The term episiotomy refers to the intentional incision of the vaginal opening to hasten delivery or to avoid or decrease potential tearing. Episiotomy is the most common procedure performed in modern day obstetrics. Some authors estimate that as many as 50 to 60% of patients who deliver vaginally in the will have an episiotomy. Rates of episiotomy vary throughout the rest of the world and may be as low as 30% in some European countries.
The episiotomy procedure was first described in 1742; it subsequently gained widespread acceptance, peaking in the 1920s. Its reported benefits included preservation of the integrity of the pelvic floor and prevention of uterine prolapse and other vaginal trauma. Since the 1920s, the number of women who receive an episiotomy during their delivery has steadily declined. In modern obstetrics, episiotomy is not routinely performed. However, in certain circumstances and when performed by a skilled physician, episiotomy may be beneficial.
Common reasons to perform an episiotomy:
- Prolonged second stage of labor;
- Fetal distress;
- Vaginal delivery requires assistance with use of forceps or a vacuum extractor;
- Baby in a breech presentation;
- Twin or multiple deliveries;
- Large-sized baby;
- Abnormal position of the baby’s head; and
- When the mother has a history of pelvic surgery.
Care of the episiotomy wound begins immediately after delivery and should include a combination of local wound care and pain management. During the first 12 hours after delivery, an ice pack may be helpful in preventing both pain and swelling of the site of the episiotomy. The incision should be kept clean and dry to avoid infection. Frequent sitz baths (soaking the area of the wound in a small amount of warm water for about 20 minutes several times a day), can help keep the area clean. The episiotomy site should also be cleaned after a bowel movement or after urination; this can be accomplished with use of a spray bottle and warm water. A spray bottle may also be used during urination to decrease the pain that occurs when urine comes in contact with the wound. After the site has been sprayed or soaked, the area should be dried by gently blotting with tissue paper (or a hair dryer can be used to dry the area without the irritation of abrasive paper).
The severity of a vaginal episiotomy or tear is often referred to in degrees, depending on the extent of the incision and/or laceration. Third- and fourth-degree episiotomies involve incision of the anal sphincter or the rectal mucosa. In these cases, stool softeners may be employed to prevent further injury or re-injury of the episiotomy site. To facilitate the healing of a larger wound, a patient may be kept on stool softeners for more than a week.
Several studies have evaluated the use of different pain medications in the management of pain associated with episiotomies. The nonsteroidal, anti-inflammatory medications, such as ibuprofen (Motrin), have consistently been found to be the best type of pain reliever. However, acetaminophen (Tylenol) has also been used with encouraging results. When a large episiotomy has been performed, the doctor may prescribe a narcotic medication to help ease the pain.
Patients should avoid the use of tampons or douches in the postpartum period to ensure proper healing and to avoid re-injury of the area. Patients should be instructed to abstain from sexual intercourse until the episiotomy has been reevaluated and is completely healed. This may take up to four to six weeks after delivery.
There are few, if any, reasons for episiotomy to be performed on a routine basis. The doctor or nurse-midwife must make a decision at the time of delivery regarding the need for an episiotomy. Open dialogue between the provider and the patient during prenatal care visits and at the time of delivery is a critical part of the decision making process. There are circumstances when an episiotomy may be very beneficial and may prevent the need for cesarean section or assisted vaginal delivery (with the use of forceps or a vacuum extractor).