Episiotomy
Advantages & Disadvantages
Episiotomy can prevent significant childbirth injury and should be used for some women. However, making episiotomy a routine practice is unnecessarily traumatic. Childbirth without tearing (or the need for stitches) is possible in many women, including first time moms! The problem is that until the baby's head crowns and progressive, gentle stretching of the perineum is performed, one cannot determine if the baby's head will slowly slide out or if an episiotomy is indicated.
What is an episiotomy?
Episiotomy is a minor surgical procedure in which an incision is made
to enlarge the vaginal opening just prior to the birth of the baby. Midline
episiotomy is made from the vaginal opening down towards the rectum, whereas
a mediolateral episiotomy angles off towards the side away from the rectum.
Episiotomy was developed in Ireland in 1742 for difficult childbirth,
but had not been in wide use until the early to mid 1900s. Today, it is
estimated that episiotomy is utilized in 80-90% of first time births and
50% of subsequent births.
What are the advantages of episiotomy?
When used properly, episiotomy can prevent more extensive childbirth injury.
A single cut edge is easier to surgically repair than an extensive jagged
edge, or multiple jagged edges. Episiotomy can shorten pushing by 15-30
minutes, critical in the case of fetal distress and helpful with maternal
exhaustion. The use of episiotomy in difficult births, such as shoulder
dystocia (trapped shoulders), can prevent permanent and disfiguring injury
to the baby. Proponents of routine episiotomy believe it can lessen stretching
of vaginal muscles, which can result in long term laxity.
What are the disadvantages of routine episiotomy?
Episiotomy used routinely can result in unnecessary trauma. Specifically,
the incision may be more extensive than a small tear and certainly more
extensive than no tear. This results in more bleeding, especially with
mediolateral episiotomy. Healing after episiotomy is painful and can result
in painful intercourse. Opponents to routine episiotomy believe that the
stretching of the vaginal muscles have already occurred prior to the time
of potential episiotomy, and that the performance of an episiotomy is
of no help to prevent vaginal muscle laxity. Kegel exercises before and
after childbirth best protect vaginal muscle integrity.
Why are Kegel exercises important during pregnancy?
During pregnancy, Kegel exercises strengthen and tone the pelvic floor
muscles, which eases childbirth. After birth, they restore vaginal integrity,
and improve sexual performance and satisfaction. Arnold Kegel, an American
obstetrician-gynecologist, developed "Kegel" exercises more
than fifty years ago to strengthen the pubovisceral muscles of the pelvic
floor. These muscles surround the vagina. The technique is simple: contract
and relax the muscles in quick succession for 10 seconds, then rest for
10 seconds. Next contract and hold the pelvic floor muscles for 10 seconds
then rest for 10 seconds. Repeat the routine as many times as you can
until fatigue, because when you tire, you cease to perform the exercise
correctly. A woman can be certain she is using the correct muscles by
stopping urination mid-stream or by placing a finger in her vagina and
squeezing it. Do at least 25 repetitions at various times throughout the
day, gradually increasing the total number to 100-150.
Can a first time mom realistically avoid an episiotomy?
Absolutely! The vagina is remarkably elastic and can stretch to a surprising
degree. The key to preventing episiotomy and perineal trauma is slow,
controlled delivery of the baby's head while gently stretching the
vaginal opening. The delivering physician must be extremely patient to
wait for this stretching to occur. In our experience using this technique,
75% of first time moms and 90% of those with subsequent births, have avoided
episiotomy and have required only minimal stitches, if any. The decision
of whether or not an episiotomy is indicated for you should not take place
in the office but rather in the delivery room. Talk with your doctor.
