One of the most controversial practices in childbirth is undoubtedly the episiotomy . We will start by defining what this word means, something difficult to pronounce but very easy to remember when you have suffered it firsthand.
It is a surgical incision in the female perineum (or perineum), specifically in the part that is between the vagina and the anus, which is made at the time of delivery to enlarge the vaginal opening and allow the baby’s head to come out.
How is the episiotomy performed?
It is done with scissors or a scalpel just when the baby’s head is about to crown. There are two ways to make the cut: a downward midline or an angled mediolateral incision, which involves the least risk of damage to the anal sphincter and rectum, but is also believed to take longer to heal. After the birth, the doctor makes a few stitches to close the opening.
Episiotomy is a frequent obstetric practice in some countries, especially in the case of new mothers, but its use is highly controversial, since its benefits are highly debated and its complications are numerous.
Pros : Injury from a severe tear is believed to pose an increased risk of bruising and infection. Also that the cut helps to avoid an excessive strain of the perineum muscles, which in the long run could lead to problems such as genital prolapse and urinary incontinence. In addition, it contributes to shorten the expulsion phase of the baby. Against: the short and long-term complications and sequelae that we will detail later.
Indications for doing an episiotomy
In which cases is it indicated? According to the SEGO, there are certain maternal and fetal factors that influence when performing an episiotomy.
Maternal factors:
The perineum is not very elastic or very resistant, very muscular, very short (less than 4-6 centimeters from ano-pubic distance), thin and with atrophic musculature or not very elastic vagina. Primiparous women (first childbirth).
Fetal factors:
- Macrosomic babies, or with a weight over 4 kilos
- Prematurity
- Shoulder dystocia
- Baby with a large head circumference
- Expulsive very fast, that is, babies that are born in a single push, since the perineum does not have time to gradually dilate
- Instrumental delivery
- A very long labor, to avoid fetal distress
Against Routine Episiotomy
Although the incidence of this practice is gradually decreasing, the truth is that it is still widespread despite being unnecessary in some cases .
The World Health Organization (WHO) in its recommendations for a positive birth experience is positioned against routine episiotomy in uncomplicated deliveries:
“Routine or extended use of episiotomy is not recommended in women with spontaneous vaginal delivery.”
She insists that episiotomy should be done selectively or in difficult deliveries.
For its part, a review of 12 studies published in Cochrane also supports performing episiotomy only when necessary: “selective episiotomy policies result in fewer women with severe perineal / vaginal trauma .” He adds: “The review shows that the belief that routine episiotomy reduces perineal / vaginal trauma is not justified by current evidence.”
Current recommendations regarding episiotomy are as follows:
- Routine episiotomy should not be performed in spontaneous delivery . Only do it if it is really considered necessary.
- The episiotomy will be carried out if there is clinical need (if you want the delivery to be faster due to suspected fetal distress, for example).
- Analgesia should be administered prior to episiotomy, unless performed in an emergency.
- Episiotomy should not be performed routinely during a vaginal delivery in women who have suffered third or fourth degree tears in previous deliveries.
Complications of episiotomy
It is often believed that a cut of nothing, harmless, but episiotomy has its risks and consequences in the short and long term, such as:
- Infection
- Episiotomy Separation
- Edema, bruising
- Pain during sexual intercourse (temporary or permanent)
- Painful or bothersome scarring
- Allergic reaction to the suture thread
- Underlying abscesses
- Muscle or nerve retraction
- Nodules, ano-vaginal fistulas, inflammatory granulomas
- Scar endometriosis
- Blood loss, anemia
- Psychological trauma
How long does the episiotomy take to heal?
It is necessary to take care of the episiotomy points after delivery, maintaining the hygiene of the scar and always drying it very well. Cold compresses or local ice (not applied directly) can be used to lower inflammation and relieve pain.
Every woman is different and most of them heal the wound without problems, but it can take 3 to 4 weeks to heal .
The stitches are not removed, as the internal ones are resorbed on their own and the external ones will fall out. You can return to normal activities as soon as the pain and discomfort disappear, but you have to wait six weeks to: use tampons, have sex or perform any activity that can open the stitches.
Can I avoid episiotomy?
There is nothing to ensure that you will not have an episiotomy, but you can help prevent it with:
- Perineal massage : the objective of perineal massage is to stretch the perineum, soften it and give it elasticity so that at the time of delivery it is more prepared to open. Here we explain how to do it step by step.
- Kegel exercises: they will help you gain strength and elasticity in the perineal area.
- Control weight gain in pregnancy.
- Stay active and fit during pregnancy.
The posture of delivery is also important for the non-performance of the episiotomy . The vertical posture makes the pressure exerted by the baby’s weight on the perineum favoring the baby’s exit, reducing the need to practice a cut. Studies have shown that significantly more episiotomies are performed in lithotomy (lying position) deliveries than in any other position during delivery.
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