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| |    Episiotomy by Elisa Ross, MD and Marjorie Greenfield, M.D. reviewed by Marjorie Greenfield, M.D. What is an episiotomy? An episiotomy is a surgical incision (cut) at the opening of the vagina. Its purpose is to allow more room for delivery and to prevent tears (lacerations) of the tissues around the vagina. Some practitioners believe that episiotomy protects the pelvic muscles and helps the woman maintain normal function of those muscles later in her life. Others believe that episiotomy causes damage to the vaginal opening and to the muscles. These conflicting beliefs help to explain why there are different rates of episiotomy with different practitioners, birth setting and cultures. Will I need an episiotomy? Some practitioners perform an episiotomy on all first-time mothers, but many wait to see if it seems necessary. In a first pregnancy, it is hard to say for sure if an episiotomy will be required, until the baby's head has applied pressure to the vaginal opening (perineum) for a while. Some perineums are stretchier than others. Episiotomy is a judgment call. Sometimes, in trying to avoid episiotomy, multiple tears can occur, and the process of sewing them up is worse for the mother than if a single episiotomy were done. In my practice, about half of first-time mothers get an episiotomy. Even if you require an episiotiomy, the chance of needing one during subsequent deliveries is lower. How will the decision about episiotomy be made? If delivery is needed quickly, as in the case of fetal distress, the vaginal opening doesn't have time to stretch, and episiotomy may be required. If, after multiple pushes, all that stands between you and your baby is persistently tight skin, or if the tissues at the front of the vagina are beginning to tear, most practitioners will do an episiotomy. If you are expecting a very large baby, the practitioner might do an episiotomy to make delivery easier. What exactly is cut? In a midline episiotomy, the tissues at the back of the vaginal opening are cut in the middle, heading toward, but not involving, the rectum. In unusual situations, and more commonly outside the U.S., a medio-lateral episiotomy may be used. This involves an incision from the middle of the vaginal opening out toward the buttock. Proponents of the midline method note that it is quicker healing, less painful, and has a more natural appearance when healed. If the cut extends into the rectum, the rectum can be repaired. Proponents of medio-lateral episiotomy say that it better protects the rectum from damage. Recovery While some say that a laceration provides easier recovery than does an episiotomy, either one can be quite uncomfortable for a week or more. Ice packs are helpful for the first 24 hours, and hot soaks (sitz baths) after that. Witch hazel pads (Tucks®) and anesthetic spray are often offered in the hospital, and can be continued at home. A donut-shaped inflatable pillow, available from the hospital or your local drugstore, can make sitting more comfortable. The stitches dissolve on their own. While it is not uncommon to have some discomfort for many weeks after birth, most practitioners want to know if you are still having pain at six weeks.
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