When An Irresistible Force Meets An Immovable Object

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.

Why Episiotomy

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.

Tearing During Delivery

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:

  • Quickly dissolving --usually chromic, which dissolves in about two weeks and usually softens during this time.
  • Delayed dissolving--usually a "polyglycolic," which dissolves over about 6 - 8 weeks, or longer, but can stiffen and give a sticking sensation sometimes.
  • Permanent suture --used when there is an infection and previous episiotomy repair break-downs.  I don't use this. So far, anyway.

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.

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