Episiotomy
There are two types of episiotomies: midline and mediolateral. A midline episiotomy is cut straight down the perineum, toward the anus. This is the common type used in the United States and Canada. A mediolateral episiotomy, preferred in other parts of the world, is cut slanted off to one side. Comparatively, midline episiotomies are easier to repair, heal easier with fewer complications, and cause less pain afterward. Even so, they are much more likely to extend into the anus.
Episiotomies have been thought to prevent serious tears, prevent stretching or injury to the the pelvic floor, be easier to repair, heal easier than tears, be less painful postpartumly, offer an improved newborn outcome, and facilitate instrumental delivery (vacuum or forceps). So does this “tiny cut” really do all of these things? The answer is no – in reality the “tiny cut” does none of these things. An intact perineum is actually very resistant to tearing, and even more so if supported during delivery. To understand just how much an episiotomy does not prevent tearing, take a piece of cloth (like an old sheet) and try to rip it. Odds are you can't. Now cut a small slit with scissors, then try to rip it. That cloth will tear in half with surprising ease. The perineum works in the same way, giving easily when cut, extending the cut that started small into something much larger. Likewise, episiotomy does not prevent injury to the pelvic floor muscles, rather it either creates an injury, or acts as a vehicle for one when extending into vaginal (or worse, anal) muscle.
Like all procedures, an episiotomy certainly brings its very own risks into play. When compared to not doing an episiotomy, the risks associated with one are: blood loss, postpartum pain, infection, long-term (possibly chronic) pain and/or painful intercourse, rectovaginal fistula (an opening between the vagina and the rectum), and anal incontinence.
When is an episiotomy necessary?
The most honest answer to this question is almost never. If your baby is truly in trouble and very close to birth, or if you have reached physiological maternal exhaustion, your care provider may choose to do an episiotomy, as they may shorten labor by an average of nine minutes. These situations are rare in normal birth, and therefore make necessary episiotomies very rare. In turn, the overuse of episiotomy, almost to the point that it is seen as routine, is indeed extremely questionable. A reasonable episiotomy rate for any caregiver to have is 10% or even lower.
What can you do to avoid an episiotomy?
- Include a strong statement against an episiotomy in your birth plan.
- Discuss your birth plans often with your doctor, including your wish to avoid an episiotomy.
- When you arrive at the hospital, tell your nurse about your desire to not have an episiotomy.
- Avoid delivering in the lithotomy (lying flat on your back), since it causes the perineum to stretch tightly.
- Avoid getting an epidural, as it increases episiotomy probability and need for instrumental delivery.
- Assign someone on your birth team to guarding against episiotomy. This is a great job for dad, since he can legally speak up for your desires. If you are asking another support person, such as your labor assistant, then your lookout will have to tell you when they are getting ready to perform an episiotomy so that you can speak up for yourself.
An intact perineum is the best outcome of any birth, though it doesn't always end up that way. Remember, though, that the most important ingredient of a healthy pelvic floor after birth and later in life is strong pelvic floor muscles. KEGEL, KEGEL, KEGEL!!!
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