Short cut or sweet release?

All you need to know about an episiotomy, writes Margot Bertelsmann

YOU MAY HAVE heard the term “episiotomy”. But finding out what it is requires a bit of an anatomy lesson. So here goes…

Meet your perineum. The muscle tissue that connects the back posterior wall of your vagina to your rectum is your perineum.

The skin between your vulva and your anus has to stretch an incredible amount during a vaginal delivery – a baby with a head circumference of 50cm or more needs to pass through a small space, after all. It can be done, but stretching takes time. And sometimes, there’s no time.

During many births, it’s common for the pressure the baby exerts on the perineum to actually tear the skin in the perineal area – sometimes a little bit, and sometimes quite badly. In fact, says Dr Nirvashni Dwarka, an obstetrician and gynaecologist in private practice in Johannesburg, “Most primagravidas (first-time mothers) tear. When weighing up the pros and cons of episiotomies, balance the risk and benefits of a cut versus a natural tear.”

The tears are divided into degrees of severity: first-degree tears involve only skin and mucosa, if perineal muscle is also torn, it’s a second-degree tear, a torn anal sphincter complex is a third-degree tear, and a fourth-degree tear involves damage to the anal mucosa (tissue). Your doctor may decide to leave a small tear to heal on its own; larger tears may require a few stitches directly after the delivery, or later under general anaesthetic, according to Dr Dwarka. “Third- and fourth-degree tears have to be repaired in an operating theatre. Those tears involve either the external or the external and internal anal sphincters, and for the sphincter to work again properly after a tear, the two sides must be correctly approximated and repaired in the right position in order to prevent faecal incontinence later.”

WHAT IS AN EPISIOTOMY?

It’s not a great leap to see how the episiotomy was invented. In births where the baby is struggling a little to pass through the birth canal, the doctor or midwife can make a quick, clean surgical cut into that skin, either vertically or at a 45° angle, which instantly widens the space that may be holding the baby back from getting his or her head out. And obviously, this invention has been a merciful relief, shortening labour and possibly saving lives for many a mother and baby. Plus, the tear is controlled and clean, rather than badly positioned or damaging, as can happen with a natural tear – so a win-win, right?

Episiotomy for deliveries that were complicated and needed forceps or other instruments to help ease the baby out of the birth canal started becoming routine practice in the USA from about 1851. Next, doctors started doing episiotomies as a routine part of their vaginal delivery processes, even uncomplicated ones where no instruments were needed, believing the benefits were demonstrable.

But times have changed again, and it’s no longer recommended to perform routine episiotomies to patients, according to the world-famous Mayo Clinic in the US. This is probably because no research has been able to convincingly demonstrate that either episiotomies or natural tears heal better and have fewer long-term negative consequences for the mother.

Dr Dwarka echoes that sentiment, saying that routine episiotomies are also not indicated in South Africa. But she emphasises that an episiotomy’s aim is to prevent the really bad tears – and that, “There’s no substitute for surgical judgement in the moment.” This means that, if a trained medical eye reckons you are about to tear badly, they may advise an episiotomy instead – and that happens in the moment and is not planned for in advance. “The surgeon will use her clinical judgement at the time,” Dr Dwarka explains.

WHEN YOU MAY NEED AN EPISIOTOMY

If your baby needs to be delivered quickly, an episiotomy shortens the second stage of labour by an estimated 5 to 15 (crucial) minutes. An episiotomy is indicated if:

• Your baby’s shoulder is stuck behind your pelvic bone

• You need an instrument delivery (forceps or ventouse)

• Your baby’s heart rate shows that he or she is in distress. Additionally, an episiotomy also controls the direction of a tear, says Dr Dwarka. “Lateral tears are more painful to recover from, but vertical tears have greater incidences of postoperative side effects. So we don’t cut vertically anymore, we prefer to cut mediolaterally (45° angle).”

While a 2008 study found that up to 85 percent of women experience some sort of perineal trauma during delivery, there are ways to reduce your chances of tearing in the first place. There is no way of knowing how well these interventions work, but they are certainly worth a try if you’d prefer to avoid an episiotomy.

PREP YOUR PERINEUM

WAYS TO AVOID TEARING

• Massage and stretch your perineum with oils before the birth.

• Place a warm, moist cloth or pad on the perineum while pushing during labour to help circulation to the area and because heat relaxes tissue.

• Allow the pushing part of labour to happen gradually (unless baby is in distress and needs to come out fast).

THE TWO TYPES OF EPISIOTOMY

A vertical or midline cut heals better but has a greater chance of extending into the anal tissue. A mediolateral (45°) episiotomy reduces the chances of the tear extending into the rectal region, but women have reported it to be more painful to recover from.