Episiotomy

What is Episiotomy?

Episiotomy is a surgical procedure commonly performed during childbirth. It involves making a

deliberate incision in the perineum, the region of skin and muscle between the vaginal opening
and the anus. This incision is typically made when a healthcare provider deems it necessary to
aid in the safe delivery of the baby or to prevent severe tearing of the perineum during
childbirth.

Why is an Episiotomy done?

It is important to note that episiotomy is not recommended in case of spontaneous vaginal
delivery. However, the procedure can be done under the following conditions:
 If the baby is in distress (increased/decreased heart rate) there is a serious risk to the
baby’s life if not born quickly.
  If the baby is larger than normal (fetal macrosomia).
 If there is a clinical need for forceps delivery or vacuum delivery.
 In case of breech birth, in which the baby is not born head-first.
 If the mother is exhausted from a prolonged labor.
 If the mother suffers from a serious health condition a speedy delivery is required to
keep her safe.

What are the types of Episiotomy?

1. Midline Episiotomy: In this type, the incision is made directly along the midline of the
perineum. It provides a straightforward, centrally located cut.

2. Mediolateral Episiotomy: A mediolateral episiotomy involves making an incision at an

angle to the midline. This angled incision is believed to be less likely to extend further
during childbirth and potentially cause more significant tears.
Classification of Episiotomies Based on the Extent of the Tear
Episiotomies are classified based on the extent of the tear into the following four categories:
 First Degree: In this type of episiotomy, the tear only penetrates the vaginal lining.
 Second Degree: This is the most common type of episiotomy, where the tear penetrates
the vaginal lining and the underlying vaginal tissues.
 Third Degree: In this type of episiotomy, the tear extends through the vaginal lining,
vaginal tissues, and part of the anal sphincter.
 Fourth Degree: This is the most severe of the four types of episiotomies. In this type of
episiotomy, the tear extends through the vaginal lining, vaginal tissues, anal sphincter
and the rectal lining.

The Episiotomy Procedure

Both types of episiotomies (midline or mediolateral) are relatively straightforward and easy to
perform. Episiotomy is done under local anesthesia. To perform the episiotomy, the obstetrician
will wait till the baby’s head protrudes approximately 4 cm through the vaginal opening.
 Local anesthesia: Prior to the procedure, local anesthesia is administered to numb the
perineal area. This ensures the mother doesn't feel pain during the incision and suturing.

Once crowning occurs, the obstetrician will insert two fingers into the vagina to protect the
baby’s head from coming in contact with the surgical scissors. An incision will then be made
either straight down towards the anus (midline incision) or at an angle of ~45° to the vaginal
orifice (mediolateral incision). The perfect timing for the episiotomy is when the baby is about
to be delivered (within the next 3-4 contractions).
 Incision: The healthcare provider makes a controlled cut in the perineum to facilitate the
baby's passage through the birth canal.
After the delivery of the baby and the placenta, the vagina and perineum are cleaned and
thoroughly examined for any extension of the episiotomy. The anal canal is also checked to
exclude anal sphincter injury. The episiotomy is then repaired by suturing the vaginal lining and
the underlying tissue. The sutures are dissolvable and are absorbed by the tissues usually within
a month. So, there is no need to visit the doctor to take out the stitches.
 Repair: Following childbirth, the episiotomy incision is sutured with dissolvable stitches
to promote healing.

What are the Risks & Complications of Episiotomy?

As with any surgical procedure, episiotomy is not without risk. Complications can arise due to
penetration of the episiotomy incision into deeper structures, as well as due to various other
reasons.
 Excessive Blood Loss: This can occur either at the time of the episiotomy or after the
repair.
 Extension of the wound: The wound may extend beyond its intended limits. It may also
include the anal region resulting in fecal incontinence.
 Perineal Infections: Infections are very rare but can nevertheless occur. Necrotizing
fasciitis is a rare but potentially fatal complication of episiotomy. Moreover, methicillin-
resistant Staphylococcus aureus infection arising from the episiotomy site has also been
reported.
 Postpartum Perineal Pain: Excessive perineal pain after childbirth can be a sign of the
formation of a hematoma, a blood clot in the wound.
  Wound Dehiscence: Wound dehiscence is the rupture of the stitched-up wound along
the line of incision that can occur after an episiotomy. However, dehiscence of an
episiotomy usually occurs less than 2% of the time.
 Dyspareunia: This is commonly known as painful sexual intercourse. It can last anywhere
up to 18 months postpartum. Episiotomy during first birth and scarring of the perineum
during the procedure are major risk factors for long-term dyspareunia.

Recovery after Episiotomy

The recovery period varies with the type of episiotomy performed. In the case of first or second-
degree episiotomy, the recovery will be faster than in the case of third or fourth-degree
episiotomy. In the latter cases, the pain will last longer. On average, it can take about a month
for the episiotomy wound to heal and the stitches to be dissolved. During this period, follow the
doctor’s advice to facilitate the healing process. Some simple strategies are given below:
 Ease the pain: Painkillers can be taken as advised by your doctor to ease the pain.
Acetaminophen or paracetamol is the safest choice since it can be taken even while
breastfeeding. You can take ibuprofen if your baby is not premature or of low birth
weight and does not suffer from any other health issues. Diclofenac gel patches applied
to the perineum can also ease the pain. Since ibuprofen and diclofenac are both non-
steroidal anti-inflammatory drugs (NSAIDs), they not only take care of the pain but also
reduce inflammation and swelling. Aspirin is not recommended as it can pass to your
baby through the breast milk.
 Soothe the wound: Cool the wound by placing an ice pack or ice-cubes wrapped in cloth
on the affected area. This will have a soothing effect and also help to ease the pain.
 Keep the wound clean: Keep the episiotomy wound and the surrounding area clean.
Rinse the perineal region with warm water after defecation and urination.
 Avoid pressure on your stitches: Your doctor may prescribe a laxative to ease
constipation. This will reduce the pressure on your stitches during bowel movements.
 Do pelvic floor exercises: Resume your pelvic floor exercises as soon as possible after
birth. These exercises will strengthen the muscles of the pelvic floor as well as increase
blood circulation, thereby aiding the healing process.