Episiotomy

Episiotomy, also known as perineotomy, is a surgical incision of the perineum and the posterior vaginal wall generally done by a midwife or obstetrician. Episiotomy is usually performed during second stage of labor to quickly enlarge the opening for the baby to pass through. The incision, which can be done at a 90 degree angle from the vulva towards the anus or at an angle from the posterior end of the vulva (medio-lateral episiotomy), is performed under local anesthetic (pudendal anesthesia), and is sutured after delivery. Its routine use is no longer recommended. Despite this, it is one of the most common medical procedures performed on women. In the United States, as of 2012, it was performed in 12% of vaginal births. It is still widely practiced in many parts of the world, including Japan, Taiwan, China, and Spain. Vaginal tears can occur during childbirth, most often at the vaginal opening as the baby's head passes through, especially if the baby descends quickly. Episiotomy is done in an effort to prevent against soft-tissue tearing which may involve the anal sphincter and rectum. Tears can involve the perineal skin or extend to the muscles and the anal sphincter and anus. The midwife or obstetrician may decide to make a surgical cut to the perineum with scissors or a scalpel to make the baby's birth easier and prevent severe tears that can be difficult to repair. The cut is repaired with stitches (sutures). Some childbirth facilities have a policy of routine episiotomy. Specific reasons to do an episiotomy are unclear. Though indications on the need for episiotomy vary and may even be controversial (see discussion below), where the technique is applied, there are two main variations. Both are depicted in the above image. In 2009, a Cochrane meta-analysis based on studies with over 5,000 women concluded that: 'Restrictive episiotomy policies appear to have a number of benefits compared to policies based on routine episiotomy. There is less posterior perineal trauma, less suturing and fewer complications, no difference for most pain measures and severe vaginal or perineal trauma, but there was an increased risk of anterior perineal trauma with restrictive episiotomy'. The authors were unable to find quality studies that compared mediolateral versus midline episiotomy. There are four main types of episiotomy: Traditionally, physicians have used episiotomies in an effort to deflect the cut in the perineal skin away from the anal sphincter muscle, as control over stool (faeces) is an important function of the anal sphincter, i.e. lessen perineal trauma, minimize postpartum pelvic floor dysfunction, and as muscles have a good blood supply, by avoiding damaging the anal sphincter muscle, reduce the loss of blood during delivery, and protect against neonatal trauma. While episiotomy is employed to obviate issues such as post-partum pain, incontinence, and sexual dysfunction, some studies suggest that episiotomy surgery itself can actually cause all of these problems. Research has shown that natural tears typically are less severe (although this is perhaps not surprising since an episiotomy is designed for when natural tearing will cause significant risks or trauma). Slow delivery of the head in between contractions will result in the least perineal damage. Studies in 2010 based on interviews with postpartum women have concluded that limiting perineal trauma during birth is conducive to continued sexual function after birth. At least one study has recommended that routine episiotomy be abandoned for this reason. In various countries, routine episiotomy has been accepted medical practice for many years. Since about the 1960s, routine episiotomies have been rapidly losing popularity among obstetricians and midwives in almost all countries in Europe, Australia, Canada, and the United States. A nationwide U.S. population study suggested that 31% of women having babies in U.S. hospitals received episiotomies in 1997, compared with 56% in 1979. In Latin America it remains popular, and is performed in 90% of hospital births.