Episiotomy

Procedure Overview

What is an episiotomy?

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An episiotomy is an incision through the vaginal wall and the perineum (the area between the thighs, extending from the vaginal opening to the anus) to enlarge the vaginal opening and facilitate childbirth.

During a vaginal birth, the physician will assist the fetus' head and chin out of the vagina when it becomes visible. Once the head is out of the vagina, the physician usually rotates the fetus to the side and eases the shoulders out, followed by the rest of the body.

In some cases, the vaginal opening does not stretch enough to accommodate the fetus. The physician may perform an episiotomy to help enlarge the opening and deliver the fetus. The episiotomy is usually performed when the fetal head has stretched the vaginal opening to several centimeters during a contraction.

An episiotomy may be classified into two types:

• midline or median - refers to a vertical incision that is made from the lower opening of the vagina toward the rectum. This type of episiotomy usually heals well but may be more likely to tear and extend into the rectal area, called a third or fourth degree laceration.
• mediolateral - refers to an incision that is made at a 45-degree angle from the lower opening of the vagina to either side. This type of episiotomy does not tend to tear or extend, but is associated with greater blood loss and may not heal as well.

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After the delivery of the baby, the mother is asked to continue to push during the next few uterine contractions to deliver the placenta. Once the placenta is delivered, the episiotomy incision is sutured. If a mother does not have regional anesthesia such as an epidural, a local anesthesia may be injected in the perineum to numb the area for repair of a tear or episiotomy after delivery.

Other related procedures that may be used during labor and birth include caesarean delivery and external and internal fetal monitoring. Please see these procedures for additional information.

Reasons for the Procedure

Not all women will require an episiotomy, and assisting the tissues to stretch naturally may help reduce the need for this procedure. If an episiotomy is not performed, tearing of the perineal tissues may or may not occur. An episiotomy may be used to assist in the treatment of the following conditions:

• fetal distress
• complicated birth such as a breech presentation (bottom or feet first) or shoulder dystocia (when the fetal head has been delivered but the shoulders are trapped)
• prolonged second stage (pushing stage of labor)
• forceps or vacuum delivery
• large baby
• preterm baby

There may be other reasons for your physician to recommend an episiotomy.

Risks of the Procedure

As with any surgical procedure, complications may occur. Some possible complications of an episiotomy may include, but are not limited to, the following:

• bleeding
• tearing past the incision into the rectal tissues and anal sphincter
• perineal pain
• infection
• perineal hematoma (collection of blood in the perineal tissues)
• pain during sexual intercourse

Patients who are allergic to or sensitive to medications or latex should notify their physician.

If the birth of the baby occurs too rapidly, an episiotomy may not be performed.

There may be other risks depending upon your specific medical condition. Be sure to discuss any concerns with your physician prior to the delivery.

Before the Procedure

• Your physician will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.
• You will be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if something is not clear. The consent form for an episiotomy may be included as part of the general consent for your delivery.
• Notify your physician if you are sensitive to or are allergic to any medications, iodine, latex, tape, and anesthetic agents (local and general).
• Notify your physician of all medications (prescribed and over-the-counter) and herbal supplements that you are taking.
• Notify your physician if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure.

Based upon your medical condition, your physician may request other specific preparation.

During the Procedure

An episiotomy may be performed as part of a vaginal birth. The procedure and the type of episiotomy may vary depending on your condition and your physician’s practices.

Generally, an episiotomy follows this process:

1. You will be positioned on a labor bed, with your feet and legs supported for the birth.
2. If you have not been given any labor or delivery anesthesia, a local anesthetic may be injected into the perineal skin and muscle to numb the tissues before the incision. If epidural anesthesia is used, you will have no feeling from your waist down and no additional anesthesia will be needed for the episiotomy.
3. During the second stage of labor (pushing stage), as the fetal head stretches the vaginal opening, the physician will use special scissors or a scalpel to make the episiotomy incision.
4. The baby will be delivered.
5. The placenta will be delivered.
6. The episiotomy incision will be examined for any further tearing.
7. A local anesthetic may be injected into the perineal skin and muscle to numb the tissues.
8. The perineal tissues and muscle will be repaired using sutures, which will dissolve over time.

After the Procedure

After an episiotomy, you may experience incisional pain. An ice pack may be applied immediately after birth to help reduce swelling and pain. During your stay in the hospital and at home after your baby’s birth, sitz baths (warm or cold shallow baths) may relieve soreness and speed healing. Medicated creams or local anesthetic sprays applied to your perineum may also be helpful.

You may take a pain reliever for soreness as recommended by your physician. Aspirin or certain other pain medications may increase the chance of bleeding. Be sure to take only recommended medications.

You should keep the incision clean and dry, using the cleansing method recommended by your physician after urination and bowel movements. If bowel movements are painful, stool softeners recommended by your physician may be helpful.

You should not douche, use tampons, or have intercourse until the time instructed by your physician. You may also have other restrictions on your activity, including no strenuous activity or heavy lifting.

You may resume your normal diet unless your physician advises you differently.

Your physician will advise you when to return for further treatment or care.

Notify your physician if you have any of the following:

• bleeding from the episiotomy site
• foul-smelling drainage from the vagina
• fever and/or chills
• severe perineal pain

Your physician may give you additional or alternate instructions after the procedure, depending on your particular situation.