Episiotomy

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Overview
An episiotomy International Phonetic Alphabet for English is a surgical incision through the perineum made to enlarge the vagina and assist childbirth. The incision can be midline or at an angle from the posterior end of the vulva, is performed under local anaesthetic (pudendal anesthesia) and is sutured closed after delivery. It is one of the most common medical procedures performed on women, and although its routine use in childbirth has steadily declined in recent decades, it is still widely practiced in Latin America.

Uses
Many physicians use episiotomies because they believe that it will lessen perineal trauma, minimize postpartum pelvic floor dysfunction by reducing anal sphincter muscle damage, reduce the loss of blood at delivery, and protect against neonatal trauma. In many cases though, episiotomies cause all of these problems. Research has shown that natural tears typically are less severe.

Episiotomies may be indicated if:
 * there is any sign of fetal distress while the baby is in the birth canal
 * a delivery occurs too quickly for the vagina to stretch naturally
 * the baby's head is too large for the opening
 * the baby's shoulders are stuck (When a baby's shoulders are stuck they are stuck behind bony pelvis, not soft tissue, so this indication is disputed)
 * it is a breech birth or forceps delivery

Controversy about common usage
In various countries, routine episiotomy has been accepted medical practice for many years. Various urban legends circulate on the fact that after very rapid natural births, young doctors would still make episiotomies so as not to displease their professors.

Since about the 1960s, routine episiotomies are rapidly losing popularity among obstetricians and midwives in Europe, Australia and the United States. A nationwide US population study by Weber and Meyn (2002) suggested that 31% of women having babies in U.S. hospitals received episiotomies in 1997, compared with 56% in 1979. In Latin America it's still popular, where it's done on 90% of hospital births and in most cases without the mother's consent. There, routine episiotomy is a major cause of infections, some of them fatal.

Recent studies indicate that routine episiotomies should not be performed, as they may increase morbidity. Hartmann et al (2005), reviewing the literature, indicate that this procedure is not helpful for routine patients, though there are certain instances, such as a narrow birth canal and other problems as described above.

Having an episiotomy may increase perineal pain in the postpartum period, resulting in trouble defecating (particularly in midline episiotomies, as demonstrated by Signorello et al 2000). In addition it may complicate sexual intercourse by making it painful and replacing erectile tissues in the vulva with fibrotic tissue.

In cases where an episiotomy is indicated, a mediolateral incision may be preferable to a median (midline) incision as the latter is associated with a higher risk of injury to the anal sphincter and the rectum. (ACOG Practice Bulletin).

Informed consent
Expectant mothers frequently make "birth plans" during their antenatal care, and are generally encouraged to discuss their views on episiotomy with their caregivers, or as early as possible in labour. In the final stages of delivery the midwife or obstetrician may not have time to discuss the benefits, risks and alternatives without endangering the mother or baby. However, staff restrictions or complications in labour often mean that these plans have to be altered in the course of the birth.

Avoidance
Perineal massage beginning around the 34th week has been shown to reduce perineal damage by 6% (Shipman MK. Antenatal perineal massage and subsequent perineal outcomes: A Randomized trial. BrJObGyn 1997;104:787.

Controlled delivery of the head that allows slow gradual stretching of the perineal tissue can help in minimising damage to the perineum. Episiotomy is almost never required. If the tissue is stretching, some studies suggest that small natural tears heal quicker and are less painful, so a tear is preferrable to an episiotomy.

There are also devices which are made to stretch the perineal tissue gradually to train it in preparation for birth. One example is the "Epi-no", which consists of an inflatable balloon pumped with the same pump as a sphygmomanometer. The Epi-no device has been shown to reduce perineal damage by 50% at first births.