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Labor & Delivery: Types of Episiotomy

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An episiotomy is a surgical cut made in the perineum during childbirth. The perineum is the muscular area between the vagina and the anus. Your doctor may make an incision in this area to enlarge your vaginal opening before you deliver your baby.

An episiotomy used to be a normal part of childbirth, but it has become much less common in recent years. In the past, an episiotomy was done to help prevent severe vaginal tears during delivery. It was also believed that an episiotomy would heal better than a natural or spontaneous tear.

More recent research, however, suggests that an episiotomy may actually cause more problems than it prevents. The procedure can increase the risk of infection and other complications. Recovery also tends to be lengthy and uncomfortable.

For these reasons, an episiotomy usually isn’t performed. In some cases, however, the procedure may need to be done. Your doctor might recommend an episiotomy if:

  • you are likely to experience extensive vaginal tearing during delivery
  • your baby is in an abnormal position
  • your baby is larger than normal
  • your baby needs to be delivered early

If an episiotomy has to be done, talk to your doctor early on about the procedure. Ask them why they want to perform an episiotomy during delivery and how it might help you avoid tearing.

The two most common types of episiotomy are midline episiotomy and mediolateral episiotomy. Midline episiotomies are much more common in the United States and Canada. Mediolateral episiotomies are the preferred method in other parts of the world. Both types have various advantages and disadvantages.

Midline Episiotomy

In a midline episiotomy, the incision is made in the middle of the vaginal opening, straight down toward the anus.

The advantages of a midline episiotomy include easy repair and improved healing. This type of episiotomy is also less painful and is less likely to result in long-term tenderness or problems with pain during sexual intercourse. There is often less blood loss with a midline episiotomy as well.

The main disadvantage of a midline episiotomy is the increased risk for tears that extend into or through the anal muscles. This type of injury can result in long-term problems, including fecal incontinence, or the inability to control bowel movements.

Mediolateral Episiotomy

In a mediolateral episiotomy, the incision begins in the middle of the vaginal opening and extends down toward the buttocks at a 45-degree angle.

The primary advantage of a mediolateral episiotomy is that the risk for anal muscle tears is much lower. However, there are much more disadvantages associated with this type of episiotomy, including:

  • increased blood loss
  • more severe pain
  • difficult repair
  • higher risk of long-term discomfort, especially during sexual intercourse

Episiotomies are classified by degrees that are based on the severity or extent of the tear:

  • First Degree: A first-degree episiotomy consists of a small tear that only extends through the lining of the vagina. It doesn’t involve the underlying tissues.
  • Second Degree: This is the most common type of episiotomy. It extends through the vaginal lining as well as the vaginal tissue. However, it doesn’t involve the rectal lining or anal sphincter.
  • Third Degree: A third-degree tear involves the vaginal lining, the vaginal tissues, and part of the anal sphincter.
  • Fourth Degree: The most severe type of episiotomy includes the vaginal lining, vaginal tissues, anal sphincter, and rectal lining.

The severity of the episiotomy is directly associated with the likelihood for long-term complications. As the degree of the episiotomy increases, there is more potential for infection, pain, and other problems after the procedure.

Both midline and mediolateral episiotomies are easy to perform. Your doctor will make the incision when 3 or 4 centimeters of your baby’s head is visible at the vaginal opening. You will receive anesthesia before the procedure so you don’t feel any pain. You shouldn’t feel your doctor making the incision or repairing it after delivery.

The area will first be cleaned with soap. Your doctor will insert two fingers into your vaginal opening to protect the baby’s head. Then, a small incision will be made. Depending on the type of episiotomy being performed, the cut may be straight down or at a slight angle from the vaginal opening. After the incision has been made, your doctor will gently pinch the tissue just below the incision to prevent further tearing. Gentle pressure is also placed against the top of the baby’s head to keep it from coming out too quickly or abruptly.

After delivery, the vagina and perineum are cleaned and carefully examined. Your doctor will then check for any tearing in the vaginal walls or cervix. They may use a special instrument called a metal retractor to view the vagina and cervix more easily. Once your doctor is that certain that there hasn’t been any further tearing, the episiotomy itself will be cleansed. Your doctor may wash the incision site with sterile water or an antibacterial soap solution. In most cases, the episiotomy will only affect the lining of the vagina and the tissue directly below the vagina. However, when the episiotomy extends into the anal sphincter or the rectal lining, these wounds will be repaired first.

All repairs are performed with suture, or surgical thread, that absorbs into the body and doesn’t require removal. Thin sutures are used to close the rectal lining, while larger and stronger sutures are used to repair the anal sphincter. After the rectal lining and the anal sphincter have been repaired, your doctor will close the remaining section of the incision. Several stitches may be needed to bring together the deeper tissues below the vaginal lining.

An episiotomy is usually repaired within an hour after delivery. The incision may bleed quite a bit at first, but this should stop once your doctor closes the wound with sutures. Since the sutures dissolve on their own, you won’t need to go to the hospital to have them removed. The sutures should disappear within one month. Your doctor may tell you to avoid doing certain activities during recovery.

After having an episiotomy, it is normal to feel pain around the incision site for two to three weeks. Women who have third- or fourth-degree episiotomies are more likely to experience discomfort for a longer period of time. The pain may become more noticeable while walking or sitting. Urinating can also cause the cut to sting.

You can try to ease the pain by:

  • applying cold packs on the perineum
  • using personal lubricant when having sexual intercourse
  • taking pain-relieving medications
  • using a squirt bottle instead of toilet paper to clean yourself after using the toilet

Your incision should be completely healed within four to six weeks after delivery. The recovery time may be slightly longer if you had a third- or fourth-degree episiotomy.

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