Episiotomy: An episiotomy
is an incision performed between the vagina and the rectum that is used to increase the
size of the opening of the vagina to assist in delivery of a baby.
Indications:
- There
is a serious risk to the mother of second- or third-degree
tearing
- In
cases where a natural delivery is adversely affected, but a Caesarean section
is not indicated
- "Natural"
tearing will cause an increased risk of maternal disease being vertically
transmitted
- The
baby is very large
- When
perineal muscles are excessively rigid
- When
instrumental delivery is indicated
- When
a woman has undergone FGM (female genital mutilation),
indicating the need for an anterior and or mediolateral episiotomy
- Prolonged
late decelerations or fetal bradycardia
during active pushing
- The
baby's shoulders are stuck (shoulder dystocia),
or a bony association (Note that the episiotomy does not directly resolve
this problem, but it is indicated to allow the operator more room to
perform maneuvers to free shoulders from the pelvis)
Types: There are four main types of episiotomy:
- Medio-lateral:
The incision is made downward and outward from midpoint of fourchette either to
right or left. It is directed diagonally in straight line which runs about
2.5 cm away from the anus
(midpoint between anus and ischial tuberosity).
- Median:
The incision commences from centre of the fourchette and extends on
posterior side along midline for 2.5 cm.
- Lateral:
The incision starts from about 1 cm away from the centre of
fourchette and extends laterally. Drawback include chance of injury to Bartholin's duct;
thus some practitioners have totally condemned it.
- J-shaped:
The incision begins in the centre of the fourchette and is directed
posteriorly along midline for about 1.5 cm and then directed
downwards and outwards along 5 or 7 o'clock position to avoid the anal sphincter.
This is also not done widely.
Advantages: An episiotomy can decrease the amount of
pushing the mother must do during delivery. It can also decrease trauma to the vaginal tissues and expedite delivery of the baby when delivery is necessary
quickly. Doctors who favor episiotomies argue that a surgical incision is
easier to repair than a spontaneous irregular or extensive tear, and is likely
to lead to a more favorable outcome with fewer complications.
Episiotomy
repaired: The repair is straightforward and is
fairly simple to perform. The incision is repaired by
suturing (sewing) the wound together.
What
are the possible complications of an episiotomy, and should an episiotomy be
part of a routine delivery?
Episiotomy can be associated with extensions or
tears into the muscle of the rectum or even the rectum itself. Other
complications can include:
- bleeding,
- infection,
- swelling,
- defects
in wound closure,
- local
pain, and
- a
short-term possibility of sexual dysfunction.
Studies have shown conflicting results regarding
the question of whether performing an episiotomy results in greater postpartum
pain than not performing the procedure.
However, it is important to note that if the baby
needs to be delivered more urgently, then waiting for the mother to push it out
without the assistance of an episiotomy may in certain cases cause harm to the fetus.
Also, there are some tears that occur when no incision is made that are very
difficult to repair and cause greater blood loss than might otherwise occur.
The American
College of Obstetricians and Gynecologists supports the position of
restricted, instead of routine, use of episiotomy. Instead, episiotomy should
be considered in certain situations when there is a high risk of severe
lacerations or the need to facilitate rapid delivery of a fetus.
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