Episiotomy

Original Editor - Vidya Acharya

Top Contributors - Vidya Acharya  

Description

An episiotomy is the most common obstetric surgical procedure performed in the second stage of labor. It is done to reduce the incidence of severe perineal tears (third and fourth-degree) during labor. A controlled incision is made in the perineum to enlarge the vaginal orifice, thereby facilitating a difficult delivery resulting in an easily repairable incision compared to an uncontrolled vaginal trauma.

Episiotomy was first introduced in the 18th century for preventive measures. The rate of performing this intervention increased gradually in the first half of the 20th century worldwide. Also, with an increasing trend for hospital births and for physicians to get involved in the normal uncomplicated birth process, there was rise in the number of episiotomies. According to reports, episiotomy rates in the year 1977 in the United States varied from 9.8% for home births to 91% for primipara deliveries in selected hospitals, and the data from British maternity units in 1984 indicated rates ranging from 14% to 96% for primiparas and 16% to 71% for multiparas. Although episiotomy had become one of the most commonly performed surgical procedures, there was no solid scientific evidence of its effectiveness . A review (Lede 1996) suggested that the routine use of episiotomy gave fewer benefits; instead, it involved a greater need for surgical perineal repair, thereby involving higher costs of medical care and more maternal discomfort. Furthermore, the routine use resulted in poor muscle tone, fecal and /or urinary incontinence, and poorer sexual function.

A meta-analysis comparing routine episiotomy with restrictive episiotomy suggests that the restrictive episiotomy was associated with lesser posterior perineal trauma, lesser need for suturing, and fewer complications related to healing.The World Health Organization (WHO) and other professional societies recommend restrictive over routine episiotomy since the 1990s. The prevalence of episiotomy varies worldwide, with rates declining in developed countries but higher in less industrialized and developing  countries.

Indication

Episiotomy is suggested to be administered during difficult vaginal deliveries to control and avoid potentially perineal lacerations at the time of delivery.

It is done in conditions such as:

• complicated vaginal deliveries (breech, shoulder dystocia, forceps, vacuum),
• incision-related scars in the genital area,
• poorly healed or 4th-degree tears, and fetal distress,
• when there is poor perineal tissue elasticity, that perineal tear seems unavoidable,
• or short perineal length, research based on the traditional views thinks that the Asian women have shorter perineal length than Caucasians, putting them at increased risk of tears,

There are varying beliefs about the benefits of this procedure.

Benefits thought for the mother are:

• reduction in the likelihood of third-degree perineal tears,

• the preservation of the muscle relaxation of the pelvic floor and perineum, leading to improved sexual function,
• reduced risk of fecal and urinary incontinence,
• ease of repair and better healing than laceration because it is a straight and clean incision

Benefits for the baby:

It is also suggested that episiotomy increases the APGAR score of the baby, reduces the prolonged second stage, and may also reduce the possibility of fetal shoulder dystocia. In some cases, rigid perineum could lead to fetal asphyxia, cranial trauma, cerebral hemorrhage, and mental retardation.

Types of Episiotomy

Episiotomy

The two main types of episiotomy are the median and mediolateral, although seven different incisions have been described in the literature. Episiotomy is classified into the following types: Midline, Mediolateral, Lateral, the modified-median, J-shaped, anterior, and radical (Schuchardt incision). Mediolateral episiotomy was preferred in Britain and most European countries, whereas midline episiotomy was done most frequently in North America. There is a debate regarding which method is best for episiotomy. Research states mediolateral episiotomy lowers the risk of third-degree tear. Midline compared to mediolateral episiotomy resulted in more deep perineal tears. .

The procedure is done with scissors or scalpel during the last part of the second stage of labour to enlarge the vaginal orifice and is repaired by suturing.

Management

The patient should be monitored for pain and urinary incontinence in the post-delivery phase.  The sutures used to close an episiotomy will reabsorb in the tissues within 6 to 8 weeks.There is no specific treatment and personal hygiene is a key to healing.

Medical management

• A paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) can cause pain relief.
• Laxatives are recommended following perineal repair as the passage of stool can result in wound dehiscence. Stool softeners (eg lactulose) should be titrated to keep the stools soft, not loose and are prescribed for 10 days postoperatively.
• Broad-spectrum antibiotics are recommended in the immediate postoperative period to reduce the risk of infections and wound healing.
• In the initial 48 hours, the patient should be placed in positions that will avoid strain on the episiotomy site and help reduce perineal oedema. Lie on a flatbed and on to their side when breastfeeding, and avoid overuse of seated positions. The patient should also be informed to avoid activities that may increase intra-abdominal pressure for the first six to 12 months after delivery.
• To ensure that wound should be washed and patted dry after toileting. The patient should inspect the wound daily using a hand mirror for any signs of wound breakdown.

Physiotherapy Management

• Sitz baths help in relaxing the pelvic floor and relieving pain.
• Ice packs help in reducing swelling and can cause analgesia. RCT suggests that 20 minutes of one cryotherapy application (bag of crushed ice on the perineal region) effectively provided perineal pain relief in women in the immediate postpartum period after vaginal birth with episiotomy.
• TENS is effective in pain relief. According to RCT, low frequency Tens (5 Hz and 100 µs pulse) and high frequency Tens (100 Hz and 100 µs pulse) applied for 30 minutes near the episiotomy site was found to be safe and effective in reducing pain.
• Kegel exercises are to be taught to the patient to train the pelvic floor muscles.

Complications

Complications include:

• bleeding
• infection
• urinary retention seen particularly after instrumental deliveries that may result in urinary tract infections, prolonged voiding difficulties
• prolonged wound healing,
• dyspareunia,
• pelvic floor dysfunction
• urinary fistulas, and
• inappropriate wound scarring

According to a study evaluating early complications after delivery with episiotomy in Vietnamese women, pain in sitting position (30.4%) was the most prominent trouble, and pelvic disorders such as urinary incontinence (11.4%), urinary retention (10.8%), or flatus incontinence (8.9%) were observed in a remarkable number of participants, and sexual dysfunction ( 40.7% )was seen with trouble occurring commonly in the domains of desire (68.9%) and pain (58.5%).

Contraindications

Episiotomy may pose an increased risk for third and fourth-degree tears in multiparous women.

Clinical Significance

Different opinions exist about the applicability of episiotomy. Traditional views suggest that routine episiotomy reduces the pressure of the fetal head on the pelvic floor tissues and prevents third-degree or fourth-degree perineal laceration. Additionally, it is considered easy to suture because an open wound is smoother than a spontaneous wound. However, there are published reports that claim that episiotomy has no such benefits and, extensive studies stress that routine implementation of episiotomy should be abandoned. According to American College of Obstetricians and Gynecologists (ACOG) guidelines, “the best available data do not support the liberal or routine use of episiotomy. As a matter of fact, an episiotomy is essentially a type of birth injury. It does not reduce the incidence of severe perineal lacerations. Instead, research suggests that it increases the risk of complications, including perineal tears, perineal pain (compared with no laceration), puerperal infection, postpartum hemorrhage, and later dyspareunia. Therefore, the clinician must ensure that the benefits of the intervention outweigh the risks during the decision-making process. It is seen that many obstetricians have begun to limit the use of episiotomy in recent years.