During your pregnancy, you’ve probably come across the term episiotomy. Or tried to avoid reading about it.
Let’s face it, no one really wants to read about getting their vagina cut.
An episiotomy isn’t something you can plan for. So you may be wondering why you need to learn about an episiotomy in pregnancy.
The reason is informed consent.
An episiotomy is a medical procedure that often has to be performed in emergency situations or at the height of labor.
Both of these are situations which leave you unable to think straight or take important information on board.
If you know about them beforehand you are more likely to understand what is happening and the effect it may have on you.
I’ve created this guide to give you all the information you need to know before baby arrives. There is quite a lot to take in, especially if your head is spinning with birthing info.
Pin it now so you can refer to it later in your pregnancy. Also, remember to share with your pregnant friends who will find it useful.
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Episiotomy Guide For Birth
What is an episiotomy?
An episiotomy is a medical cut that is made to the perineum or the area of skin and muscle between your vagina and anus.
This area of skin can often restrict the amount of space a baby has or can slow the delivery.
The cut is made during the pushing stage of labor as your baby’s head starts to crown. Ideally, the damage from an episiotomy should be equal to a second-degree tear (vaginal skin and muscle only).
The tear then needs to be repaired with stitches after your baby is born.
Types of Episiotomy Cut
There are two types of episiotomy: midline and mediolateral. Each has its own benefits and drawbacks.
This is a cut made straight down toward the anus (between 12 and 6 on a clock). This type is common in the USA and Canada.
A midline episiotomy is often preferred as it is easier for doctors to perform and repair. This type of cut results in less bleeding, pain, and pain during sex.
The biggest risk of a midline episiotomy is extended tearing. If you continue to tear even after this type of cut, it extends into your anus. This can cause life-changing medical problems which may leave you unable to control your bowels.
This cut is made at a 45-degree angle towards the butt cheeks. This type of episiotomy is preferred in Europe.
The main advantage of this type of cut is avoiding any cut or tearing to the anus.
The drawbacks of this type of episiotomy are that it takes greater skill to repair, which may make healing more uncomfortable.
Reasons for episiotomy
In the 70s and 80s, episiotomies were performed routinely during vaginal delivery. Fortunately, that practice has long gone. However, an episiotomy can provide some benefits during birth.
We’ve already discussed that the perineum can slow a delivery or reduce the space baby has. These are situations where you may need either of these:
Delayed second stage
Once you dilate to 10cm your baby is ready to be born. This is the part when you start to push with each contraction. The second stage can last a long time if your perineum is holding your baby back. This usually happens if your perineum is particularly thick or muscular.
An episiotomy releases the resistance on babies head and provides more room for baby to be born. In this situation, an episiotomy is only justified if the baby is distressed or you have been pushing for at least an hour.
Passing over the perineum naturally can slow down the delivery. Some babies can’t cope with this stage and their heart rate drops dangerously low. To prevent any further distress to baby an episiotomy can speed up the delivery. This can prevent your baby requiring resuscitation if they have only suddenly become distressed.
The perineum stretches a lot as your baby’s head moves down the vagina. If this stretching happens to quick the perineum can’t cope and begins to tear. You can sometimes see this happening on the outside. An episiotomy may be performed to control how far this tear extends. This is more likely if a tear is extending to the urethra.
If you need help to deliver your baby with forceps or a suction cup an episiotomy is usually performed. This is because the perineum has less time to stretch and is more likely to tear. The doctor should make an assessment of your perineum to keep damage to a minimum.
This is an emergency situation where your baby’s head is delivered but the shoulders are stuck in the pelvis. An episiotomy won’t help deliver the shoulders, but it can make room to perform maneuvers that will.
There are some medical conditions (often heart-related) that can limit how much pushing you can do in labor. This is because pushing puts a lot of strain on the body. An episiotomy can speed up the delivery to help you achieve a vaginal delivery.
The benefits of an episiotomy should be weighed up against to risk of tearing. An episiotomy should never be carried out purely for convenience sake as there are a lot of potential risks.
Although an episiotomy can be used to control the extent of a tear, it can actually make it worse. In fact, most 3rd or 4th-degree tears are caused by an episiotomy that extends. This means that more damage is caused by the episiotomy than without one.
An episiotomy means a wound that requires healing from an already tired postpartum body. This includes increased risk of pain, bleeding, infection, nerve damage, immobility, and constipation. Severe health effects include anal fistulas or incontinence.
Having an episiotomy performed without consent can trigger mental trauma. This can worsen if there are long-term health issues that have resulted from this procedure.
Any type of vaginal damage will weaken that area for future births. That means you are at higher risk of tearing and requiring stitches. If an episiotomy extends to cause anal trauma you may be recommended to have a C-section for future babies.
It’s common for an episiotomy to result in reduced sensation or increased pain during sex. Reluctance and fear to have sex can lead to huge strain on relationships.
The cost of long-term health conditions which require lifelong treatment can cause a huge financial strain. This includes medical bills and therapy, therefore make sure you have good health insurance in place before you have your baby.
You may have strong feelings about avoiding an unnecessary episiotomy or requesting one during delivery. It’s a procedure that is still carried out in around 12% of vaginal births in the USA.
I would highly recommend having a discussion about episiotomy with your caregiver. Ask them how often they perform them and under what circumstances.
You may also want to know what they do to prevent tearing during delivery. Good perineal support and communication during crowning can reduce tears. Doctors are more likely to perform an episiotomy than a midwife.
It’s important to know that routine episiotomy is not evidence-based. The ACOG and World Health Organization (WHO) advise against them.
There is also no benefit of a planned episiotomy if you have has a tear or episiotomy from a previous birth. Although you’re at a higher risk of tearing in this area again as the skin is weaker.
Episiotomy vs Tearing
Most normal vaginal deliveries that are progressing well do not require an episiotomy.
Without an episiotomy, the risk is that you may naturally tear instead. Although you may tear even if you do have an episiotomy.
If there is no good reason for an episiotomy then it’s likely you will have similar or lesser damage than an episiotomy would cause. Most tears don’t require any stitches at all.
A tear is much more likely to result in quicker healing and less blood loss. Although a ragged tear can be more difficult to repair than a straight cut.
Current evidence favors natural tearing over an episiotomy for healing, blood loss, and long-term damage unless there is a valid medical need.
The first step of an episiotomy should always to obtain consent from you. This is a legal requirement, not a guideline. The details of this may depend on the urgency of the situation. An episiotomy should never be performed without your knowledge or consent, regardless of the need.
Sometimes a birth situation can be hectic and it can be difficult to take things on board. Discuss with your birthing partner that they should also be made aware if an episiotomy is to be performed. Let them be your advocate if one is about to be done without good reason.
An episiotomy is a quick procedure is usually completed within a minute or two. This is what will happen.
- Consent is obtained from you (with justification for need)
- If you don’t have an epidural your perineum is numbed with local anesthetic and that’s given a few minutes to work
- Two fingers are inserted between your perineum and your baby’s head to prevent any injury to your baby.
- The episiotomy should be performed at the height of contraction so only skin and superficial muscles are cut.
- A cut should be made is one firm cut about 4-5cm long.
- Your baby’s head will deliver, followed by the body
- After delivery, your vagina will be inspected for further tearing.
- The episiotomy and any additional tearing will be repaired with stitches.
Your vagina will feel like its gone through the wars after delivery. It will fell bruised and swollen and your stitches may feel sore and tight.
It can take anything from a week to a month for your perineum to heal. If it takes longer its best to seek medical advice for a review.
Check out my guide to caring for your vaginal stitches. You find all you need to know about hygiene, pain relief, comfort, intimate issues and seeking advice. Plus I’ve recommended some product you can use at home to provide relief and prevent infection.
Always report any concerns or signs of infection to your caregiver. These are your red signals:
- Excessive swelling
- hot to touch
- offensive smell
- increasing pain (even with pain relief)
- fever symptoms
If you experience any of these symptoms, seek a medical review ASAP. Untreated postpartum infection can cause you to become extremely unwell and be admitted to hospital.
Related: Postpartum Recovery Essentials
Can I prevent an episiotomy?
An episiotomy is not indicated when your labor is progressing well. Good position and communication with your caregiver can reduce tearing. Check out my guide on vaginal tearing during labor for more tips on preventing cuts and tears.
Does and episiotomy cut hurt?
An episiotomy should always be performed with your consent and adequate pain relief. This may be from your epidural or local anesthetic. It’s a quick procedure and is performed at the point when your baby’s head is crowning. This point of labor is described as the ‘ring of fire’ even without an episiotomy so you’ll probably be more focused on that sensation than the episiotomy.
When will I be able to exercise after an episiotomy?
It’s always best to wait for medical approval before starting postpartum exercise. If you are fit and well most doctors will approve this at 4-6weeks after birth.
Exercise will help strengthen your pelvic floor muscles. You should introduce Kegel exercises to target the muscles that have been weakened by pregnancy and birth.
Will need an episiotomy for my next birth?
A planned episiotomy is not necessary for previous tearing or episiotomy. However, you are at higher risk of tearing again in these areas as they are weaker. It’s unlikely any tearing will extend beyond your previous tear. This means if you do tear its likely to be equal to or less than a previous cut or tear.
If you had a previous 3rd or 4th-degree tear with extensive damage, it’s advisable to consider a planned C-section.
Will I be left with a scar?
An episiotomy will leave a scar on your perineum. If repaired well it should heal well and become virtually unnoticeable. It’s important to contact your caregiver for a review if your scar has loss of sensation, constant pain or is painful during sex.
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