What is Episiotomy, and When to Use It?

An episiotomy is a surgical incision made from the vagina toward the rectum to enlarge the vaginal outlet. The incision is usually midline (straight), but can be mediolateral (angled to the side). (See Figure 8.8) Caregivers most often perform episiotomies when the baby’s head begins to stretch the perineum. At this time, a natural anesthesia is in effeet, and the woman may not feel the incision. However, a local aesthetic is necessary for the repair of the epi- siotomy following delivery. Most caregivers give the local prior to making the incision.

Figure 8.8 The two types of episiotomy are midline and mediolateral.

Caregivers perform episiotomies to expedite birth in cases of fetal distress or during a prolonged second stage if the woman is exhausted and the perineum is taut. Some doctors do them routinely because they feel that a straight incision is easier to repair and heals better than a jagged tear. Recent studies refute these sentiments, however. While women who deliver with intact perineums recover the fastest, those who have episiotomies heal just about the same as women with spontaneous tears. Also, some doctors feel that an episiotomy prevents tearing, but once a cut is made, the incision is more likely to tear further. In addition, if an episiotomy is not performed and tearing occurs, the tearing may be superficial in nature, whereas an episiotomy cuts into muscle. For these reasons, the American College of Obstetricians and Gynecologists does not recommend episiotomies in uncomplicated deliveries.

Another reason many doctors offer for performing an episiotomy is to avoid loss of vaginal tone and control, which could result in prolapsed organs and a decrease in sexual pleasure for both partners. Other caregivers say that practicing Kegel exercises during pregnancy and following birth strengthens the vaginal muscles and eliminates this problem naturally. Additionally, some experts feel that severing of the perineal tissue during an episiotomy permanently weakens it.

Occasionally, caregivers overstitch the repair to “tighten up” a woman. This overstitching is also known as the “honeymoon stitch.” However, stitching too tightly can result in painful intercourse.

Avoiding Episiotomy

Lithotomy Position

You can decrease your chances of having an episiotomy in several ways. Most importantly, talk to your caregiver about your desire not to have one. Ferforming perineal massage beginning around the thirty-fourth week of pregnancy may also help. (For instructions, see “Perineal Massage”.) Many caregivers feel that perineal massage not only stretches the perineal tissues, but also prepares a woman emotionally for some of the physical sensations of birth. While you are pushing during delivery, some caregivers perform perineal massage and apply hot compresses to stretch the perineal tissues. Listen to your caregiver’s directions and push gently to allow the baby to slowly stretch the birth canal. Avoid the lithotomy position during delivery. With your legs apart and your feet in stirrups, your perineum is taut and is more likely to tear.

An episiotomy takes several weeks to heal. You may experience soreness and itching. Try sitting on pillows or air rings, taking sitz baths, and applying anesthetic pads, creams, and sprays to help alleviate some of the discomfort.