Episiotomy

Childbirth is a complicated process that could, at times, pose complications. It is important that the safest route is taken to bring the baby into the world. An episiotomy is a process that is performed when there are certain complications during delivery. In an episiotomy, a small incision is made on the mother-to-be’s vagina so that the baby can come out safely.

What Is an Episiotomy?

Just before childbirth, a surgical cut or incision may be made in the muscular perineum area between the vagina and the anus to enlarge the opening. This procedure is called an episiotomy. This enlarges the exit area for the baby so that it can come out safely.

Why Is Episiotomy Done?

The following conditions are an indication of episiotomy situation:

• During childbirth, the perineum stretches slowly to accommodate the baby’s head. Sometimes, it doesn’t have enough time to open fully even when the birth is imminent. This situation would require an episiotomy.
• If the baby’s heart rate drops, it is an indication of foetal distress and that the baby isn’t handling the labour well. In such cases, delivery needs to be expedited and a cut is made in the perineum to deliver the baby quickly. Here, a pair of forceps is used, or a vacuum assisted delivery is conducted.
• The doctor may recommend an episiotomy if there is a risk of foetal trauma due to the baby’s head being pushed against the perineum for a long time.

How Is an Episiotomy Performed?

Once a decision is taken to perform an episiotomy, a local anaesthetic is given to you. A small cut or incision is then made in your perineum using surgical scissors just before the birth of the baby. Also, if your perineum is already numb due to the pressure of the baby’s head, or if you have had an epidural, an episiotomy is performed without any anaesthetic.

There are different types of episiotomies based on the depth of cut. The cut can be superficial, where only the skin is cut, or it can be deep.

• When only the skin is cut, it is called a first-degree episiotomy.
• If the underlying tissue is also cut, it becomes a second-degree episiotomy.
• If the muscle around the anus is cut, it is a third-degree episiotomy.
• If the cut goes through the rectal mucosa, it is a fourth-degree episiotomy.

After birth, another shot of local anaesthesia is given to be sure you’re completely numb and then the incision is stitched up.

The incisions can be of two types:

• A vertical incision called a midline or median incision – this is an incision from the vagina to the rectum. A midline incision can heal easily, but there are higher chances of a tear extending into anal area.
• An angular incision called a medio-lateral incision – the cut is about 3-4 cm. This starts at the vagina but slants away from the rectum. The chances of a tear affecting the anal area is less from this type of incision, but it cannot heal easily and can be painful.

Risks of Having an Episiotomy

As explained earlier, an episiotomy is an incision, and as with all such surgical procedures, it does carry some risks. In some cases, episiotomy complications may arise as follows:

• There could be infection around the incision
• Bruising and swelling could be present leading to bleeding around the tear area
• The tear may have an extended healing time
• There could be scarring that might be painful, and it might require a period of abstinence from sexual intercourse
• There could be a future risk of incontinence

Episiotomy Infection

You should watch out for episiotomy infection symptoms, which typically include:

1. Swelling near the stitches
2. Increased redness around the wound
3. Pus discharge or bleeding from the wound
4. A warm feeling near the wound
5. An unpleasant odour from the wound
6. Pain that keeps increasing
7. A fever of 38C (100.4F) or above
8. Any sign of swollen glands

What Should You Do to Avoid a Perineal Tear?

The key here is to allow your perineum to stretch slowly to accommodate your baby. The delivery should be slow and controlled which will assist slow stretching and help in preventing a perineal tear. You may need to control the urge to push when the baby’s head is crowning.

Here are a few things you can do to avoid a perineal tear:

• Stand or squat while pushing the baby out.
• Push at short intervals of five to seven seconds at a time, instead of pushing hard.
• Ask the doctor to apply a gentle counter-pressure to the perineum so that it is supported, and does not tear when the baby’s head emerges.
• Chances of perineal tear can be reduced by eating a balanced diet and taking prenatal vitamins.
• Use a warm compress on the perineum during the latter part of the second stage of labour. When the pushing is done, it could lower the risk of serious tears.

It helps to look for a doctor who does not routinely perform episiotomies and has adequate experience in helping giving birth without perineal tearing. However, you should understand that in certain cases it may be beyond your control and there may be no alternative without a tear taking place. This becomes unavoidable especially if your baby is large or in a difficult position, or if your perineum is fragile.

How Can You Recover?

If you have an episiotomy, you might experience pain while walking or sitting as the tear wound is in a very tender area. A general rule is, the deeper the cut or tear, the longer is the recovery time. The discomfort may last for a few days or even a month if the tear or incision is extensive. Normally, the stitches that are used to repair the episiotomy are self-absorbed by the body.

In the meantime, here are a few episiotomy healing tips to promote healing:

• Soothe and cool the wound using an ice pack immediately after giving birth and for the next 12 hours intermittently.
• During urination, you can pour warm water over your vulva, and after urination use a squeeze bottle to rinse yourself.
• During bowel movement, press a clean pad against the wound.
• Be careful while sitting down. While lowering yourself to a seated position, tighten your buttocks. Sit on a soft pillow or padded ring.
• You can use prescription medications or use a pain reliever or stool softener if recommended by your doctor. For episiotomy wounds, pain-relieving ointments or creams are generally not effective.
• Add a few drops of essential lavender oil to your bath water. If your doctor approves, you can directly apply lavender essential oil to the tissue between your anus and vaginal opening.
• As your tear heals, you can feel your discomfort reducing. Sometimes, there can be pus formation or a fever, accompanied by intense pain. If this occurs, contact your doctor immediately as the wound may be infected.
• Pat yourself dry from front to back to avoid infections due to the introduction of germs from the rectum to the tear.
• Expose the wound to air as much as possible.
• Drink plenty of fluids and get enough roughage in your diet to prevent constipation.

When Can You Start Having Sex?

But sex after episiotomy should be attempted only after your perineum has completely healed. This normally takes about four to six weeks after delivery. After that, all that is required is the doctor’s approval. If the laceration is severe or deep, it is very important to wait to be thoroughly examined before you have sex to avoid any complications.

There might be some initial tenderness and tightness. Try taking a warm bath and do plenty of foreplay. You might prefer a position that is comfortable to you, either on top or the side, where you can control the degree of penetration.

Relax as much as possible. Lactation reduces oestrogen levels, and this might reduce vaginal lubrication. You can use a good water-soluble lubricant; it can be especially helpful if you’re breastfeeding. Many women continue to use a lubricant during sex until they stop nursing.

Talk to your doctor about possible treatments if you still find sex painful. You may require pelvic rehabilitation and may need to see a specialist.

It is always better to be safe than sorry and not to compromise on such an important aspect of your life. Ensure that all precautions are taken care of before you go ahead with the episiotomy. Seek treatment if you continue to have pain for a couple of months after you’ve given birth.