vaginal tissue. However, it doesn’t involve the rectal lining or anal sphincter.
  • Third degree: A third-degree tear involves the vaginal lining, the vaginal tissues, and part of the anal sphincter.
  • Fourth degree: The most severe type of episiotomy includes the vaginal lining, vaginal tissues, anal sphincter, and rectal lining. 

Episiotomy complications

Although an episiotomy is necessary for some women, there are risks associated with this procedure. Possible complications include:

  • painful sexual intercourse in the future
  • infection
  • swelling
  • hematoma (collection of blood at the site)
  • leaking of gas or stool due to tearing of rectal tissue
  • bleeding

Episiotomy recovery

An episiotomy is usually repaired within an hour after delivery. The incision may bleed quite a bit at first, but should stop once your doctor closes the wound with sutures. Since the sutures dissolve on their own, you won’t need to return to the hospital to have them removed. The sutures should disappear within one month. Your doctor may suggest avoiding certain activities during recovery. 

After having an episiotomy, it’s normal to feel pain around the incision site for two to three weeks. Women who have third- or fourth-degree episiotomies are more likely to experience discomfort for a longer period of time. The pain may become more noticeable while walking or sitting. Urinating can also cause the cut to sting. 

To reduce pain:

  • apply cold packs on the perineum
  • use personal lubricant during sexual intercourse
  • take a stool softener, pain medications, or use medicated pads
  • sit in a sitz bath
  • use a squirt bottle instead of toilet paper to clean yourself after using the toilet 

Ask your doctor about safe pain medication to take if you're breast-feeding, and don’t wear tampons or douche until your doctor says it’s OK.

Your incision should completely heal within four to six weeks after delivery. The recovery time may be slightly longer if you had a third- or fourth-degree episiotomy.

Contact your doctor if you have bleeding, foul-smelling drainage, or severe pain at the episiotomy site. Also seek medical care if you experience a fever or chills.

Bottom line

An episiotomy isn’t performed on a routine basis. Your doctor must make this decision at the time of delivery. An open dialogue during prenatal care visits and at the time of delivery is a critical part of the decision-making process.

Talk to your doctor about ways to prevent an episiotomy. For example, applying a warm compress or mineral oil to the area between the vaginal opening and anus during labor may prevent tears. Massaging this area during labor can also prevent tearing. To prepare for a vaginal delivery, you can start massaging this area at home as early as six weeks before your due date. 

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