| EPISIOTOMY
To Epis Or Not To Epis…that is the question.
Many of our patients ask our philosophy and practice of
performing episiotomy during the second stage of labor. Is it routine? Will it improve
outcome..Is it necessary? Episiotomy is the cutting of the perineum prior to delivery of
the fetal head. The perineum is the area that spans between the vagina and anus and the
cut is usually done with a scissors following administration of a local anaesthetic. The
actual cut is classically a direct vertical downward incision (medial) although depending
on the women's anatomy it may in certain cases be done at an angle or mediolateral. The
traditional belief is that a well-defined and controlled "cut" is preferable to
a natural tear and easier to repair. Other justifications have included a reduction of
anal spincter and rectal tears and prevention of pelvic relaxation (cystoceles or
rectoceles), all of which may contribute to urinary or fecal incontinence. Other claims
include protection of the newborn from intracranial hemorrhage or asphyxia and a reduction
in maternal bloodloss from the uncontrolled tear. The most recent clinical reviews and
trials have refuted all of the above In fact many studies have shown a contradiction to
the above dogma and gone so far as to suggest that an episiotomy should never be
performed. Other studies have attempted to conclude what a normal "episiotomy
rate" should be for an individual practitioner. Your doctor takes many factors into
account when the decision to perform an episiotomy is made. These include but are not
limited to anatomy, need for expeditious delivery, the presenting part (breech, vertex,
occiput posterior vs anterior), fetal size and prior surgery or tears. While there is some
proof that episiotomy will reduce the frequency of anterior tears i.e. those involving the
labia and area around the clitoris and urethra, it does so at the expense of posterior
tears and the risk of anal sphincter tears. The repair of anterior tears may involve
difficult suturing and the possible use of a bladder catheter immediately post partum. The
literature does not support the claims of a reduction in pelvic relaxation and its sequel
nor does it support the claim of protection from third or fourth degree tears i.e. those
that extend to the anal sphincter or rectum. Finally there is no data supporting a
reduction in intracranial hemorrhage or fetal asphyxia.
The doctors at the Arizona Wellness Center for Women do not
routinely perform episiotomy. During the second or pushing stage of labor we try to
promote vaginal outlet compliance to improve tissue stretching. Position changes and
perineal manual massage may promote this compliance and allowing the fetal head to gently
stretch the perineum. We believe that most patients do not need an episiotomy and
encourage our patients to discuss episiotomy during their prenatal care. It is important
to understand that despite the best intentions to "protect the perineum" during
delivery tears do and will occur. Ultimately the decision to perform an episiotomy is one
that should be made with the risks, and benefits weighed and you our patient informed and
an integral part of the decision making process.
REFERENCES
Wooley RJ, Benefits and Risks of Episiotomy:A Review of the
English Literature Since1980, PartI and II, Obstetrical and Gynecological Survey1995
Vol50;11 page806-835
Lede RL,Belizan JM, Carroli G, Clinical Opinion American
Journal of Obstetrics and Gynecology 1996 Vol174;5 Is routine use of episiotomy justified?
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