Episiotomy

What is an episiotomy?

An episiotomy is a procedure, which involves cutting the skin of the perineum (this is the area between the vagina and the anus). An episiotomy is usually carried out under local anaesthetic, so that the patient cannot feel any pain. Episiotomies used to be very common, but nowadays they are only carried out in around 10 percent of births.

Why would I need an episiotomy?

In most cases, an episiotomy will be carried out when the baby needs to be delivered quickly; this is usually the result of the baby becoming distressed during labour. An episiotomy may also be done if the midwife or doctor uses forceps, to allow more room for the forceps.

If the baby becomes distressed (this is detected by changes in the baby’s heart rate or the presence of meconium, the baby’s first stool) but it is already moving down the birth canal, forceps or Ventouse will usually be preferred to a caesarean section; if the baby is not moving down the birth canal and is becoming distressed, a caesarean section may be recommended.

An episiotomy may be needed in the following situations:

• If the baby is larger than average
• If the baby is in an awkward position
• When the baby is in distress and forceps are required to help speed up delivery
• When the perineum is shorter than usual

Episiotomies are much more common in assisted births, than unassisted births.

How is an episiotomy performed?

The episiotomy is a very simple procedure, which is carried out under local anaesthetic; if the patient has already had an epidural, they will not require additional local anaesthetic but their epidural may be topped up to ensure they don’t feel any pain.

Once the anaesthetic has been given, a horizontal incision will be made at the back of the vagina in a downward, diagonal direction and off to one side; this is called a mediolateral incision.

After the baby has been born and the placenta has been delivered, the incisions are stitched up and the wounds will heal naturally over the course of time; dissolvable stitches are used during this procedure.

How long does recovery take?

After the birth, it is likely that you will feel tired, confused and sore; you can ask for pain relief to help reduce the pain. It usually takes around three to four weeks for the stitches to heal; most women have dissolvable stitches, so they don’t have to come back to hospital to have the stitches removed.

Managing pain

During the recovery period, you may experience soreness and discomfort; you can take painkillers or try alternative remedies such as ice packs (or a bag of frozen vegetables), massage, warm baths and calendula cream. It is also beneficial to do pelvic floor exercises to speed up recovery; this will help the muscles to recover quickly. During the recovery period, it is important to keep the wound as clean as possible.

What are the risks?

The risk of serious complications is very low; however, there are some negative side-effects, including:

• Constipation: constipation is very common after giving birth. If you do suffer from constipation, try to drink plenty of fluid. You do not need to worry about damaging your stitches when you do go to the toilet; some women are worried about this and consequently delay going to the toilet, which can make the condition worse.
• Pain: if you experience pain or soreness while your stitches are healing, you can take painkillers or soothe the affected area with warm water (by having a bath, for example) or applying ice to the area, using ice packs or even a bag of frozen pain (make sure the ice is covered with a towel or cloth, as this will prevent the skin from getting damaged).
• Incontinence: this is rare but it can happen. In most cases, incontinence will subside once the swelling and bruising go down; if you do suffer from persistent symptoms, you may be referred to a specialist.
• Soreness: many women may experience discomfort when they are sitting on hard surfaces; it may help to sit on soft cushions if this is the case. At first, sex may also be painful, so it may be advisable to wait until the wounds have fully healed.
• Scar tissue: scar tissue may become irritated and sore in some cases, but this is rare. If this is the case you should arrange to see your GP.

Can I choose not to have an episiotomy?

If you are really against having an episiotomy you can discuss this with your midwife; it is helpful to write this in your notes or birth plan so that the medical staff are aware of your preferences. Episiotomies are much rarer than they used to be and midwives and doctors try to avoid using them; if there is no other option, your doctor or midwife will discuss this with you and you can then make an informed decision.

When will I be able to have sex again?

Once your stitches have healed you should be able to have sex again without experiencing any pain; some women may not be ready to have sex for longer than this period of time; it depends on the individual.

Prevention

There are some steps you can take to help reduce the likelihood of needing an episiotomy; these include:

• Labour positions: try out different positions during labour; choosing a more upright position, such as kneeling or being on all fours, may reduce the risk of you needing an episiotomy as the baby is encouraged to move down the birth canal in tandem with gravity.

• Ventouse: you are less likely to need an episiotomy if you have Ventouse, rather than forceps.

• Perineal massage: massaging the perineum on a daily basis during the last six weeks of pregnancy can help to stretch it and make it more flexible so it can expand more easily to accommodate the baby’s head; this will reduce the likelihood of tearing as well as decreasing the risk of you needing an episiotomy. Perineal massage is particularly beneficial for women over the age of 20 and those who are having their first baby. Perineal massage helps to prepare the muscles and makes you accustomed to the muscle contractions, which you will experience during labour. Perineal massage helps to increase circulation, speeds up recovery and healing after the birth and prepares you for the sensations your body will experience during labour and birth.

To practise perineal massage you should find a private, quiet place and sit upright in front of a mirror; this will help you to find the perineum and see what you are doing. Make sure your hands are clean (if your partner is massaging you, you should ensure their hands are clean before they begin), relax the muscles with warm water or a warm compress. Once the muscles are warm and relaxed, apply lubricant (you can use KY jelly or oil) to the area and your hands (or your partner’s hands), insert your thumbs inside the vagina (about one inch inside) and pull the skin of the perineum to the point where it starts to feel slightly uncomfortable; hold this stretch for around two minutes. Massage the area gently with your thumbs and pull the muscles and skin outwards gently; this will mimic the movement of the muscles when the baby’s head comes out.

If you have had an episiotomy in the past, be careful around the scar tissue. You should not practise perineal massage if you have a vaginal infection or herpes lesions (this could cause the herpes to spread).

• A ‘hands on’approach; if the midwife allows the delivery of the shoulders to go ahead without intervening there is a slightly lower risk of tearing; however, this approach may cause more pain and recovery may take longer than if the midwife applies gentle pressure to the baby’s head and protects the perineum.