Episiotomy, also known as perineotomy, is a surgical incision of the
perineum
The perineum in humans is the space between the anus and scrotum in the male, or between the anus and the vulva in the female. The perineum is the region of the body between the pubic symphysis (pubic arch) and the coccyx (tail bone), includi ...
and the posterior vaginal wall generally done by a
midwife
A midwife is a health professional who cares for mothers and newborns around childbirth, a specialization known as midwifery.
The education and training for a midwife concentrates extensively on the care of women throughout their lifespan; co ...
or
obstetrician
Obstetrics is the field of study concentrated on pregnancy, childbirth and the postpartum period. As a medical specialty, obstetrics is combined with gynecology under the discipline known as obstetrics and gynecology (OB/GYN), which is a surgi ...
. Episiotomy is usually performed during second stage of labor to quickly enlarge the opening for the baby to pass through. The incision, which can be done from the posterior midline of the
vulva
The vulva (plural: vulvas or vulvae; derived from Latin for wrapper or covering) consists of the external sex organ, female sex organs. The vulva includes the mons pubis (or mons veneris), labia majora, labia minora, clitoris, bulb of vestibu ...
straight toward the
anus
The anus (Latin, 'ring' or 'circle') is an opening at the opposite end of an animal's digestive tract from the mouth. Its function is to control the expulsion of feces, the residual semi-solid waste that remains after food digestion, which, d ...
or at an angle to the right or left (medio-lateral episiotomy), is performed under
local anesthetic
A local anesthetic (LA) is a medication that causes absence of pain sensation. In the context of surgery, a local anesthetic creates an absence of pain in a specific location of the body without a loss of consciousness, as opposed to a general an ...
(
pudendal anesthesia Pudendal anesthesia, also known as a pudendal block, or saddle block, is a form of local anesthesia commonly used in the practice of obstetrics to relieve pain during the delivery of baby by forceps. The pudendal nerve block prevents fainting durin ...
), and is
sutured after delivery.
Its routine use is no longer recommended, as
perineal massage
Antenatal perineal massage (APM) or Birth Canal Widening (BCW) is the massage (painless stretching) of a pregnant woman's perineum – the skin and deep tissues around the opening to the vagina or ('birth canal' – when a baby is in this passage) ...
is an alternative painless method of enlarging the opening for baby.
[ Despite this, it is one of the most common surgical procedures specific to women. In the United States, as of 2012, it was performed in 12% of vaginal births.] It is still widely practiced in many parts of the world, including Korea
Korea ( ko, 한국, or , ) is a peninsular region in East Asia. Since 1945, it has been divided at or near the 38th parallel, with North Korea (Democratic People's Republic of Korea) comprising its northern half and South Korea (Republic o ...
, Japan
Japan ( ja, 日本, or , and formally , ''Nihonkoku'') is an island country in East Asia. It is situated in the northwest Pacific Ocean, and is bordered on the west by the Sea of Japan, while extending from the Sea of Okhotsk in the north ...
, Taiwan
Taiwan, officially the Republic of China (ROC), is a country in East Asia, at the junction of the East and South China Seas in the northwestern Pacific Ocean, with the People's Republic of China (PRC) to the northwest, Japan to the nort ...
, China
China, officially the People's Republic of China (PRC), is a country in East Asia. It is the world's most populous country, with a population exceeding 1.4 billion, slightly ahead of India. China spans the equivalent of five time zones and ...
, and Spain
, image_flag = Bandera de España.svg
, image_coat = Escudo de España (mazonado).svg
, national_motto = ''Plus ultra'' (Latin)(English: "Further Beyond")
, national_anthem = (English: "Royal March")
, i ...
.
Uses
Vaginal tears can occur during childbirth, most often at the vaginal opening as the baby's head passes through, especially if the baby descends quickly. Episiotomy is done in an effort to prevent
Prevention may refer to:
Health and medicine
* Preventive healthcare, measures to prevent diseases or injuries rather than curing them or treating their symptoms
General safety
* Crime prevention, the attempt to reduce deter crime and crimin ...
against soft-tissue
Soft tissue is all the tissue in the body that is not hardened by the processes of ossification or calcification such as bones and teeth. Soft tissue connects, surrounds or supports internal organs and bones, and includes muscle, tendons, ligam ...
tearing (perineal tear
A perineal tear is a laceration of the skin and other soft tissue structures which, in women, separate the vagina from the anus. Perineal tears mainly occur in women as a result of vaginal childbirth, which strains the perineum. It is the most com ...
) which may involve the anal sphincter and rectum. Tears can involve the perineal skin or extend to the muscles and the anal sphincter and anus. The midwife or obstetrician may decide to make a surgical cut to the perineum with scissors or a scalpel
A scalpel, lancet, or bistoury is a small and extremely sharp bladed instrument used for surgery, anatomical dissection, podiatry and various arts and crafts (either called a hobby knife or an X-acto knife.). Scalpels may be single-use disposa ...
to make the baby's birth easier and prevent severe tears that can be difficult to repair. The cut is repaired with stitches (sutures). Some childbirth facilities have a policy of routine episiotomy.
Specific reasons to do an episiotomy are unclear.[ Though indications on the need for episiotomy vary and may even be controversial (see discussion below), where the technique is applied, there are two main variations. Both are depicted in the above image.
* In one variation, the midline episiotomy, the line of incision is central over the anus. This technique bifurcates the ]perineal body
The perineum in humans is the space between the anus and scrotum in the male, or between the anus and the vulva in the female. The perineum is the region of the body between the pubic symphysis (pubic arch) and the coccyx (tail bone), includi ...
, which is essential for the integrity of the pelvic floor. Precipitous birth can also sever—and more severely sever—the perineal body, leading to long-term complications such as incontinence. Therefore, the oblique technique is often applied (also pictured above).
* In the oblique technique, the perineal body is avoided, cutting only the vagina epithelium, skin, and muscles (transversalius and bulbospongiosus
The bulbospongiosus muscle (bulbocavernosus in older texts) is one of the superficial muscles of the perineum. It has a slightly different origin, insertion and function in males and females. In males, it covers the bulb of the penis. In femal ...
). This technique aids in avoiding trauma to the perineal body by either surgical or traumatic means.
In 2009, a Cochrane meta-analysis based on studies with over 5,000 women concluded that: "Restrictive episiotomy policies appear to have a number of benefits compared to policies based on routine episiotomy. There is less posterior perineal trauma, less suturing and fewer complications, no difference for most pain measures and severe vaginal or perineal trauma, but there was an increased risk of anterior perineal trauma with restrictive episiotomy". The authors were unable to find quality studies that compared mediolateral versus midline episiotomy.
Types
There are four main types of episiotomy:
* Medio-lateral: The incision is made downward and outward from the midpoint of the fourchette either to the right or left. It is directed diagonally in a straight line which runs about away from the anus
The anus (Latin, 'ring' or 'circle') is an opening at the opposite end of an animal's digestive tract from the mouth. Its function is to control the expulsion of feces, the residual semi-solid waste that remains after food digestion, which, d ...
(midpoint between the anus and the ischial tuberosity
The ischial tuberosity (or tuberosity of the ischium, tuber ischiadicum), also known colloquially as the sit bones or sitz bones, or as a pair the sitting bones, is a large swelling posteriorly on the superior ramus of the ischium. It marks th ...
).
* Median: The incision commences from the centre of the fourchette and extends on the posterior side along the midline for .
* Lateral: The incision starts from about away from the centre of the fourchette and extends laterally. Drawbacks include the chance of injury to the Bartholin's duct, therefore some practitioners have strongly discouraged lateral incisions.
* ''J''-shaped: The incision begins in the centre of the fourchette and is directed posteriorly along the midline for about and then directed downwards and outwards along the 5 or 7 o'clock position to avoid the internal
Internal may refer to:
*Internality as a concept in behavioural economics
*Neijia, internal styles of Chinese martial arts
*Neigong or "internal skills", a type of exercise in meditation associated with Daoism
*''Internal (album)'' by Safia, 2016
...
and external anal sphincter
The external anal sphincter (or sphincter ani externus ) is a flat plane of skeletal muscle fibers, elliptical in shape and intimately adherent to the skin surrounding the margin of the anus.
Anatomy
The external anal sphincter measures about 8 ...
. This procedure is also not widely practised.
Controversy
Traditionally, physicians have used episiotomies in an effort to deflect the cut in the perineal skin away from the anal sphincter muscle, as control over stool (faeces) is an important function of the anal sphincter, i.e. lessen perineal trauma, minimize postpartum pelvic floor dysfunction, and as muscles have a good blood supply, by avoiding damaging the anal sphincter muscle, reduce the loss of blood
Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood in the c ...
during delivery, and protect against neonatal
An infant or baby is the very young offspring of human beings. ''Infant'' (from the Latin word ''infans'', meaning 'unable to speak' or 'speechless') is a formal or specialised synonym for the common term ''baby''. The terms may also be used to ...
trauma. While episiotomy is employed to obviate issues such as post-partum pain, incontinence, and sexual dysfunction
Sexual dysfunction is difficulty experienced by an individual or partners during any stage of normal sexual activity, including physical pleasure, desire, preference, arousal, or orgasm. The World Health Organization defines sexual dysfunction as ...
, some studies suggest that episiotomy surgery itself can cause all of these problems. Research has shown that natural tears typically are less severe (although this is perhaps not surprising since an episiotomy is designed for when natural tearing will cause significant risks or trauma). Slow delivery of the head in between contractions will result in the least perineal damage. Studies in 2010 based on interviews with postpartum women have concluded that limiting perineal trauma during birth is conducive to continued sexual function after birth. At least one study has recommended that routine episiotomy be abandoned for this reason.
In various countries, routine episiotomy has been accepted medical practice for many years. Since about the 1960s, routine episiotomies have been rapidly losing popularity among obstetrician
Obstetrics is the field of study concentrated on pregnancy, childbirth and the postpartum period. As a medical specialty, obstetrics is combined with gynecology under the discipline known as obstetrics and gynecology (OB/GYN), which is a surgi ...
s and midwives
A midwife is a health professional who cares for mothers and newborns around childbirth, a specialization known as midwifery.
The education and training for a midwife concentrates extensively on the care of women throughout their lifespan; co ...
in almost all countries in Europe
Europe is a large peninsula conventionally considered a continent in its own right because of its great physical size and the weight of its history and traditions. Europe is also considered a Continent#Subcontinents, subcontinent of Eurasia ...
, Australia
Australia, officially the Commonwealth of Australia, is a Sovereign state, sovereign country comprising the mainland of the Australia (continent), Australian continent, the island of Tasmania, and numerous List of islands of Australia, sma ...
, Canada
Canada is a country in North America. Its ten provinces and three territories extend from the Atlantic Ocean to the Pacific Ocean and northward into the Arctic Ocean, covering over , making it the world's second-largest country by tot ...
, and the United States. A nationwide U.S. population study suggested that 31% of women having babies in U.S. hospitals received episiotomies in 1997, compared with 56% in 1979. In Latin America
Latin America or
* french: Amérique Latine, link=no
* ht, Amerik Latin, link=no
* pt, América Latina, link=no, name=a, sometimes referred to as LatAm is a large cultural region in the Americas where Romance languages — languages derived f ...
it remains popular, and is performed in 90% of hospital births.
Discussion
Having an episiotomy may increase perineal pain during postpartum
The postpartum (or postnatal) period begins after childbirth and is typically considered to end within 6 weeks as the mother's body, including hormone levels and uterus size, returns to a non-pregnant state. The terms puerperium, puerperal perio ...
recovery, resulting in trouble
Trouble may refer to:
Film and television
* ''Trouble'' (1922 film), an American silent comedy-drama film directed by Albert Austin
* ''Trouble'' (1933 film), a British comedy film
* ''Trouble'' (1977 film), a Soviet drama film
* ''Trouble'' ...
defecating
Defecation (or defaecation) follows digestion, and is a necessary process by which organisms eliminate a solid, semisolid, or liquid waste material known as feces from the digestive tract via the anus. The act has a variety of names ranging f ...
, particularly in midline episiotomies. In addition, it may complicate sexual intercourse
Sexual intercourse (or coitus or copulation) is a sexual activity typically involving the insertion and thrusting of the penis into the vagina for sexual pleasure or reproduction.Sexual intercourse most commonly means penile–vaginal penetrat ...
by making it painful and replacing erectile tissue Erectile tissue is tissue in the body with numerous vascular spaces, or cavernous tissue, that may become engorged with blood. However, tissue that is devoid of or otherwise lacking erectile tissue (such as the labia minora, the vestibule/vagina an ...
s in the vulva
The vulva (plural: vulvas or vulvae; derived from Latin for wrapper or covering) consists of the external sex organ, female sex organs. The vulva includes the mons pubis (or mons veneris), labia majora, labia minora, clitoris, bulb of vestibu ...
with scar
A scar (or scar tissue) is an area of fibrous tissue that replaces normal skin after an injury. Scars result from the biological process of wound repair in the skin, as well as in other organs, and tissues of the body. Thus, scarring is a na ...
tissue.
In cases where an episiotomy is indicated, a mediolateral incision may be preferable to a median (midline) incision, as the latter is associated with a higher risk of injury to the anal sphincter and the rectum. Damage to the anal sphincter caused by episiotomy can result in fecal incontinence
Fecal incontinence (FI), or in some forms encopresis, is a lack of control over defecation, leading to involuntary loss of bowel contents, both liquid stool elements and mucus, or solid feces. When this loss includes flatus (gas), it is referred ...
(loss of control over defecation). Conversely, one of the reasons episiotomy is performed is to prevent tearing of the anal sphincter, which is also associated with faecal incontinence.
Impacts on sexual intercourse
Some midwives compare routine episiotomy to female genital mutilation
Female genital mutilation (FGM), also known as female genital cutting, female genital mutilation/cutting (FGM/C) and female circumcision, is the ritual cutting or removal of some or all of the external female genitalia. The practice is found ...
. One study found that women who underwent episiotomy reported more painful intercourse and insufficient lubrication 12–18 months after birth but did not find any problems with orgasm or arousal.
Pain management
Perineal pain after episiotomy has immediate and long-term negative effects for women and their babies. These effects can interfere with breastfeeding and the care of the infant. The pain from injection sites and episiotomy is managed by the frequent assessment of the report of pain from the mother. Pain can come from possible lacerations, incisions, uterine contractions and sore nipples. Appropriate medications are usually administered. Nonpharmacologic interventions can also be used: a warm sitz bath increases blood flow to the area, decreases local discomfort, and promotes healing. Routine episiotomies have not been found to reduce the level of pain after the birth.
See also
* Husband stitch
* Perineal massage
Antenatal perineal massage (APM) or Birth Canal Widening (BCW) is the massage (painless stretching) of a pregnant woman's perineum – the skin and deep tissues around the opening to the vagina or ('birth canal' – when a baby is in this passage) ...
References
External links
Episiotomy
Merck Manual Professional Edition
Merck Manual Professional Edition-->
Merck Manual Professional Edition
{{Obstetrical procedures
What I Don’t Tell My Students About ‘The Husband Stitch’
Electricliterature.com
Obstetrical procedures
Theriogenology