Scientifically, with the term episiotomy means that incision which is done on the external genitals of the woman during a spontaneous birth in the expulsive phase, or when the baby is about to be born. There are two types, median and paramedian. The first is performed vertically towards the anus, the second instead laterally towards the buttock. We will now see together how it is practiced and when. First of all, I would like to say that it should not be a routine practice, it should not be performed on all women.
There are precise indications drawn from the scientific literature that tell us when it is absolutely necessary and consequently when it is not.
These absolute indications are:
- if the child shows up with one dystocia (i.e. a non-optimal position) especially in the shoulder
- if we are in the presence of one significant fetal suffering
- if we have to perform an operative birth (ie with an obstetric suction cup and in some very rare cases for the use of forceps).
All other situations, including prematurity or excessive distension of maternal tissues that can tear, must be evaluated individually and at the time.Read also: Video: 'natural' birth with episiotomy
Episiotomy, how to do it
The incision is performed with specific scissors when the woman's tissues are particularly stretched, or when the head is said to be "crowns" when it is about to come out of the genitals. Depending on the modality, the incision angle varies and affects different muscles. However, it is important to point out that it is a full thickness engraving, that is, the skin, subcutis and muscle are cut. Obviously, before making this cut, it is done an injection of local anesthetic around the area where you intend to make the incision. For paramedian episiotomies, so those performed towards the buttock laterally, it is normally practiced on your right side, not because there is a particular reason why it is better on the right than on the left, simply because most midwives use the right hand better than left and left handed people are taught how to perform an episiotomy with the right hand.
Muscles involved in episiotomy
As we have said, the cut takes place at full thickness so the muscle fibers are also cut, depending on the type of episiotomy different muscles will be affected.
- Let's start with the most common episiotomy, that one paramedian. It is carried out by cutting the cavernous bulb muscle (to be clear that of the labia majora) for about 3 centimeters. But it also affects other muscles, the deep muscle of the perineum and some of the more central muscle fibers of the levator ani. As you can guess it is therefore quite an extensive incision It is important that it touches some of the core muscles of the perineal area.
- episiotomia median instead it does not sever real muscle fibers, in fact it is practiced from the fork (the lower part of the vaginal introitus) towards the anus, cutting the fibers of the central fibrous nucleus of the perineum. This time it is not three centimeters but very few millimeters, depending on the distance (characteristic of each woman) between the vagina and anus.
Natural childbirth with episiotomy
Can we really define a birth with an episiotomy a natural birth? I have often asked myself this question, in reality there is no single answer, many argue that since there is a human intervention, however minimal, which involves the use of tools and anesthesia, it cannot be called natural. However, if the episiotomy is done with knowledge in the strictly necessary cases, I tend to consider it a natural birth, or at least a spontaneous birth. It is not absolute naturalness and I want to emphasize this because many times I hear of episiotomies done for fear of spontaneous lacerations. The spontaneous lacerations are due to the fact that the local tissues reach the maximum of their relaxation and yield, pass me the term a bit bloody, breaking. Scientific studies for decades now show that healing and the recovery of the function of the genital area is much faster with a spontaneous laceration than with an episiotomy. We must always keep this in mind when we propose to perform the incision. Indeed, the mother should give her consent before it is practiced or be advised that it is about to be performed.
Episiotomy, fa male?
This is one of the most commonly asked questions. I can say that the execution of the incision does not hurt for two reasons.
- The first is that often a local anesthetic is injected in the area where you intend to make the cut.
- The second is the fact that of course that area in the expulsive period is practically devoid of pain sensitivity. This is because i tissues are so stretched out, that the nerve fibers that are usually involved in transferring the pain stimulus to the brain are crushed, and this prevents the transmission of pain. So many times you don't even need local anesthesia. However, anesthesia is performed during the repair of the episiotomy, therefore when the points are placed. In this case, without the anesthetic, many women report a lot of pain, because the fibers are once again able to transmit the sensation to the brain. So let's say that between the episiotomy and its repair what hurts the most is the repair.
How to avoid episiotomy
Assuming that it should not be done except in extreme cases, there may be some precautions to be performed during pregnancy in order to make the tissues rather elastic and therefore be able to reduce the risk of performing episiotomies motivated by tissue rigidity.
- First of all it is important drink and keep skin and tissues hydrated, it seems trivial, but a dehydrated tissue is stiffer than a well hydrated one and therefore stretches with more effort.
- Another trick that can help is to perform a perineal massage with moisturizing oil, not perfumed, preferably with all natural components such as almond oil. The perineal massage consists in the execution of an external and internal massage that softens and elasticises the tissues.
I will now try to explain some techniques that you can perform as perineal massage.
- The first is very simple, it is performed with two fingers, one inside the vagina and the other outside. You have to think that you have like a watch instead of the vulva. The two fingers act like pliers that hold the fabric tight. At this point you think you have to run the fabric from 3 to 9 o'clock. Being a simple one massage to relax the muscles and tissues of that area, there is no need for a lot of pressure or pain.
- Another maneuver is to insert the thumb into the vagina and pull the tissue outward at all points from 3 to 9 o'clock. Again, not much force is required. When performed consistently, the perineal massage showed good results in terms of prevention of episiotomies.
- However, it should be emphasized again that if the episiotomy is necessary because the birth is getting complicated then it must be performed, regardless of massages or whatever you think.
Scar and stitches
The stitches of the episiotomy they are normally absorbable points so it is not necessary to remove them. It happened to me a few times, however, that the external points were instead non-absorbable, so an appointment was made for removal. In any case, you will be notified at the time of discharge. If you are wondering if a scar remains, the answer is yes. In both types of episiotomy, however, a small scar remains. If the suture is done well, however, only the eye of an expert can know exactly where it was done. This is because if the edges of the tissues are brought together well, only a very thin line that is lighter than the rest of the skin is seen. The execution of a good suture is important not only from an aesthetic point of view, but also for the recovery of the functionality and sensitivity of the genital area after childbirth.
Episiotomy and healing
Like all surgical wounds it takes some time for the scar to form and the wound to heal. In the first few days after giving birth, you may have pain and difficulty moving, or sitting down. Mild analgesics can be taken to relieve severe pain, but consult your doctor especially if you are breastfeeding about which is best. Having said that, some tips to understand how to speed up healing and monitor that everything is going well.
- First of all it is important hygiene, not manic, but every time you change your tampon wash the area with plain water as well. The bidet, on the other hand, remains as for all basic hygiene rules, that is, to be done after it has been evacuated.
- To help deflate the area, one solution containing calendula to use as compresses during the day can be helpful.
- Don't keep the part too moist it helps healing, so if possible and as far as possible compatibly with the losses after childbirth, stay without underwear for an hour a day.
- Finally, to monitor wound closure and healing, I suggest you observe yourself with a mirror. If the surface is smooth and over time it deflates and regains the color of the surrounding skin, everything is going well. If there are very swollen and red spots instead go and show her because she could have become infected. In any case, at the inspection after 40 days they will tell you how it is going.
Episiotomy and sexual intercourse
We conclude with a topic that few talk about but which is actually very important. Or the resumption of sexual relations after an episiotomy. After 40 days and ascertained that the healing has occurred correctly, there is no limitation. Clearly it can happen that in the early days, given the trauma suffered by the area, there is some pain in intercourse, it is all about accepting this pain and gradually recovering. Pain is a message that the tissues are sending us: they are telling us that it is better to wait a little longer. On the other hand, if the pain is very mild, almost a nuisance, no problem, it is only the muscles and tissues that need new "training" to get back to how they were before.
Consequences of episiotomy
Usually episiotomia it does not leave long-term consequences, the tissues heal completely and only a small mark remains visible from the outside. It can happen in the first period after the healing and scar formation that there is a reduced sensitivity of the area that resolves spontaneously, or it can be helped with a particular massage called "Scar treatment". It is the same massage that is performed for the Caesarean section wound and that can be taught by specialized operators and managed independently at home.