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Episiotomies: What are they? Benefits and Drawbacks

Episiotomies: What are they? Benefits and Drawbacks

What’s an Episiotomy?

An episiotomy is a surgical incision made in the perineum — the tissue between the vaginal opening and the anus, performed to enlarge the birth outlet and facilitate delivery of a baby. The incision is usually done during the last part of the second stage of labor or delivery. Doctors will typically inject local anaesthetic in the area where the episiotomy will be cut to numb the pain. If you’re planning a vaginal delivery, here’s what you need to know about episiotomy and childbirth.

The episiotomy tradition

An episiotomy used to be a normal part of childbirth, however in recent years its popularity has decreased. In the past, an episiotomy was done to help prevent severe vaginal tears during delivery. Doctors also believed that an episiotomy would heal better than a natural or spontaneous tear.

A growing body of research has led to a general consensus that episiotomy should not be conducted as a standard practice as it 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. 

Episiotomy is now performed on an individualized basis. It is considered when the baby is in distress, in breech presentation, and there is a complication during delivery, when the baby’s head is too large for the vaginal opening, or when the mother needs a forceps or vacuum-assisted delivery, is not able to control her pushing, or when birth is imminent and the perineum has not had time to stretch slowly.

Types of Episiotomies

Although seven episiotomy incisions are described in literature, only two are commonly practiced.

  • Median (midline, medial) episiotomy. A midline incision is made in the middle of the vaginal opening, straight down toward the anus. It is easier to repair and has improved healing, but has a higher risk of extending into the anal area. This type of injury can result in complications including urinary incontinence, or the inability to control bowel movements.  Although, it is less painful and is less likely to result in long-term tenderness or problems with pain during sexual intercourse. The median episiotomy often has less blood loss as well. This type is commonly used in the USA and Canada.
  • Mediolateral episiotomy. The incision is done at a 45-degree angle from the vaginal opening to the side, cutting more into the muscle rather than tendon. Beginning in the midline and directed laterally and downwards away from the rectum, a mediolateral incision offers the best protection from an extended tear affecting the anal area. It is, however, more painful, has increased blood loss, higher risk of long-term discomfort, especially during sexual intercourse and is difficult to repair. This type is most common in Europe.

What are the benefits of an Episiotomy?

Although controversial, there are some benefits of an episiotomy. The best available data does not support the liberal or routine use of episiotomy. Nonetheless, those supporting the use of the procedure believe that if there is an emergency and an immediate need to get the baby out, the extra space made by an episiotomy would allow for easier instrumental birth — with use of forceps or vacuum extraction. Others of the same thought also see the usefulness of an episiotomy for larger babies, to make room for the baby’s passage.

An episiotomy is also said to be beneficial when the health care provider believes that the perineum will tear on its own. Logic being that an episiotomy is easier to repair as compared to the ragged edge of a natural tear.

Point to note, however, is that women need to be involved in the decision-making process in the event that an episiotomy might be needed. Performing an episiotomy, or any other intervention without a woman’s informed consent is a violation of her right to respectful maternity care. The procedure should also be performed in a way that maximizes outcomes for the mother and infant.

Episiotomy drawbacks

Episiotomy has not become unpopular for no good reason. The procedure comes with some risks. For one, episiotomy recovery is uncomfortable, and sometimes the surgical incision is more extensive than a natural tear would have been. In fact, the midline episiotomy has a greater risk of third or fourth-degree vagina tearing. This tearing which extends through the anal sphincter and into the mucous membrane that lines the rectum, may lead to fecal and urinary incontinence, painful sex and infection.

Many health care providers are in support of the occurrence of a natural tear of the perineum to an episiotomy. Women who have an episiotomy do not have significantly improved labor, delivery, and recovery compared with those who do not have one. And there are those of the view that women’s bodies know how to give birth.

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