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Episiotomy

Episiotomy

Definition

An episiotomy is a surgical incision made in the perineum, the area between the vagina and anus. Episiotomies are done during the second stage of labor to expand the opening of the vagina to prevent tearing of the area during the delivery of the baby.


Purpose

An episiotomy is usually done during the birthing process in order to deliver a baby without tearing the perineum and surrounding tissue. Reasons for an episiotomy include:

  • Evidence of maternal or fetal distress (i.e. no time to allow perineum to stretch).
  • The baby is premature or in breech position, and his/her head could be damaged by a tight perineum.
  • The baby is too large to be delivered without causing extensive tearing.
  • The delivery is being assisted by forceps.
  • The mother is too tired or unable to push.
  • Existing trauma to the perineum.

Some experts believe that an episiotomy speeds up the birthing process, making it easier for the baby to be delivered. Speed can be important if there is any sign of distress that may harm the mother or baby. Because tissues in this area may tear during the delivery, another reason for performing an episiotomy is that a clean incision is easier to repair than a jagged tear and may heal faster. Although episiotomies are sometimes described as protecting the pelvic muscles and possibly preventing future problems with urinary incontinence, it is not clear that the procedure actually helps.


Demographics

In 2000, one study calculated the percentage of episiotomies performed in the United States out of all vaginal deliveries to be 19.4%. This was a dramatic reduction from the 1983 rate of 69.4%. Episiotomy rates were higher among white women (32.1%) than African American women (11.2%). Similar differences have been reported in other obstetric procedures (e.g. cesarean section and epidural use).

Episiotomy rates differ according to care providerpatients of midwives have lower rates than patients of medical doctors. One study comparing perineal outcomes for women being cared for by midwives or medical doctors found the episiotomy rate among midwives at 25% and 40% among medical doctors. Younger doctors are also less likely to perform an episiotomy than older doctors; one study found the rate of episiotomies performed by residents to be 17%, while the rate among doctors in private practice was 66%.


Description

An episiotomy is a surgical incision, usually made with sterile scissors, in the perineum as the baby's head is being delivered. This procedure may be used if the tissue around the vaginal opening begins to tear or does not seem to be stretching enough to allow the baby to be delivered.

In most cases, the physician makes a midline incision along a straight line from the lowest edge of the vaginal opening toward the anus. In other cases, the episiotomy is performed by making a diagonal incision across the midline between the vagina and anus (called a mediolateral incision). This method is used much less often, may be more painful, and may require more healing time than the midline incision. After the baby is delivered through the extended vaginal opening, the incision is closed with stitches. A local anesthetic may be applied or injected to numb the area before it is sewn up (sutured).

Episiotomies are classified according to the depth of the incision:

  • A first-degree episiotomy cuts through skin only (vaginal/lierineal).
  • A second-degree episiotomy involves skin and muscle and extends midway between the vagina and the anus.
  • A third-degree episiotomy cuts through skin, muscle, and the rectal sphincter.


  • A fourth-degree episiotomy extends through the rectum and cuts through skin, muscle, the rectal sphincter, and anal wall.

Diagnosis/Preparation

Although there are some reasons for anticipating an episiotomy before labor has begun (e.g. breech presentation of the baby), the decision to perform an episiotomy is generally not made until the second stage of labor, when delivery of the baby is imminent.


Aftercare

The area of the episiotomy may be uncomfortable or even painful for several days. Several practices can relieve some of the pain. Cold packs can be applied to the perineal area to reduce swelling and discomfort. Use of a sitz bath can ease the discomfort. This unit circulates warm water over the area. A squirt bottle with water can be used to clean the area after urination or defecation rather than wiping with tissue. Also, the area should be patted dry rather than wiped. Cleansing pads soaked in witch hazel (such as the brand Tucks) are very effective for soothing and cleaning the perineum.


Risks

Several side effects of episiotomy have been reported, including infection (in 0.3% of cases), increased pain, increased bleeding, prolonged healing time, and increased discomfort once sexual intercourse is resumed. There is also the risk that the incision will be deeper or longer than is necessary to permit the birth of the infant. An incision that is too long or deep may extend into the rectum, causing more bleeding and an increased risk of infection. Additional tearing or tissue damage may occur beyond the episiotomy itself.


Normal results

In a normal and well-managed delivery, an episiotomy may be avoided altogether. If an episiotomy is considered necessary, a simple midline incision will be made to extend the vaginal opening without additional tearing or extensive trauma to the perineal area. Although there may be some pain associated with the healing of the incision, relief can usually be provided with mild pain relievers and supportive measures, such as the application of cold packs.


Morbidity and mortality rates

Studies have found that the rates of urinary/fecal incontinence, postpartum perineal pain, and sexual dysfunction are generally the same between women who have had an episiotomy and those who had a spontaneous tear of the perineum. There does appear to be a higher risk of more extensive perineal trauma when an episiotomy is performed (20.9% experienced third- or fourth-degree lacerations) then when it is not (3.1% experienced major perineal damage).

Alternatives

It may be possible to avoid the need for an episiotomy. Pregnant women may want to talk with their care providers about the use of episiotomy during the delivery. Kegel exercises are often recommended during the pregnancy to help strengthen the pelvic floor muscles. Prenatal perineal massage may help to stretch and relax the tissue around the vaginal opening. During the delivery process, warm compresses can be applied to the area along with the use of perineal massage. Coaching and support are also important during the delivery process. Slowed, spontaneous pushing during the second stage of labor (when the mother gets the urge to push) may allow the tissues to stretch rather than tear. Also, an upright birthing position (rather than one where the mother is lying down) may decrease the need for an episiotomy.


Resources

books

Enkin, Murray, Marc Keirse, James Neilson, et al. A guide to effective care in pregnancy and childbirth. Third edition. Oxford: Oxford University Press, 2000.


periodicals

Carroli, G., and J. Belizan. "Episiotomy for vaginal birth." The Cochrane Library (2000).

Goldberg, Jay, David Holtz, Terry Hyslop, and Jorge Tolosa. "Has the Use of Routine Episiotomy Decreased? Examination of Episiotomy Rates From 1983 to 2000." Obstetrics and Gynecology 99 (March 2002): 395400.

Kane-Low, Lisa, Julia Seng, Terri Murtland, and Deborah Oakley. "Clinician-specific episiotomy rates: Impact on perineal outcomes." Journal of Midwifery and Women's Health 45 (March 2000): 8793.

Klein, M. C., R. J. Gauthier, J. Kaczorowski, et al. "Relationship of Episiotomy to Perineal Trauma and Morbidity, Sexual Dysfunction, and Pelvic Floor Relaxation." American Journal of Obstetrics and Gynecology 171 (1994): 5918.

McCandlish, Rona. "Perineal Trauma: Prevention and Treatment." Journal of Midwifery and Women's Health 46 (November 2001): 396401.

Roberts, Joyce E. "The 'Push' for Evidence: Management of the Second Stage." Journal of Midwifery and Women's Health 47 (January 2002): 215.

Yokoe, Deborah, Cindy Christiansen, Ruth Johnson, et al. "Epidemiology of and Surveillance for Postpartum Infections." Emerging Infectious Diseases 7 (2001).


organizations

American College of Nurse-Midwives. 818 Connecticut Ave., NW, Suite 900, Washington, DC 20006. (202) 728-9860. <http://www.midwife.org>.

American College of Obstetricians and Gynecologists. 409 12th St., SW, PO Box 96920, Washington, DC 20090-6920. <http://www.acog.org>.

midwives alliance of north america. 4805 lawrenceville highway, suite 116-279, lilburn, ga 30047. (888) 923-mana. <http://www.mana.org>.

other

"episiotomy faq sheet." perinatal education associates, inc. 2002 [cited february 25, 2003]. <http://www.birthsource.com/proarticlefile/proarticle98.html>.

marcus, adam. "episiotomy rates dropping in u.s." healthfinder. may 7, 2002 [cited february 25, 2003]. <http://www.healthfinder.gov/news/newsstory.asp?docid=507067>.


Altha Roberts Edgren Stephanie Dionne Sherk

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?


An episiotomy is performed by the health care provider attending to a woman's labor and delivery, typically an obstetrician/gynecologist or midwife. An obstetrician/gynecologist is a medical doctor who has completed specialized training in the areas of women's general health, pregnancy, labor and childbirth, prenatal testing, and genetics. A midwife is a person who has been trained to provide care, support, and supervision to women in all stages of pregnancy, labor, delivery, and the postpartum period. The procedure is performed at the site of labor and delivery, most often a hospital or birth center.

QUESTIONS TO ASK THE DOCTOR


  • What is your episiotomy rate?
  • For what reasons would you perform an episiotomy?
  • What are my alternatives to having an episiotomy?
  • How should I care for my episiotomy when I return home?

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"Episiotomy." Gale Encyclopedia of Surgery: A Guide for Patients and Caregivers. . Encyclopedia.com. 21 Oct. 2017 <http://www.encyclopedia.com>.

"Episiotomy." Gale Encyclopedia of Surgery: A Guide for Patients and Caregivers. . Encyclopedia.com. (October 21, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/episiotomy-1

"Episiotomy." Gale Encyclopedia of Surgery: A Guide for Patients and Caregivers. . Retrieved October 21, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/episiotomy-1

Episiotomy

Episiotomy

Definition

An episiotomy is a surgical incision made in the area between the vagina and anus (perineum). This is done during the last stages of labor and delivery to expand the opening of the vagina to prevent tearing during the delivery of the baby.

Purpose

This procedure is usually done during the delivery or birthing process when the vaginal opening does not stretch enough to allow the baby to be delivered without tearing the surrounding tissue.

Precautions

Prior to the onset of labor, pregnant women may want to discuss the use of episiotomy with their care providers. It is possible that, with adequate preparation and if the stages of labor and delivery are managed with adequate coaching and support, the need for an episiotomy may be reduced.

Description

An episiotomy is a surgical incision, usually made with sterile scissors, in the perineum as the baby's head is being delivered. This procedure may be used if the tissue around the vaginal opening begins tearing or does not seem to be stretching enough to allow the baby to be delivered.

In most cases, the physician makes a midline incision along a straight line from the lowest edge of the vaginal opening to toward the anus. In other cases, the episiotomy is performed by making a diagonal incision across the midline between the vagina and anus. This method is used much less often, may be more painful, and may require more healing time than the midline incision. After the baby is delivered through the extended vaginal opening, the incision is closed with stitches. A local anesthetic agent may be applied or injected to numb the area before it is sewn up (sutured).

Several reasons are cited for performing episiotomies. Some experts believe that an episiotomy speeds up the birthing process, making it easier for the baby to be delivered. This can be important if there is any sign of distress that may harm the mother or baby. Because tissues in this area may tear during the delivery, another reason for performing an episiotomy is that a clean incision is easier to repair than a jagged tear and may heal faster. Although the use of episiotomy is sometimes described as protecting the pelvic muscles and possibly preventing future problems with urinary incontinence, it is not clear that the procedure actually helps.

The use of episiotomy during the birthing process is fairly widespread in the United States. Estimates of episiotomy use in hospitals range from 65-95% of deliveries, depending on how many times the mother has given birth previously. This routine use of episiotomy is being reexamined in many hospitals and health care settings. However, an episiotomy is always necessary during a forceps delivery because of the size of the forceps.

Preparation

It may be possible to avoid the need for an episiotomy. Pregnant women may want to talk with their care providers about the use of episiotomy during the delivery. Kegel exercises are often recommended during the pregnancy to help strengthen the pelvic floor muscles. Prenatal perineal massage may help to stretch and relax the tissue around the vaginal opening. During the delivery process, warm compresses can be applied to the area along with the use of perineal massage. Coaching and support are also important during the delivery process. A slowed, controlled pushing during the second stage of labor (when the mother gets the urge to push) may allow the tissues to stretch rather than tear. Also, an upright birthing position (rather than one where the mother is lying down) may decrease the need for an episiotomy.

Aftercare

The area of the episiotomy may be uncomfortable or even painful for several days. Several practices can relieve some of the pain. Cold packs can be applied to the perineal area to reduce swelling and discomfort. Use of the Sitz bath available at the hospital or birth center can ease the discomfort, too. This unit circulates warm water over the area. A squirt bottle with water can be used to clean the area after urination or defecation rather than wiping with tissue. Also, the area should be patted dry rather than wiped. Cleansing pads soaked in witch hazel (such as Tucks) are very effective for cleaning the area and also feel soothing.

Risks

Several side effects of episiotomy have been reported, including infection, increased pain, prolonged healing time, and increased discomfort once sexual intercourse is resumed. There is also the risk that the episiotomy incision will be deeper or longer than is necessary to permit the birth of the infant. There is a risk of increased bleeding.

Normal results

In a normal and well managed delivery, an episiotomy may be avoided altogether. If an episiotomy is deemed to be necessary, a simple midline incision will be made to extend the vaginal opening without additional tearing or extensive trauma to the perineal area. Although there may be some pain associated with the healing of the episiotomy incision, relief can usually be provided with mild pain relievers and supportive measures, such as the application of cold packs.

Abnormal results

An episiotomy incision that is too long or deep may extend into the rectum, causing more bleeding and an increased risk of infection. Additional tearing or tissue damage may occur beyond the episiotomy incision, leaving a cut and a tear to be repaired.

Resources

OTHER

Childbirth.org. http://www.childbirth.org.

KEY TERMS

Kegel exercises A series of contractions and relaxations of the muscles in the perineal area. These exercises are thought to strengthen the pelvic floor and may help prevent urinary incontinence in women.

Perineum The area between the opening of the vagina and the anus in a woman, or the area between the scrotum and the anus in a man.

Sitz bath A shallow tub or bowl, sometimes mounted above a toilet, that allows the perineum and buttocks to be immersed in circulating water.

Urinary incontinence The inability to prevent the leakage or discharge of urine. This situation becomes more common as people age, and is more common in women who have given birth to more than one child.

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"Episiotomy." Gale Encyclopedia of Medicine, 3rd ed.. . Encyclopedia.com. 21 Oct. 2017 <http://www.encyclopedia.com>.

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"Episiotomy." Gale Encyclopedia of Medicine, 3rd ed.. . Retrieved October 21, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/episiotomy-0

episiotomy

episiotomy Once memorably described as ‘the unkindest cut of all’, episiotomy is a surgical cut in the perineum that is effected by knife or scissors shortly before delivery of a baby. The procedure has undoubted merit when there are signs of distress in the baby, or a need for forceps delivery, or where there is a risk of serious and extensive tearing of tissues. However, episiotomy has been applied, in some countries, to an extent that is almost routine; thus hence the controversial nature of this procedure. The wound is stitched immediately after delivery.

J. Neilson


See also birth; labour.

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episiotomy

e·pi·si·ot·o·my / iˌpēzēˈätəmē/ • n. (pl. -mies) a surgical cut made at the opening of the vagina during childbirth, to prevent rupture of tissues.

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episiotomy

episiotomy (ep-izi-ot-ŏmi) n. an incision into the perineum during a difficult birth. The aim is to make delivery easier and to avoid extensive tearing of adjacent tissues.

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