Childbirth and labor
The process of childbirth includes 3 stages of labor.
- First stage begins from the onset of labor or contractions and lasts until the cervix is completely dilated to 10 cm.
- Second stage continues after the cervix is dilated to 10 cm until the delivery of your baby.
- Third stage is the delivery of your placenta.
In the second stage, the mother has to push the baby out. The baby comes out of vagina, stretching it. In the process there can be some tears in the area.
To prevent this tear, your doctor may carry out an episiotomy. An episiotomy is a surgical incision made in the perineum, the area between the vagina and anus. It is done under the effect of local anesthesia and does not cause pain.
An episiotomy gives more space for the baby to come out and prevents the perineum and surrounding tissue from tearing.
When episiotomy is not given, there is a chance of tear in the perineum. This tear could be ragged and involve the anal canal or rectum making it more difficult to suture.
Episiotomy may be needed under certain circumstances. These are:
- When the mother or baby is in distress and that’s why there is no time to allow perineum to stretch.
- Or the baby is premature. In this case his/her head could be damaged by a tight perineum.
- Or the baby is in breech position. In this case, since the head comes out later, one needs to create more space for the head.
- Or the baby is too large to be delivered without causing extensive tearing.
- Or the delivery is being assisted by vacuum or forceps.
- Or the mother is too tired or unable to push.
An episiotomy is a surgical incision, usually made with sterile scissors, in the perineum as the baby’s head is just about to deliver. Decision to perform an episiotomy is generally not made until the second stage of labor, when delivery of the baby is imminent. In very few cases, episiotomy may be anticipated for e.g., when the baby is in breech position.
This procedure may be used if the tissue around the vaginal opening begins to tear or does not seem to be stretching enough to allow the baby to be delivered.
In most cases, the episiotomy is performed by making a diagonal incision across the midline between the vagina and anus (called a mediolateral incision). After the baby is delivered through the extended vaginal opening, the incision is closed with stitches. Usually local anesthesia is given in the area during suturing. Sometimes if the episiotomy is big or if the patient requests, general anesthesia may be given.
The area of the episiotomy may be uncomfortable or even painful for several days. Also, the area is prone being infected because of the proximity to the passage of defecation and urination. Keeping the area clean is of utmost importance. Hygienic precautions must be taken after urination or defecation to prevent infection around the area.
This is a standard routine procedure and not commonly associated with major complications. Some women may experience increased pain and discomfort for first few days. The infection of the stitches is little higher because it is difficult to maintain hygiene at the episiotomy site. Sometimes the incision gets further torn or deepened by the baby coming out. This may cause extension of the episiotomy and needs to be sutured.
If the tear or extension involves rectum or anal canal, this injury can sometimes lead to incontinence and sphincter dysfunction, and development of fistula.
These complications are not of the episiotomy per say but caused by the baby while coming out. Very rarely there may be blood collection in the area of the episiotomy called as episiotomy hematoma. This requires reopening of the sutures and may require general anesthesia.
Do I need an episiotomy?
Whether or not you need an episiotomy will have to be decided by your doctor at the delivery table. It depends on the individual case. The chance of tear depends upon many factors, such as, the size of the baby, position of the head, force applied by the mother, capacity of perineum to stretch. Sometimes it is difficult for the doctor to judge whether there is a need of episiotomy or no. The doctors who believe in doing an episiotomy feel that it speeds up the birthing process, making it easier for the baby to be delivered. They also believe that a clean incision is easier to repair than a jagged or irregular tear since a clean incision is believed to heal faster. It is also believed that problems of urinary incontinence will be prevented.