Episiotomy

In order to facilitate the passage of the baby's head in the process of delivery and avoid a potentially dangerous perineal tear, which, according to statistics, occurs in 80% of physiologic births, an obstetric surgical intervention - episiotomy - is performed. [1]

Indications for the procedure

Episiotomy or perineotomy refers to operations that prepare the birth canal for labor, i.e. Episiotomy is performed during labor. And, since a cut wound heals better than a laceration, the main indication for this manipulation is the threat of spontaneous perineal rupture during labor. [2]

This threat occurs if the pelvis is anatomically narrow (and does not correspond to the size of the fetal head) or if the perineum is high in the woman in labor; if it is scarred (leading to muscle stiffness and prolonging the second stage of labor); large fetus or difficulty in passing the fetal shoulders (dystocia); in premature or prolonged labor, or due to excessive labor or rapid labor. [3]

In addition, perineal dissection is used if obstetric forceps or vacuum extraction of the fetus must be used during vaginal delivery.

Obstetricians have noted that performing an episiotomy/perineotomy minimizes the potential for intracranial hemorrhage and reduces the likelihood of craniocerebral injury in newborns. [4]

Preparation

Since episiotomy is performed during the postpartum (second) period of labor - at the stage of expulsion of the fetus after full opening of the cervix, and the obstetrician-gynecologist must decide to perform this manipulation in an emergency, preparation for it consists only in antiseptic treatment of the skin and local anesthesia - by conduction (infiltration) anesthesia with the injection of an anesthetic agent into the area innervated by the genital nerve (nervus pudendus), including the perineum and the lower segments of the wall of the vagina and vulva. [5]

Technique of the episiotomies

What is the sequence of actions of an obstetrician-gynecologist - the algorithm of episiotomy? After anesthesia and treatment of the perineum with antiseptic in the interval between exertions - to protect the pre-pregnant part of the baby and fix the tissue at the site of the proposed incision - two fingers of one hand are inserted between the tissue of the perineum and the wall of the external vaginal yawn and the pre-pregnant part; with the other hand at an inclination (approximately 45 °), the branche of surgical blunt-pointed scissors is introduced; when the subsequent exertion reaches its maximum, the tissue is cut (with the baby's head held by the hand). [6]

After the birth of the baby and the placenta, the incision is sutured. This can be a figure-eight suture simultaneously through all layers (episiorrhaphy) or more expedient from the point of view of healing and strength layer-by-layer stitching of the wound: first, continuous sutures using absorbable suture materials connect the mucosa of the vaginal wall, then - the cut fascia and perineal muscles, and then the skin is sewn together - with knotted or subcuticular sutures. [7]

Depending on the direction of the cut differs:

• lateral or lateral episiotomy - a lateral incision of the perineum, which begins about 2 cm from the center of the posterior vaginal commissure (frenulum of the labia) and runs towards the sciatic tubercle (the angle of incision is 30-40°);
• medial or midline episiotomy (perineotomy) - from the center of the posterior vaginal commissure along the midline of the perineum, the incision is made vertically, dissecting the vaginal mucosa, perineal fascia and muscles, skin and subcutaneous tissue (standard length of the incision is 2.5-3 cm);
• mediolateral episiotomy/mediolateral episiotomy - a perineal incision from the posterior vaginal commissure towards the sciatic tubercle (avoiding the muscular ring of the external anal sphincter). A 45-60° incision can be made to the right, and this right-sided mediolateral episiotomy is safer than a left-sided mediolateral episiotomy (in which the incision is made to the left).

Contraindications to the procedure

Episiotomy is contraindicated if the woman in labor has a low obstetric perineum (less than 30 mm), in which there is a threat of direct and indirect injury to the subcutaneous portion of the external anal sphincter or rectum.

Consequences after the procedure

The violation of tissue integrity with damage to part of their cells that occurs during episiotomy, as well as during the incision of tissues of any localization, has consequences. Local edema develops, there is pain in the perineum area, in which women complain that the suture after episiotomy hurts. [8]

Possible complications after the procedure include:

• bleeding;
• internal soft tissue hematoma (caused by ruptured capillaries);
• Infection and inflammation after an episiotomy involving the suture and some of the surrounding tissue;
• Suture suppuration, in which there is discharge after episiotomy and there may be an increase in body temperature;
• Dissection of sutures with pain and discharge of serous-bloody character;
• focal overgrowth of connective tissue in the area of the suture - granuloma after episiotomy, as well as the formation of epidermal cysts;
• Urinary or vaginal fistula after episiotomy;
• Spastic constipation after episiotomy associated with inhibition of bowel emptying due to fear of suture separation;
• urinary incontinence after episiotomy due to weakening of the pelvic floor muscles and prolapse of the internal genitalia.

Episiotomy and hemorrhoids. During this manipulation, internal hemorrhoidal nodes are not affected, but in the presence of external nodes, it is not excluded their damage with bleeding.

It should be borne in mind that sexual life after episiotomy for some time may be complicated by dyspareunia - painful sensations.

Care after the procedure

To recover from a perineal incision during childbirth as quickly as possible and without complications, proper care with personal hygiene is necessary - both in the medical facility and after discharge home.

Recommendations from obstetricians and gynecologists address practical all aspects of care and rehabilitation after the procedure. [9]

• What is the proper way to perform a perineal toilet?

In the maternity hospital, the perineum is treated with antiseptics (most often potassium permanganate solution is used). At home, the suture is treated with hydrogen peroxide, antiseptic Chlorhexidine, furacilin solution; washing is performed with light pink manganese solution, decoctions of medicinal plants (chamomile, calendula, sage, plantain). The perineum is not wiped, but blotted with a soft sterile tissue. It should also be borne in mind that in the first one and a half to two months after this surgical manipulation is contraindicated to take a bath.

• How long should I not sit after an episiotomy? And how do you sit after an episiotomy?

The healing process is different for every woman in labor, but in standard cases, sitting on a soft seat is not allowed for a week and a half to two weeks. It is possible to sit slightly sideways on the edge of a chair, with the feet of both legs bent at the knees and resting on the floor.

Emerging problems with defecation, commonly formulated in the form of the phrase "how to go to the bathroom after episiotomy", obstetricians recommend solving them with the help of appropriate means. Thus, rectal glycerin suppositories after episiotomy are used (contributing to the softening of dense fecal masses) or loosening microclysters Microlax.

In addition, a more comfortable emptying of the intestines helps diet at episiotomy - with the use of fermented milk products, vegetable oils, oatmeal fruits with soft pulp, fresh vegetables (except cabbage and all vegetables of the cruciferous family). But it is better not to use bread, pasta and sweets. [10]

• How long does it take for the pain to go away after an episiotomy, and what painkillers can be used after an episiotomy?

Gradually the pain will subside and by the end of the second week it will be quite tolerable. To reduce the intensity of the pain, you should use pain relieving suppositories after childbirth. Cold compresses on the perineal area also relieve pain and reduce swelling. [11]

• How long does the suture heal after an episiotomy?

External sutures on the perineum (threads after episiotomy) are removed after five days, the internal ones gradually resorb, and it will take about a month for complete healing.

• What to ointment after episiotomy, that is, what external remedies to use to heal the perineum?

Ointments recommended by obstetricians after episiotomy are ointments that relieve inflammation, including antibacterial ointments Levomekol and Baneocin.

And the episiotomy scar/episiotomy scar formed on the perineal area can be reduced by applying ointment to resorb scars, e.g. Contractubex ointment. Over time, post-episiotomy plastic surgery will help to almost completely remove the scar. [12]

And lastly. The stitched perineum after the incision can not be strained, so at least six months any sport after episiotomy is contraindicated. [13]

• How to avoid episiotomy?

To avoid episiotomy, it is recommended to systematically perform Kegel exercises for pregnant women, as well as perineal massage, see - Pregnancy massage.

List of authoritative books and studies related to the study of episiotomy

1. "Williams Obstetrics, by F. Gary Cunningham, Kenneth J. Leveno, Steven L. Bloom, Catherine Y. Spong (Year: 2021)
2. "Labor and Delivery Nursing: Guide to Evidence-Based Practice" - by Michelle Murray (Year: 2018)
3. "Operative Obstetrics" - by Joseph J. Apuzzio, Anthony M. Vintzileos, Leslie Iffy (Year: 2007)
4. "Clinical Obstetrics and Gynecology" (journal series) - various authors and years of publication, including articles dealing with episiotomy.
5. "Best Practices in Midwifery: Using the Evidence to Implement Change" - by Barbara A. Anderson (Year: 2015)
6. "Midwifery and Women's Health Nurse Practitioner Certification Review Guide" - by Beth M. Kelsey (Year: 2014)
7. "Obstetrics: Normal and Problem Pregnancies" - by Steven G. Gabbe, Jennifer R. Niebyl, Joe Leigh Simpson (Year: 2020)
8. "Comprehensive Gynecology" - by Rogerio A. Lobo, David M. Gershenson, Gretchen M. Lentz (Year: 2020)
9. "Varney's Midwifery - by Tekoa L. King, Mary C. Brucker, Jan M. Kriebs (Year: 2020)

Literature

Obstetrics : a national guide / edited by G. M. Savelieva, G. T. Sukhikh, V. N. Serov, V. E. Radzinsky. - 2nd ed. Moscow : GEOTAR-Media, 2022.