Episiotomy: What It Is, Why It’s Done, Procedure, Benefits & Risks

Introduction

The word ‘episiotomy’ can spark both curiosity and concern among expectant parents. While the thought of a surgical cut during delivery may feel daunting, it is natural to have questions and concerns about this procedure.

Episiotomy was once common across most vaginal deliveries. However, over the past few decades, medical practice has changed significantly. Healthcare providers now take a more selective approach and perform an episiotomy only when there is a clear medical need.

Understanding what an episiotomy is, and why and how it is performed, empowers you to have informed conversations with your birth team. It also helps you feel more prepared and confident as you approach delivery.

Let’s explore everything you need to know about episiotomy.

What Is an Episiotomy?

An episiotomy is a surgical incision made in the perineum, the area of tissue between the vaginal opening and the anus, to enlarge the vaginal opening during childbirth.

A doctor performs this procedure during the second stage of labour, typically just before the baby’s head begins to crown.

The procedure is primarily carried out to create more space for the baby to be delivered, either to speed up birth during an emergency or to prevent severe tearing of the perineal tissue.

Historically, episiotomies were more common. It was used as recently as the late 1970s in more than 60% of vaginal deliveries across the United States. At the time, doctors believed that a clean incision would prevent severe tears between the vagina and rectum and that it would heal better than natural tearing. However, research has shown this is not necessarily the case, leading to a dramatic decline in episiotomy rates.

How Is an Episiotomy Performed?

An episiotomy is performed during the second stage of labour using surgical scissors. Local anaesthesia is used to numb the area.

Before the Procedure

Your doctor explains why an episiotomy is required. There may not be much time for discussion during emergencies, but your healthcare provider will still explain what is happening. If you do not already have an epidural, a local anaesthetic will be injected into your perineum to numb the area.

During the Procedure

The incision is made during a contraction, usually when the baby’s head is crowning. The tissue is stretched thin at this point, and you are less likely to feel the cut even without anaesthesia due to the natural numbness caused by the pressure. The healthcare provider makes a clean and controlled incision through the perineal tissue using sterile surgical scissors. The length of the cut depends on how much extra space is needed. 

After Delivery

The episiotomy is stitched after your baby and placenta are delivered. The repair involves closing the muscles, tissues and skin in layers. Stitching typically takes 20-40 minutes, depending on the extent of the cut and whether any additional tearing occurred.

What Are the Benefits of an Episiotomy?

The main benefit of an episiotomy is that it can speed up delivery during emergencies. It may also reduce severe, uncontrolled perineal tears that are more difficult to repair and may cause long-term complications.

If performed for clear medical reasons, episiotomy can offer some crucial advantages:

• It can reduce delivery time in emergencies by several minutes when the baby needs to be born quickly.
• In cases of severe foetal distress, it can be lifesaving for both the mother and baby.
• It provides immediate extra space for assisted deliveries using instruments.
• The cut creates a clean edge that is easier to repair than irregular tears.
• The controlled direction of the cut helps avoid damage to critical structures.
• It may reduce the risk of tears extending into the anal sphincter compared to uncontrolled tearing.
• It can also protect the fragile heads of premature babies from excessive pressure.

These benefits apply only when an episiotomy is performed for clear medical indications and not as a routine procedure.

What Are the Risks and Complications of an Episiotomy?

The risks of episiotomy include excessive bleeding, infection, painful healing, extension into severe tears, discomfort during intercourse and weakened pelvic floor muscles.

• Pain and Discomfort: One of the most common complaints following an episiotomy is pain. The perineal area is sensitive, and during the healing process, the patient may find it uncomfortable to sit, walk or use the toilet.
• Bleeding: While some bleeding is expected, blood vessels in the area may occasionally cause significant bleeding and may require additional treatment.
• Infection: In some cases, the episiotomy site can become infected, especially because of its proximity to the bowel. Signs include increasing pain, swelling, redness, discharge or a foul smell.
• Wound Breakdown: In some cases, stitches may not hold properly, and may lead to partial reopening of the wound. It usually happens in the case of an infection or if there is excessive strain on the area.
• Poor Healing: Conditions such as diabetes, smoking, poor nutrition or infection can slow healing and increase scar tissue formation.
• Dyspareunia (Painful Intercourse): Some women may experience pain during intercourse months or even years after an episiotomy. Research suggests episiotomy may increase this risk compared to natural tearing.
• Pelvic Floor Weakness: Cutting through pelvic floor muscles can cause this critical support system to weaken. This can contribute to problems like urinary incontinence or pelvic organ prolapse later in life.
• Psychological Impact: Some women may feel distressed if they feel an episiotomy was performed without their consent or proper explanation. It may affect their experience of childbirth as well as their relationship with their bodies.

Conclusion

By understanding what an episiotomy is and when it might be required, you can approach childbirth with realistic expectations rather than unnecessary fear. Remember that episiotomy is no longer routine. Modern obstetric practices use episiotomy selectively when there is a clear medical need.

While routine episiotomies offer little benefit for most women, in emergency deliveries, assisted births or situations where severe tearing appear likely, an episiotomy may be the safer option when performed by a skilled practitioner.

If you do require an episiotomy, proper aftercare and patience during recovery are essential for complete healing. Though some may need additional support, most women recover fully within a few weeks. Don’t hesitate to ask for help if you are dealing with pain or other complications.

Talking openly with your healthcare provider about an episiotomy is important. Understand their clinical approach and discuss your preferences, so that you feel as informed and prepared as possible.