Episiotomy
Episiotomy is a procedure
as unnatural as any elective surgery. Most folks, to be sure, prefer not
to be cut for any reason. But just because it's unnatural doesn't mean
it's unjustified. It is actually a helpful procedure, along with the other
unnatural aspects of labor and delivery--epidurals, IVs, etc. An episiotomy
involves making a vertical incision in the tissue between the floor of
the vagina and the rectum, thereby increasing the circumference of the
exit for the baby's head at the time of delivery. It is painless when done
under an epidural, local anesthetic, or pudendal (nerve) block. The circle
of tissue that is the outlet for the baby is made larger and the chance
of tearing less.
Since it is easier to
repair a surgical incision than a traumatic tear, the decision to cut an
episiotomy is made at the last moment when it looks like there may be tearing
without one. In this way, it should be looked at as preventative. But it
only prevents superficial tears. No episiotomy--no increase in diameter
of just the outlet--will prevent deep tears if the force of the delivery
(due to a large head, forceps, or precipitous expulsion) exceeds the elasticity
of the tissues of the pelvis. Something will have to give, and it's usually
the baby's head that wins.
Some espouse never cutting
an episiotomy. Although this philosophy won't cause deep tears, the superficial
ones can increase the time of recovery by a few weeks. The gamble here,
of course, is whether or not a patient will get away with nothing needing
repair. It is tempting, but it is certain that a surgical repair of a straight
incision hurts less and heals better than a disarray of tissue split in
several different directions.
What's the best approach?
Leave it up to your obstetrician-- that's why you chose your doctor. Of
course, discuss the issue ahead of time so that both of you are clear on
a common plan. But keep in mind that your doctor doesn't do episiotomies
if clearly not needed. They're included in the global fee, so there's no
financial incentive, and it's more work to repair one than not repair one.
So if it looks like the baby will deliver without unreasonable stretching
and risk, your doctor will gladly skip the episiotomy. If it looks as if
there may be some trauma, an episiotomy--the smallest necessary--will be
used for your benefit.
Absorbable suture means
you don't need the stitches removed. And because of the unique immunology
of the area, infection is rare. The area ultimately heals well, even when
there was tearing. In fact, it's often difficult to tell a woman's had
one by exam. Thinning of the floor of the vagina is from the passage of
the baby, not from the decision to do an episiotomy or not. One must remember
that childbirth is an amazing phenomenon of physics, pushing a body's capacity
to the max. Compared to the actual delivery, episiotomy can be thought
of as an inconvenience or an advantage, depending on what could have happened
with or without it. But it is a secondary consideration when an irresistible
force--the baby--meets an immovable object--you.
Q & A: With my last baby I had a midline episiotomy, but still tore badly. What
are the chances of a tear with the next delivery?
All an episiotomy does is prevent
the superficial tears. Deeper tears are usually the result of a large baby
or if the skin of the perinuem isn't given enough time to slowly elasticize
(as with pushing in Stage II of labor). Shortened Stage II's occur with
precipitous deliveries or with forceps (usually in emergency situations).
The vacuum extractor usually doesn't yield enough outward force to pull
a baby over the increased resistance of non-elasticized tissue. (It'll
pop off first--a safety feature).
With episiotomy, the midline
method is the preferable method to me, because the tissue is thinner there--therefore,
less tissue trauma, less bulk to heal, less pain. The downside is that
if it extends with a large baby, it'll tear right into the rectum. This
can be fixed right there, though. The alternative is a right or left "mediolateral"
episiotomy, in which the cut is made from the center of the floor of the
vagina down an angle, on either side of the rectum. This will spare the
rectum...maybe....but in a tear will shred in many planes much thicker
tissue than the midline would have. It's a mess. A midline is much easier
to recover from than a mediolateral. And a midline with an extension tear
into the rectum is easier to recover from than a mediolateral with extension
tears along irregular paths into all of that thicker lateral tissue.
If you've had a previously
bad tear, the chances of the same thing happening are less, since the tissues
of the vagina and perineum have already been "elasticized" once. But that's
in a perfect world where it's assumed that all other parameters are the
same--same doctor, same type of episiotomy, same size and position of baby,
same type of labor, etc. No two pregnancies are alike, however, so I'm
afraid it's going to be "I don't know." Generally, the more babies one
has, the less likely the prudence (notice I didn't say necessity) of an
episiotomy.
Do know this: most obstetricians--myself
included--love to get by without an episiotomy at all. But I'm not afraid
to cut one if I can see it's the only thing holding the head back without
nasty tearing--It's a last second call. But in my practice I cut no "automatic"
episiotomies.
It would be a good idea
to discuss with your doctor the policy on episiotomy--are they automatic,
are the midline or mediolateral...and why? Are they with quickly
dissolving suture or delayed absorbing suture, etc.?
Suture used in episiotomy
There are three main types of
suture used in episiotomy:
Technique for episiotomy repair
I was taught how to repair
an episiotomy by a nurse midwife when I was in medical school.Many
doctors use a tissue forceps called "pick-ups with teeth." This is
nothing more than a pair of tweezers with two teeth on one shaft interdigitating
with a single tooth on the other one. This sandwiching pincer grasp
is very efficient in picking up the tissue so that the necessary tension
is provided against which to drive a curved needle.
Back at Charity Hospital in
New Orleans, where I trained, there were wards (wards? What are those?)
where there would be 12 patients at a time. During "post-partum"
rounds, I began to notice that my patients had less episiotomy pain than
those of other doctors. Over the years, I've discovered what I think
is the reason:
I don't use pick-ups with teeth.
I use my index finger and thumb
to gently support the tissue I'm sewing. In other words, I use no
instruments except the actual needle holder.With pick-ups with teeth,
every time tissue is grasped, because of the design of the forceps, there
are three little holes placed into the tissue grasped. In my opinion,
a series of three-holes along the repair route become pockets of inflammation
in the recovery period, increasing the pain associated with episiotomy
repair. We're talking about perhaps 50 - 60 little holes. True,
these pose absolutely no danger, but I feel they hurt more until they heal
within a few days.
I use what's called the "modified"
midline episiotomy. In this technique, I perform a midline, but then
a make a little right angle cut on either side of the lowest part of the
cut, which then skirts the circular musculature that surrounds the rectum.
In this technique, a smaller episiotomy is needed, and this eliminates
the higher risk of any tears through the rectum.
And once again, for my patients
to know...I don't cut episiotomies automatically.
I hate them. Unless the
patient needs one. Then I love them, because if I have to cut
one, I'm averting big, bad tears that are much worse than an episiotomy
would be.
Episiotomy and future
problems
The literature has continually
pursued whether cutting episiotomies or not cutting them contributes to
future problems with urinary incontinence, "fallen" bladders, prolapse
of the uterus in later years, and rectal weakness. After exhaustive
studies and lengthy follow-up of patients in groups having and not having
episiotomies, the current thinking is that episotomy (done or not done)
does not
contribute to or cause these problems.
The direct cause
of these problems depends on how many babies have been delivered, how many
large babies have been delivered, age, gravity, and other predisposing
factors that deteriorate tissue integrity, like alcoholism, diabetes, and
smoking.