Do You Need An Episiotomy?
Provided by NoahNet.com Consulting
Episiotomy, the surgical expansion of the vaginal opening during
childbirth, has been done so often and for so long that some professionals
consider it a routine part of the birth process. Like many medical
interventions, however, episiotomy has come under scrutiny in recent
years, as health care providers and patients alike have begun to
question whether the procedure can actually cause more harm than
good in many cases.
What is an episiotomy?
An episiotomy is a surgical incision (cut) made to enlarge the vaginal
opening with the intent of helping the baby pass through more easily
during delivery. One rationale for doing an episiotomy is to forestall
the development of rips or tears around the vaginal opening, which
may occur as the opening stretches to accommodate the baby. After
the birth, the doctor or midwife uses stitches to close up the episiotomy
and any tears.
The two most common types of episiotomy are the midline, or median,
episiotomy and the mediolateral episiotomy.
The Midline Episiotomy In the midline procedure, the doctor or
midwife cuts straight down from the vaginal opening, through the
skin and the tissues directly beneath, for about two inches. This
is an easy cut that causes minimal tissue damage and heals easily,
but it can cause problems if the cut continues to tear further in
the same direction under pressure from the birth. An tear extending
from a midline episiotomy may reach as far as the rectum, creating
a serious wound that is difficult to repair and can lead to fecal
incontinence (loss of control of gas or stool) later in life.
The Mediolateral Episiotomy The mediolateral episiotomy is done
at an angle from the lower part of the vaginal opening. This procedure
is designed to reduce the chance that any additional tearing from
the episiotomy will reach the rectum, although such tears may still
happen. This type of episiotomy, however, involves more deep muscle
and causes more blood loss, so recovery is more painful.
If you have an episiotomy, it will take several weeks to heal.
Your provider will give you instructions on keeping the area clean
to prevent infection. The site of the episiotomy will be very painful
for the first few days, and sore for at least a few weeks. Your
provider may give you painkillers or an anesthetic spray to reduce
the pain. Until the episiotomy heals, you may wish to sit on a cushion
or a special donut-shaped pillow. At your next appointment -- usually
six weeks after birth -- your provider will check to make sure there
is no sign of infection or other problems.
Why do an episiotomy?
As unpleasant as this description sounds, there are several situations
in which an episiotomy is considered a medical necessity, and possibly
a means of avoiding the far more extensive procedure of cesarean
birth (C-section, in which the baby is removed surgically through
the abdomen). For example:
If the fetus is in distress (having physical trouble during birth)
or the mother is too exhausted from labor to push the baby out,
an episiotomy can reduce the length of labor and speed the delivery
of the baby.
If the mother is delivering earlier than term, then an episiotomy
can reduce the pressure on the delicate head of the premature baby.
If the provider must use forceps (a special pair of tongs) to pull
out a baby who is stuck in the birth canal, an episiotomy may be
necessary to make room for the forceps.
If the baby is breech (coming out bottom-first), then an episiotomy
can assist in speeding and easing the delivery with less risk to
the baby.
Many episiotomies, however, are performed for a reason other than
the above: to minimize damage to the tissues around the vaginal
opening. It has long been assumed that the clean cut of an episiotomy
will heal faster and better than the tears that can occur naturally
during labor, and that a single, carefully placed cut is less likely
to cause severe damage than an unpredictable tear. If the damage
is controlled and repair straightforward, the reasoning goes, the
woman will have less risk of problems later from the weakening of
structural tissues and the loss of muscle function.
Recent research, however, has suggested that episiotomy does not
necessarily heal faster than a natural tear and that it does not
reduce the amount of damage to the tissue involved, perhaps because
tears tend to be only skin deep, while an episiotomy cuts more deeply
into muscle. The assumption that an episiotomy decreases the risk
of a severe tear also is being reevaluated, given evidence that
an episiotomy may encourage further tearing at the already-cut episiotomy
site -- meaning that episiotomy may actually increase the chance
of a severe tear that extends to the rectum.
In light of such concerns, the episiotomy rate has fallen considerably
over the past 30 years. Once performed in almost every birth, especially
among first-time mothers, episiotomies are now far less frequent,
with some hospitals reporting rates of 20 percent or less.
Will you have an episiotomy?
Given the wide differences of opinion on episiotomy, your chances
for having one depend a great deal on the opinion and practices
of your provider. You should ask your provider what he or she thinks
about the advantages and disadvantages of the procedure, and in
what circumstances he or she performs it. If you wish to avoid an
episiotomy, you should seek out a provider who believes that episiotomy
is not necessary in most circumstances. Then make your preference
clear, both well in advance of the birth, and again at the time
of labor.
How can you reduce your chances of needing an episiotomy?
If you would like to avoid an episiotomy, here are a few steps you
can take to reduce your chances of having one:
Attend childbirth classes to prepare yourself and your partner
for the events and sensations of labor and to learn how to work
with labor.
Use warm compresses against the perineum. Some midwives use ginger
water or lubricants at this time.
Listen to the directions of your midwife or doctor during the second
stage of labor, when he or she tells you when to push and when not
to push. Some labor coaches and providers point out that a slow,
controlled delivery of the head allows for gradual expansion of
the vaginal opening with each push, and is less likely to prompt
tearing than a sudden, intense effort.
Possibly the best way both to avoid an episiotomy and to minimize
tearing is to loosen and stretch the tissues of the vaginal opening
well in advance of labor. The technique for doing this, called perineal
massage, involves exercises to gently stretch the tissues on a daily
basis for several weeks preceding delivery. You can do this yourself,
or your partner can assist you. Ask your health care provider for
directions, or search on the Internet under the keywords perineal
massage.
In the end, however, you will have to trust your provider to use
his or her best judgment at the time of the birth. Choose a provider
whose beliefs are compatible with yours and who will listen to and
respect your wishes. If an episiotomy is necessary, your provider
should inform you of the reason.
Last Reviewed: June 3 2002 by M. Kelly Shanahan, M.D.
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