What is an Episiotomy
Normal birth can cause tears to the vagina and the surrounding tissue, usually as the baby’s head is born, and in a small number of cases, these tears extend to the back passage. These more complicated tears are repaired in the operating theatre under anaesthetic and can take longer to heal. An episiotomy is a procedure which aims to prevent complicated tears from going through into the back passage1.
Why might I need an Episiotomy?
An episiotomy is usually performed shortly before the baby’s head is delivered, during the pushing stage of labour. The midwife or doctor will inject local anaesthetic into the vaginal muscle close to the perineal body (area between vagina and anus which is 1.5-5.5cm long), in a ‘mediolateral’ angle downwards away from the anus.
This is to enlarge the vaginal outlet and reduce vaginal tissue stretching and tension during the birth. In some countries, a ‘routine’ approach is taken where all women undergo an episiotomy, whereas others, like the U.K, U.S.A and most of Europe take the ‘selective’ approach and only perform episiotomies on women at imminent risk of severe perineal tears involving the back passage2.
Selective or Routine Approach?
The answer is largely based on which country you give birth in. China has a 100% episiotomy rate for first time mothers as it takes the ‘routine’ approach, whereas Finland has one of the lowest rates at 9.1% due to its ‘selective’ approach. It is important to remember that sometimes episiotomies are also performed to enlarge the vaginal outlet for instrumental delivery with forceps or vacuums caps, as well as expedite delivery due to maternal or fetal complications during labour1.
Tears to the vagina and surrounding tissue occur in up to 85% of normal births, however, the vast majority of these tears are uncomplicated (i.e. involve the skin only or the vaginal muscle only rather than the internal or external anal sphincters). Some uncomplicated vaginal tears, such as those involving the skin only do not need to be sutured, or those involving the vaginal muscle only may not need as many stitches. However, an episiotomy is always surgically repaired, thereby guaranteeing stitches are needed for the mother. The side-effects of suturing after an episiotomy may include severe pain, bleeding, infection, pain during sexual intercourse and long-term pelvic floor disorders, which is classed as severe perineal trauma. Despite geographical differences in clinical practice, there is good quality evidence available via the Cochrane Review1 which shows ‘selective’ episiotomy reduces severe perineal trauma by 30% compared to ‘routine’ episiotomy. So, the rationale for conducting routine episiotomies to prevent severe perineal trauma is not justified by current evidence and does not have any significant benefits to mother or baby for low-risk women aiming for a vaginal birth.
Conclusion
If you live in a country which performs ‘routine’ episiotomies, you will have dedicated time antenatally to discuss this issue with your midwife or doctor. However, if your local maternity care provider practices ‘selective’ approach, you may not have the opportunity to discuss risks and benefits during the pushing stage of labour. This is why it is important to have access to unbiased evidence-based information in order to make an informed decision about your birth plan before labour.
References
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