Families For Life | Pushing and Delivery: Is an Episiotomy Needed?

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Is it necessary for the doctor to make "the cut" down below?

When you are at full dilatation (i.e. your cervix is 10 cm dilated), you are ready to push and deliver your baby. You may then ask — “To facilitate my delivery, will the doctor make the ‘cut’ down below?”

What is an episiotomy?

An episiotomy is often referred to as the ‘cut’. An episiotomy is a clean cut with a pair of sterile scissors made under a local anesthetic (so that it is painless) by the doctor or midwife when the baby’s head is about to deliver — what is commonly referred to as ‘crowning’. This cut is made into the perineum (skin and muscles between the vaginal opening and anus) in order to enlarge the space at the outlet, facilitating the birth of your baby.

What are the advantages of an episiotomy?

The main purpose of an episiotomy is to prevent multiple tears, which may occur if your pushing is overly fast and strong, or if your perineum is short. A bad, ragged tear is more difficult to repair, and can have healing problems, especially if the tear goes into the anus.

However, even though an episiotomy was done, there may still be a rather extensive tear at times, especially if the pushing was too fast and strong.

Patients in their first pregnancy tend to need an episiotomy more than patients in their second or subsequent pregnancies. This is because the perineum is less elastic and thus, less able to stretch to accommodate the delivering head.

In the past, there has been a belief that routine episiotomies can prevent incontinence, protect the pelvic floor and reduce trauma to the delivering head. However, this theory is yet to be conclusively proven and women delivered without episiotomies seem to do as well as those with episiotomies performed. As such, it is no longer a routine practice.

Nonetheless, there are still a few situations in which an episiotomy may be necessary. These include:

Your baby’s heart rate shows that it is not able to tolerate the last part of the labour well and therefore it needs to be delivered as soon as possible.
Your baby is big and the doctor or midwife needs some extra room to manipulate within your birth canal so that the baby can be delivered.
Your doctor needs some extra room to use the forceps or vacuum to help deliver your baby.
Your perineum looks like it is about to tear in multiple places and it is deemed safer to make a single clean cut than to allow the tear to happen.
You have a rather short perineum.

Types of episiotomy

In general, there are 3 types of episiotomy:

Midline
Medio-lateral
J-shaped episiotomy

In a midline episiotomy, the skin of the perineum is cut vertically downwards, towards the anus.

In a medio-lateral episiotomy, the skin of the perineum is cut downwards and diagonally.

In a J-shaped episiotomy, the skin of the perineum is cut vertically downwards before being directed to the left or right.

There are pros and cons when deciding between the three types of episiotomy. In a midline episiotomy, repair, scar cosmesis, post delivery pain, blood loss and healing are more favourable. However, there is a higher chance of it extending posteriorly into your back passage (rectum) and complicating the subsequent repair and healing.

On the other hand, in a medio-lateral or J-shaped episiotomy, the cut is slanted away from your anus, thus affording greater protection to your rectum. Therefore, patients with a short perineum will benefit from a medio-lateral episiotomy. Post delivery pain and blood loss may be greater as it cuts through more layers of your perineal muscles.

Only your doctor or midwife can make a judgment at the time of delivery on your need and the type of episiotomy to be made.

Relief of pain from episiotomy

In most instances, the after pain from an episiotomy lasts only 2–3 days. This is usually mild and can be effectively relieved by either topical anesthetic cream or oral painkillers. If the episiotomy is more extensive, the pain can be managed with intermittent icing through the help of a physiotherapist. Sitting devices shaped as doughnuts may be used to relieve the pressure on your wound.

Episiotomy aftercare

The aftercare of an episiotomy is essentially a matter of cleanliness. Daily washing with water and frequent changing of soiled sanitary napkins will help keep the wound clean.

Dissolvable sutures are used to repair the episiotomy or tear. These stitches do not need to be removed as they will dissolve within two weeks after the wound has healed. You just need to keep the sutures as clean and dry as possible. As the area is richly supplied by blood vessels, the wound can usually heal quite well. Passing of urine or stools will not affect the episiotomy. In fact, you are encouraged to ambulate and walk around.

As the episiotomy heals and the wound edges are drawn together, you may feel some mild discomfort. Healing is complete after 6 weeks of delivery. It is essential that you keep to the follow up appointment and after your doctor gives you the go-ahead, you can resume your sex life and exercise.

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By Dr TAN Thiam Chye, Dr TAN Kim Teng, Dr TAN Heng Hao, Dr TEE Chee Seng John,
KK Women’s and Children’s Hospital

Sources:
The New Art and Science of Pregnancy and Childbirth, World Scientific 2008.