Episiotomy: When It’s Needed, When It’s Not
Once a routine part of childbirth, an episiotomy is now recommended only in certain cases. Learn about the risks, benefits, and recovery.
What is an Episiotomy?
An episiotomy is a surgical procedure where a small incision is made in the area between your vagina and anus, called the perineum, during childbirth. The procedure aims to widen the vaginal opening to help facilitate delivery. Although episiotomies were once routine, they are now performed less frequently as research has shown that natural tearing is often preferable.
Image sourced from Physical Therapy for Episiotomy and Perineal Tears on Mangiarelli Rehabilitation.
The Episiotomy Tradition
For years, an episiotomy was believed to prevent larger, more severe vaginal tears during childbirth. It was thought that a surgical incision would heal better than a natural tear and that it would help protect the pelvic floor muscles and connective tissue.
Today, however, research suggests that routine episiotomies may not prevent these complications. As a result, episiotomy is no longer recommended as a standard practice for all vaginal deliveries.
When is an Episiotomy Necessary?
Despite the shift in medical practice, there are still situations where an episiotomy may be needed. This includes:
- Fetal distress: If the baby’s heart rate is abnormal, signaling distress, an episiotomy may be needed to expedite delivery.
- Shoulder dystocia: If the baby’s shoulder becomes stuck behind the pelvic bone during delivery, a surgical incision may help.
- Assisted delivery: If forceps or vacuum extraction are required to assist with delivery, an episiotomy may be performed to provide space.
- Prolonged pushing: If the mother has difficulty pushing or if the delivery is prolonged, an episiotomy may help deliver the baby more safely.
How is an Episiotomy Performed?
An episiotomy is performed during a vaginal delivery. Here’s how it typically works:
- Anesthesia: If the mother hasn’t had an epidural, a local anesthetic will be injected to numb the perineal area before the incision is made.
- Incision: The obstetrician will make a cut in the perineum. There are two types of incisions:
- Midline incision: This is a vertical incision that extends toward the anus. It’s easier to repair but carries a higher risk of extending into the anal sphincter, which may lead to a fourth-degree tear.
- Mediolateral incision: This angled incision has a lower risk of extending to the anus but is more difficult to repair and may be more painful during recovery.
- Repair: After the delivery, the incision is closed with absorbable stitches. The recovery process depends on the severity of the incision.
Episiotomy Risks
While episiotomies are generally safe, there are some risks associated with the procedure, including:
- Infection: As with any surgical incision, there’s a risk of infection. Proper wound care and hygiene are essential.
- Pain during sex (dyspareunia): Many women experience discomfort during intercourse in the months following the procedure.
- Fecal incontinence: If the incision extends too far toward the anal sphincter, it can result in more severe tearing (fourth-degree tear), which may cause difficulty controlling bowel movements.
- Prolonged recovery: Healing from an episiotomy may take several weeks. It can be uncomfortable, and some women experience more pain than with a natural tear.
Healing from an Episiotomy
Recovery from an episiotomy varies depending on the type and severity of the incision. Here’s what to expect:
- Pain relief: You may be given prescription pain relievers or over-the-counter medications like ibuprofen. Stool softeners may also be prescribed to ease bowel movements, as constipation can exacerbate pain.
- Home remedies: Applying ice packs or perineal cold packs to reduce swelling, taking warm sitz baths, and using a peri bottle to clean the area after using the restroom can help soothe discomfort.
- Healing time: While healing typically takes around one month, it’s essential to monitor your recovery. If you experience worsening pain, redness, swelling, or foul-smelling discharge, contact your healthcare provider as these could indicate an infection.
Can You Refuse an Episiotomy?
Since episiotomies are no longer routine, many healthcare providers will not perform the procedure unless it’s absolutely necessary. If you have concerns, it’s crucial to discuss them with your provider ahead of time. Make sure they are aware of your preferences regarding episiotomy and childbirth.
Preventing an Episiotomy
While you can’t always prevent an episiotomy, there are a few methods that may help reduce the need for it:
- Perineal massage: Some research suggests that perineal massage during pregnancy can help reduce the risk of tearing. Massaging the perineum a few weeks before delivery may help stretch the tissue.
- Warm compresses: Applying a warm compress to the perineum during labor can help make the tissue more flexible and may reduce the need for an episiotomy.
- Controlled pushing: Listening to your body and pushing when needed rather than forcing it may help reduce tearing.
Pelvic Floor Rehabilitation for an Episiotomy or Perineal Tear
Pelvic floor rehabilitation is a highly effective treatment for addressing issues caused by perineal tearing or an episiotomy. This rehabilitation focuses on restoring strength, function, and mobility to the pelvic floor muscles, which play a key role in supporting the bladder, bowel, and uterus.
Pelvic floor rehabilitation can help alleviate common issues such as:
- Pain during sex (dyspareunia)
- Pelvic floor pain and weakness
- Urinary and fecal incontinence
- Difficulty with muscle control and recovery after childbirth
In a pelvic floor rehabilitation program, physical therapists typically use a combination of techniques, including:
- Pain management: The use of ice or heat to reduce inflammation and swelling in the perineal area.
- Scar massage and myofascial release: These techniques target tightness or restriction in the pelvic floor muscles and surrounding areas, promoting relaxation and reducing pain.
- Manual therapy: Focuses on hands-on techniques to improve mobility and function in the pelvic region.
- Neuromuscular reeducation: Helps retrain the pelvic muscles and improve coordination, ensuring the muscles work properly together.
- Core and hip muscle training: Strengthening exercises that target the core and hip muscles to support the pelvic region.
- Kegel exercises: Targeted pelvic floor exercises aimed at strengthening the pelvic muscles, promoting better control, and preventing urinary incontinence.
- Diaphragmatic breathing: A technique to improve relaxation and proper breathing patterns that support pelvic floor function.
Studies, including a 2017 report, have shown that women who participate in pelvic floor rehabilitation programs experience lower rates of both episiotomies and perineal tearing during childbirth. These programs typically involve pelvic floor exercises, perineal massaging, and other therapeutic techniques that help strengthen the pelvic floor muscles and improve tissue elasticity.
How Pelvic Floor Rehabilitation Helps
Pelvic floor rehabilitation is typically recommended by your obstetrician or midwife if you’ve experienced a perineal tear or episiotomy during childbirth. Your therapist will develop an individualized plan tailored to your needs. This program will focus on regaining strength, improving flexibility, and restoring function to the pelvic region, promoting a faster and more comfortable recovery.
Every woman’s healing process is unique, so your therapist will work with you to create a customized strategy that suits your specific needs and preferences, ensuring the best possible recovery and long-term pelvic health.
When Can I Have Sex After an Episiotomy?
Pain during sex after an episiotomy is common and can last several months. Using water-based lubricants can help reduce discomfort. Most women can expect to resume sexual activity after six weeks, but only after receiving approval from their healthcare provider.
When to Call the Doctor
You should contact your doctor if you experience any of the following after an episiotomy:
- Increasing pain that does not improve with medication
- Foul-smelling discharge or pus from the incision
- Redness or swelling around the incision site
- Heavy bleeding or fever
Summary
While episiotomies were once routine, they are now performed less frequently due to evidence that natural tearing is often preferable. However, episiotomies are still sometimes necessary in specific situations, such as fetal distress or prolonged labor. Understanding when an episiotomy may be needed, its potential risks, and the recovery process will help you make an informed decision with your healthcare provider.
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Surgery is a personal decision that should be made after exploring all options, understanding the risks, and consulting with a qualified pelvic health specialist. For some women, surgery may provide much-needed relief, but for others, a tailored program of pelvic floor therapy may offer equally effective results without the associated risks.
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