I decided to write a few words about episiotomy as well, because it’s one of the key topics when we talk about childbirth. And I know this will also spark a lot of debate.
Episiotomy is a surgical incision of the perineum in the final stage of the second stage of labour. The procedure is performed with scissors and requires wound repair with suturing (Carroli and Belizan, 2007).
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Episiotomy is a word that comes from Greek, from the words episesion (shame) and temno (I cut) (Pschyrembel, 1975, cited in Polančec, 2001). Episiotomy is a surgical incision of the perineum. The incision includes cutting the perineal skin, the superficial layer of the pelvic floor muscles, and the back wall of the vagina. It is performed in the second stage of labour with the aim of widening the birth canal and thus speeding up birth and preventing tears. This can speed up labour, but only if the presenting part of the baby is already engaged at the vaginal outlet and is pressing on the outlet tissues. If an episiotomy is performed too early, bleeding increases because the presenting part is not pressing on the outlet tissues and therefore does not create compression of the blood vessels in that area. There is also a risk that the perineum may already start to tear (Myles, 2009).
Episiotomy is indicated when the second stage of labour needs to be shortened and the vaginal outlet needs to be widened. Situations that meet these requirements are fetal distress, shoulder dystocia, or operative completion of birth. Other indications sometimes accepted include significant spontaneous lacerations at the time of birth, which can occur with a low perineum, previous tears, or very large babies. The last two studies did not show that either type of episiotomy—mediolateral or median—prevents severe perineal tears, facilitates operative birth, or improves newborn outcomes. The studies did not take the type of episiotomy into account (Myles, 2003; Bodner, 2003, cited in Hale and Ling, 2007). The authors believe the criteria are insufficient to make recommendations, so clinical judgement remains the most important (Hale and Ling, 2007).
There are several types of episiotomy:
- Lateral episiotomy, which is not recommended due to issues such as increased bleeding, levator ani muscle dysfunction, and dysfunction of the Bartholin’s ducts.
- Schuchardt episiotomy (incision) is a maximally extended mediolateral episiotomy that curves semicircularly around the rectum in an arc; it is used only when more room for manipulation is needed.
- J-shaped episiotomy (incision): this cut starts in the middle of the posterior fourchette and runs along the midline (2 cm), then curves outward to avoid the anus. This type of incision is difficult to suture and the wound heals less well (Polančec, 2001).
Since mediolateral episiotomy is performed here, let’s take a closer look at it:
With mediolateral episiotomy, some authors also believe it is necessary to ensure preventive pain relief. Most experts recommend making the incision just before the birth of the presenting part, otherwise bleeding with mediolateral episiotomy is increased (Hale and Ling, 2007). You need to wait for the blood vessels in the perineal area to be compressed under the pressure of the baby’s head, which also reduces bleeding. When we decide to make the incision, we insert fingers into the vagina, between the perineum and the baby’s head. The incision is made from the middle of the posterior fourchette toward the ischial tuberosity at a 45° angle. The incision can be made to the right or left side of the perineum. It’s important to use long, sharp scissors that allow the cut to be made in one smooth, four-centimetre-long incision. If the incision is too short, there is a chance the perineum will not widen enough and an additional cut will be needed, which is not recommended due to difficulties with later suturing and wound healing (Hale and Ling, 2007). A mediolateral incision avoids the risk of injury to the anal sphincter and the Bartholin’s gland. However, the wound is harder to suture and healing is more painful (Myles, 2009).
The perineum should be adequately numbed before the episiotomy incision itself. For this, we can use the anaesthetic lidocaine (0.5% in 10 ml or 1% in 5 ml); the more concentrated preparation is preferred because of the smaller volume. You need to wait 3–4 minutes for the anaesthetic to take effect, which is two or three contractions. The infiltration time is otherwise harder to calculate, but it is better to administer the anaesthetic and not make the incision than to make the incision without adequate analgesia (Myles, 2009). Before infiltration, the perineum is cleaned with an antiseptic solution, two fingers are inserted into the vagina, and under finger control the anaesthetic is infiltrated into the planned episiotomy area. Infiltrate 4–5 centimetres into the perineal subcutaneous tissue. Before injecting, aspirate the needle to check that you have not punctured a blood vessel. If you have, reposition the needle and repeat aspiration. The injection is performed while slowly withdrawing the needle from the perineum (Myles, 2009).
The SOGC Clinical Practice Guidelines for Operative Vaginal Birth (2004) state that it has not been proven that routine episiotomy effectively reduces the length of the second stage of labour. It is also not proven to reduce birth trauma; it may even increase it. Median episiotomy is associated with a higher number of third- and fourth-degree tears in both spontaneous and operative births.
NICE guidelines (2007) advise discontinuing routine episiotomy in spontaneous vaginal births. When an episiotomy is performed, a mediolateral episiotomy is recommended, performed to the woman’s right side. The angle of the incision should be between 45° and 60°. The incision should be performed only when there is a clinical need, such as fetal distress or operative completion of birth. Appropriate anaesthesia should be provided before episiotomy, except in an emergency such as fetal distress. Episiotomy must not be done preventively in first-time mothers, nor in cases of previous third- or fourth-degree perineal tears. The woman must be informed about all procedures that will be carried out, and all benefits, drawbacks, and possible complications must be explained to her.
The Patients’ Rights Act (2008, p. 1048–49) states: “A patient has the right, for the purpose of exercising the right to make independent decisions about treatment and the right to participate in the treatment process, to be informed about their health condition and the likely course and consequences of the illness or injury, the purpose, type and manner of performance, the likelihood of success, and the expected benefits and outcome of the proposed medical procedure or proposed treatment, possible risks, side effects, adverse consequences and other inconveniences of the proposed medical procedure or proposed treatment, including the consequences of refusing it, possible other treatment options, procedures and methods of treatment that are not available in the Republic of Slovenia or are not covered by compulsory health insurance.”
The explanations from the previous paragraph must be provided by the doctor responsible for treatment in direct contact, considerately, in a way the patient can understand, or in line with the individual’s ability to process information, fully and in a timely manner. The patient has the right to ongoing and detailed information about the course of treatment and, after the medical procedure or treatment, the right to be informed about the result of treatment or any possible complications (ZPacP, 2008). A woman must be informed about episiotomy in a way that makes her aware of the benefits and drawbacks of the procedure. All of the woman’s wishes and decisions must be documented and also respected (Myles, 2009).
Reconstruction: The right choice of suture material, needle, suturing technique, and knotting are key factors for successful wound reconstruction (Smrkolj, 2006). Performing and caring for an episiotomy is very important, as it significantly affects quality of (sexual) life. It is also important to inform the woman during labour about the possible performance of an episiotomy and to respect her decisions (Patients’ Rights Act, 2008).
Under EU Directive 36/2005 (Sectoral Directive on the recognition of professional qualifications, 2005), a future midwife must gain experience in performing episiotomy and be introduced to wound suturing. This requires knowledge of the anatomy and physiology of the pelvic floor, performing episiotomy, suturing, and the techniques and materials used.
Massage can prepare the perineum so it is softer and more stretchy during birth, which can make labour easier. The benefits of this kind of massage are improved blood flow to the perineum, greater flexibility and elasticity, reduced risk of tearing and the need for episiotomy, and it helps the woman focus more easily on the opening of the birth canal. It can also help with previous perineal injuries. Massage is recommended from the 34th week of pregnancy onwards and can be done by the pregnant woman herself or by her partner if she wishes. It should be done after a bath, when the perineum is warm, and different lubricants or oils can be used to make the massage more comfortable (Burns, 2011).
Read also:
- Preparing the perineum for birth
- The pelvic floor and pelvic floor muscles
- Techniques and procedures that help preserve the perineum
- Birth positions
- The pelvic floor and pelvic floor muscles
- Perineal injuries
This article is taken from Matjaž Leben’s thesis – Episiotomy and Reconstruction (2013), supervised by Assist. Prof. Miha Lučovnik, PhD, and co-supervised by Anita Prelec, RN, MSc (UK), senior lecturer.
