Episiotomies - Fear not

The thought of an episiotomy can make your toes curl, but, as Dr Gillian Gibson explains, this is likely a case of anticipation being worse than reality.

Every week I meet with expectant women to discuss a plan for labour and birth. I often notice women, and more particularly their partners, start to shift uncomfortably in their seats when it comes to talking about episiotomy. As a specialist obstetrician and Lead Maternity Caregiver (LMC), I am quick to reassure them that, while episiotomy is not routinely performed, it may be a necessity. Also, the majority heal without complication, and in some circumstances the procedure may save your baby's life.

What goes on in labour?
Enormous physiological changes occur during pregnancy, particularly as a woman goes into labour. Hormonal changes allow softening and stretching of the vaginal tissue and ligaments, increasing capacity to allow passage of the baby's head during labour. Once the cervix is fully dilated (the second stage of labour), the vagina stretches progressively to accommodate the baby's head as it descends through the pelvis. For women having their baby vaginally for the first time, it will take an hour or longer to push the baby out.

The baby's head will press against the perineal skin and stretch this until the widest part of the head passes through the vaginal opening (crowning). Without an epidural, women sometimes liken the feeling to burning or 'a ring of fire,' but at its maximum stretch, the nerves to the perineal skin will often become numb. Fortunately, this phase usually only lasts for two to three contractions at the most. At this stage, even if you have an epidural, you may have a sensation of stretching.

What is an episiotomy?
An episiotomy is a cut in the skin and underlying tissue at the vaginal opening using sterile scissors and made with the contraction just before the baby's head is born. It is a planned surgical procedure to make more room to either expediate the baby's birth, or to prevent a significant tear. It usually starts in the midline of the vaginal opening, it is approximately 3-5cm in length, usually at a 45° angle downwards and outwards in the direction of the right buttock. The vaginal skin (mucosa), perineal skin (the skin between the vaginal and anal opening) and underlying perineal muscles (part of the pelvic floor) are cut to a variable degree, depending on the extent of the episiotomy required. Local anaesthetic is usually administered first, although at this stage, due to the stretching that occurs, the nerves in the skin may be numb already.

How common is it?
Episiotomy is one of the most common surgical procedures in the world. Rates vary in developed countries, from as high as 75% in some European countries, to 20-40% in the United Kingdom and less than 10% in Scandinavia. New Zealand maternity statistics show the chance of women who are delivering for the first time having an episiotomy is just under 20%. An episiotomy is less likely in subsequent births, where the perineal tissues have more ability to stretch. However, sometimes scar tissue from a previous episiotomy or tear will not stretch very well, and if so, a repeat episiotomy is made – usually in the same location. Women in some ethnic groups can be more prone to perineal tears and it is worth discussing your individual situation with your LMC.

Is it better to tear?
Your LMC will be careful to minimise any unnecessary trauma to the perineum during delivery, but at the same time will take action to protect you from future complications. Perineal trauma, in general, can lead to short term consequences including bleeding, infection and pain, and longer term continence issues and discomfort with sex.

A first degree tear involves the perineal skin only, whereas a second degree also tears the muscles underneath. Perineal tears usually happen towards the anal sphincter (in the midline), therefore can be easier to repair, and cause less pain in the short and long term. A third or fourth degree tear involves the anal sphincter (the muscles around the anal opening responsible for continence) and possibly the rectal mucosa (skin) as well. They occur in 2-3% of women having a vaginal birth. A third or fourth degree tear can compromise future bowel function with inability to fully control flatus (wind) or faeces. Having said this, if such an injury occurs, providing it is recognised at the time of delivery and repaired by an experienced practitioner, the outcome is very good for most women.

In general, a small or moderate tear is preferable to an episiotomy, which tends to be longer and cuts across the tissues rather than following the midline anatomy. However, it is preferable to repair an episiotomy rather than a large ragged tear, and better to prevent a tear to the anal sphincter. It is possible that an episiotomy can extend and an anal sphincter tear may still occur, despite best efforts to try and prevent this.

In circumstances where birth needs to be assisted with forceps, because of a lack of progress or for suspected foetal distress, an episiotomy may be unavoidable. Assisted deliveries are only undertaken where there is a clear indication and it is considered the baby can be delivered safely vaginally, along with ensuring appropriate pain relief or anaesthesia. Epidural pain relief increases your chance of instrumental birth, particularly if it is your first labour, so you will be more likely to have an episiotomy, compared to women without this form of pain management.

How to prevent an episiotomy or tear
In the month before your baby is due, it is important to talk with your LMC about things you can do to prevent a perineal tear or an episiotomy. The following are suggestions they'll likely give you.

Perineal massage
I counsel women to do perineal massage from 36 weeks gestation onwards. It is recommended to be done daily for a minimum of two weeks, with placement of the thumbs inside the vaginal opening, applying pressure to the perineum. The skin should feel like it is stretching and even stinging slightly for this to be having any effect. Lubricants are recommended but you should avoid anything perfumed or other oils that may irritate the vaginal skin.

There is also an inflatable silicone device EPI-NO (the name says it all) which is available commercially for use at home. The balloon is inserted into the vagina and inflated until pressure, but not pain, is felt. The pelvic muscles are contracted and relaxed to gently expel the device to simulate childbirth. Use is recommended for at least 15 minutes per day, for a minimum of two weeks prior to birth. Studies show that perineal massage significantly reduces the need for stitches or episiotomy (by about 10-15%) for women having their first baby, but doesn't have any effect on the need for forceps or vacuum delivery, or reduce future urinary or bowel continence problems.

Position during birth
Your LMC will observe your perineum as you are delivering. When women are left to adopt a position for birth, they'll often kneel, supporting themselves on their hands and knees. If you have an epidural, you may be better to lie semi-reclined on your back, or on your left side.

Perineal guarding/warm compresses
There is evidence that applying warm compresses to the stretching perineum reduces the need for episiotomy and can prevent tears. Listen carefully to your LMC as the baby's head is crowning. At this point, your LMC will coach you through your pushing to minimise perineal trauma, but will also be watching closely to see if an episiotomy is necessary. Your LMC can support the perineum with one hand while, with the other hand, gently putting pressure on baby's visible crowning head to tilt it forward. This hands-on procedure is widely regarded as best practice. This makes the diameter of the baby's head smaller and allows it to pass more easily. You will be advised to stop pushing and directed to "breathe your baby out". This may be in the form of panting, or imagine you are blowing out the candles on a birthday cake. Once baby’s head is out, there is usually one further contraction, and with a slow controlled push, the rest of the body will deliver without further tearing.

Repair and recovery
Episiotomy repair (stitching) should be performed by an LMC or specialist obstetrician. Careful examination will determine if there has been any extension of the episiotomy and rule out any sphincter damage. Adequate anaesthesia will be administered.

It is imperative that the underlying muscles are repaired before the vaginal and perineal skin are closed over the top. The perineum has a very good blood supply and most episiotomies will heal rapidly within 10 days. An absorbable suture is used so it is not necessary to have stitches removed afterwards.

At your six-week postnatal check, you and your baby will be checked by your LMC. Key concerns at this appointment include how your perineum has healed and whether you are having any problems with pain, discomfort or bleeding.

When you are fully breastfeeding, your body has very low oestrogen levels as your ovaries are generally still 'switched off'. The effect of low levels of oestrogen hormone is thinning of the vaginal skin. Often, discomfort with intercourse is due to this, rather than the fact that you have had stitches after giving birth. Hormonal vaginal cream can be prescribed by your LMC if this is a significant symptom. However, given the demands of breast-feeding, sleep deprivation and low hormone levels, your libido is probably quite low at this stage in general, so waiting a few weeks, or liberal use of lubrication, can be all that is required to enjoy sex again.

Less than a quarter of women in New Zealand having their first baby will have an episiotomy and it is much less common for subsequent births. I hope I have reassured expectant women that episiotomy is no longer performed as a 'routine', but only when necessary, and that the vast majority will heal well and long term complications are uncommon. 

WHEN IS EPISIOTOMY NECESSARY?
There are circumstances where an episiotomy is more likely, including:
■ Prolonged second stage of labour where progress has slowed or ceased and baby’s head is close to crowning.
■ Significant tear at a previous delivery.
■ Breech or direct posterior position of the baby’s head.
■ Shoulder dystocia. In rare circumstances the baby's shoulders become caught behind the pubic bone. An episiotomy gives more room for your LMC to help deliver your baby.
■ Assisted delivery with forceps or vacuum. It is more likely with forceps which take up slightly more space in the pelvis. Episiotomy gives more space to tilt the baby's head downwards and forwards in the birth canal. There is also less time for the tissues to stretch compared to a natural birth.

Dr Gillian Gibson is an obstetrician gynaecologist working in public and private practice since 1998. She is an obstetrician LMC with Auckland Obstetric Centre.