Episiotomy

An episiotomy (pronEng|ɛˌpiːziːˈɒtəmiː) is a surgical incision through the perineum made to enlarge the vagina and assist childbirth. The incision can be midline or at an angle from the posterior end of the vulva, is performed under local anaesthetic (pudendal anesthesia) and is sutured closed after delivery. It is one of the most common medical procedures performed on women, and although its routine use in childbirth has steadily declined in recent decades, it is still widely practiced in Latin America.

Uses

Many physicians use episiotomies because they believe that it will lessen perineal trauma, minimize postpartum pelvic floor dysfunction by reducing anal sphincter muscle damage, reduce the loss of blood at delivery, and protect against neonatal trauma. In many cases though, episiotomies cause all of these problems. [Thacker, S.B., and H.D. Banta. 1983. "Benefits and risks of episiotomy: an interpretative review of the English language literature, 1860-1980." "Obstet Gynecol Surv" 38(6): 322-38.] Research has shown that natural tears typically are less severe.

Slow delivery of the head, in between contractions will result in the least perineal damage. [Albers, L.L., et al. 2006. "Factors Related to Genital Tract Trauma in Normal Spontaneous Vaginal Births." "Birth" 33(2): 94-100.] Episiotomy is indicated if:
* the baby's shoulders are stuck (When a baby's shoulders are stuck they are stuck behind bony pelvis, not soft tissue, so this indication is disputed)

Controversy about common usage

In various countries, routine episiotomy has been accepted medical practice for many years. Various urban legends circulate on the fact that after very rapid natural births, young doctors would still make episiotomies so as not to displease their professors.

Since about the 1960s, routine episiotomies have been rapidly losing popularity among obstetricians and midwives in Europe, Australia and the United States. A nationwide US population study [cite journal |author=Weber AM, Meyn L |title=Episiotomy use in the United States, 1979-1997 |journal=Obstet Gynecol |volume=100 |issue=6 |pages=1177–82 |year=2002 |pmid=12468160 |doi= |url=http://www.greenjournal.org/cgi/pmidlookup?view=long&pmid=12468160] suggested that 31% of women having babies in U.S. hospitals received episiotomies in 1997, compared with 56% in 1979. In Latin America it's still popular, where it's done on 90% of hospital births [cite journal |author=Althabe F, Belizán JM, Bergel E |title=Episiotomy rates in primiparous women in Latin America: hospital based descriptive study |journal=BMJ |volume=324 |issue=7343 |pages=945–6 |year=2002 |pmid=11964339 |doi= |url=http://bmj.com/cgi/pmidlookup?view=long&pmid=11964339] and in most cases without the mother's consent. There, routine episiotomy is a major cause of infections, some of them fatal [ [http://www.efn.org/~djz/birth/obmyth/episabst1.html Obstetric Myths Versus Research Realities: episiotomy abstracts 1-18 ] ] .

Recent studies indicate that routine episiotomies should not be performed, as they increase morbidity. This procedure is not helpful for routine patients [cite journal |author=Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J, Lohr KN |title=Outcomes of routine episiotomy: a systematic review |journal=JAMA |volume=293 |issue=17 |pages=2141–8 |year=2005 |pmid=15870418 |doi=10.1001/jama.293.17.2141 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=15870418] Having an episiotomy may increase perineal pain in the postpartum period, resulting in trouble defecating, particularly in midline episiotomies [cite journal |author=Signorello LB, Harlow BL, Chekos AK, Repke JT |title=Midline episiotomy and anal incontinence: retrospective cohort study |journal=BMJ |volume=320 |issue=7227 |pages=86–90 |year=2000 |pmid=10625261 |doi= |url=http://bmj.com/cgi/pmidlookup?view=long&pmid=10625261] . In addition it may complicate sexual intercourse by making it painful [ [http://www.mothernature.com/Library/Bookshelf/Books/62/70.cfm Total Health For Women Painful Intercourse ] ] and replacing erectile tissues in the vulva with fibrotic tissue.

In cases where an episiotomy is indicated, a mediolateral incision may be preferable to a median (midline) incision as the latter is associated with a higher risk of injury to the anal sphincter and the rectum [cite journal |author= |title=ACOG Practice Bulletin. Episiotomy. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 71, April 2006 |journal=Obstet Gynecol |volume=107 |issue=4 |pages=957–62 |year=2006 |pmid=16582142 |doi= |url=http://www.greenjournal.org/cgi/pmidlookup?view=long&pmid=16582142] .

Impacts on sexuality

Some midwives compare routine episiotomy to female circumcision. [ [http://www.internurse.com/cgi-bin/go.pl/library/article.cgi?uid=7997;article=BJM_9_3_137_142] Joan Cameron, Karen Rawlings-Anderson, "Female circumcision and episiotomy: both mutilation?" "British Journal of Midwifery", Vol. 9, Iss. 3, 01 Mar 2001, pp 137 - 142.] One study found that women who underwent episiotomy reported more painful intercourse and insufficient lubrication 12-18 months after birth, but did not find any problems with orgasm or arousal. [ [http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowAbstract&ArtikelNr=113464&Ausgabe=234533&ProduktNr=223845] Hanna Ejegård, Elsa Lena Ryding, Berit Sjögren, "Sexuality after Delivery with Episiotomy: A Long-Term Follow-Up", "Gynecologic and Obstetric Investigation", Vol. 66, No. 1, 2008.]

Informed consent

Expectant mothers frequently make "birth plans" during their antenatal care, and are generally encouraged to discuss their views on episiotomy with their caregivers, or as early as possible in labour. In the final stages of delivery the midwife or obstetrician may not have time to discuss the benefits, risks and alternatives without endangering the mother or baby. However, staff restrictions or complications in labour often mean that these plans have to be altered in the course of the birth.

Avoidance

Controlled delivery of the head that allows slow gradual stretching of the perineal tissue can help in minimising damage to the perineum.

Perineal massage beginning around the 34th week has been shown to reduce perineal damage by 6% [cite journal |author=Shipman MK, Boniface DR, Tefft ME, McCloghry F |title=Antenatal perineal massage and subsequent perineal outcomes: a randomised controlled trial |journal=Br J Obstet Gynaecol |volume=104 |issue=7 |pages=787–91 |year=1997 |pmid=9236642 |doi=] .

A perineal dilator can be used to stretch the perineal tissue gradually and train it in preparation for first births. The "Epi-no Birth Trainer" consists of a small inflatable silicone balloon pumped with the same pump as a sphygmomanometer. The Epi-no device has been shown to reduce perineal damage by 50% at first births [cite journal |author=Cohain JS |year=2004 |title=Perineal Outcomes after practicing with a Perineal Dilator. journal=MIDIRS Midwifery Digest |issue=14 |pages=37–41 |url=http://www.epi-no.com/pdf_downloads/experience_judy_slome.pdf] .

References