Episiotomy – Procedure Types, Advantanges, Complications, Scar

What is Episiotomy?

An episiotomy is an incision that is made on the perineum, the area between the vagina and the anus, during a vaginal delivery to enlarge the outlet. It is no longer considered a routine procedure during childbirth although it is performed in most first deliveries and in many multigravida women (women who have been pregnant more than one time). Much controversy exists regarding the advantages and disadvantages of this procedure as well as the type of episiotomy to be performed.

Why is an Episiotomy Done?

An episiotomy is done so as to :

• hasten the birth of a distressed baby
• prevent perineal tears
• allow for the use of instrumentation, such as the application forceps, during delivery
• protect the head of a premature baby during delivery
• minimize or avoid complications associated with abnormal presentation such as breech, face, or shoulder
• deliver a big baby or when the baby’s head is too large

An episiotomy is not done as routine procedure but considered in the circumstances mentioned above. The tissues that are incised are the vaginal epithelium (inner lining of the vagina), the perineal muscles and skin. The wound is sutured (stitched) together after delivery of the baby and placenta, and usually heals well by 4 to 6 weeks.

Types of Episiotomy

Median or Midline Episiotomy

The episiotomy incision is given in the midline, extending from the vaginal opening towards the anus.

The advantages are :

• less blood loss with this procedure.
• less pain.
• an easier to perform procedure.
• wound repair is done easily.
• better cosmetic results due to less scarring.

However, the disadvantages are is that it :

• Is ineffective in protecting the perineum and sphincters and may result in anal incontinence (inability to hold feces in the rectum) due to third degree perineal tear. A third degree perineal tear involves tear of the perineum as well as partial or complete disruption of the anal sphincters.
• May cause fourth degree perineal tear, where there is complete tear of the perineum and damage to the anal sphincters as well as rectal mucosa.

Mediolateral Episiotomy

The perineal tissue is cut diagonally from the center of the vaginal opening (6 o’clock position) outwards towards the ischial tuberosity (the rounded protuberance on the hip bone on which the body rests while in a sitting position).

The advantages are that :

• there is less chance of perineal damage.
• third degree and fourth degree perineal tears are less likely.

The disadvantages are :

• more difficult to repair.
• increased bleeding as compared to median episiotomy.
• more difficult to heal.
• greater chances of scarring.
• more pain during healing.

Episiotomy Procedure

Episiotomy should be performed at the time of maximum uterine contraction and only when the presenting part distends the vaginal opening to about 3 to 4 cm. If forceps are to be applied, episiotomy should be done just prior to its application.

• By inserting two fingers in the vagina, the perineal skin is held away from the presenting part of the fetus (head, buttocks, face, or shoulder).
• The area to be cut is infiltrated with local anesthesia if epidural anesthesia is not given.
• Still keeping the fingers within the vaginal opening, the tissue is cut by a pair of rounded episiotomy scissors.
• The incision given is approximately 3 to 5 cm in length, either in the midline or mediolaterally.
• The cut enlarges the vaginal opening and helps in easy delivery of the baby.
• If a forceps or vacuum delivery is contemplated, a larger incision may be necessary.
• After delivery of the baby and placenta, the episiotomy incision is repaired in layers by means of absorbable suture materials which will not need to be removed later.

Aftercare and Healing

The episiotomy wound normally heals by 4 to 6 weeks. The length of the incision as well as the suture material used will determine the healing time. Proper care of the episiotomy wound is necessary for quick healing and early recovery.

• Pain relief during the first 24 hours can be obtained by using ice packs.
• Pain relievers should be taken only on doctor’s advice.
• Keeping the incision area clean with warm water and soap.
• Sitting in a Sitz bath (a tub full of warm water) for 20 minutes several times a day can help to relieve pain.
• Application of local anesthetic ointments for pain relief.
• Avoiding constipation, which can put pressure on the stitches.

Advantages of an Episiotomy

• The delivery process becomes much easier.
• Less effort is required by the mother to push the baby out during delivery.
• Delivery can be hastened, especially when the baby is distressed.
• Less chance of injury to the tissues.
• A surgical incision is easier to repair than a jagged tear.
• Fewer complications during delivery.

Complications of Episiotomy

• Chances of perineal tear.
• With third or fourth degree perineal tears, there are likely to be problems with gas and feces control.
• Longer duration of painful intercourse following childbirth.
• Scarring at the incision site.
• Bleeding.
• Wound infection.
• Pain and swelling locally.
• Delay in wound healing.
• Opening of the stitches.
• Improper closing of the wound.
• Scar endometriosis.

Episiotomy Scar

• Most episiotomy incisions heal well with minimum scar formation.
• Scarring after an episiotomy is more likely after a mediolateral incision than after a midline one.
• Sometimes, excessive scar tissue may form over the incision site which may be raised or itchy.
• A minor operation known as Fenton’s procedure may help to remove the unsightly scar tissue. It is usually done at least 6 months after childbirth so as to allow complete healing of the tissues. The scar tissue is removed and the edges stitched back together again.
• Scar endometriosis is a possibility.
• Cancer in an episiotomy scar is extremely rare.