An episiotomy is a minor surgical procedure where the skin and underlying muscles of the perineum—the area between the vagina and the rectum—is cut at the end of the second stage of labor (crowning) to assist in childbirth by enlarging the birth canal opening and allowing the baby to pass through more easily. Although episiotomies are common, they are not routine—in the U.S, about 60% of all vaginal births do not need an episiotomy. The final decision to do an episiotomy is not decided until you are ready to give birth. You can try to avoid needing an episiotomy with perineal massage, and listening to your labor and delivery team about when to push and when not to push. Having an episiotomy does not add time to your hospital stay.
The Episiotomy Procedure
Note: The scissors shown are incorrect – the scissors actually used are blunt on the tips to prevent injury to the mother or baby.
An episiotomy begins with a local anesthestic (either a nerve block or an epidural injection) to numb the area where the cut will be made. Two fingers are placed between the scissors and the baby’s head for protection. This is followed by a one inch blunt-scissors cut, either a mediolateral cut (an angled cut to one side of the vagina to avoid the anal sphincter muscles) or a mid-line or median cut (a straight cut of less than an inch towards the anus). The cut enlarges the vaginal opening and helps in the delivery of your baby. If you need a forceps or vacuum delivery, the length of the incision will be longer than it would be without an instrument assisted birth. Once your baby is delivered and the placenta removed, the birth canal is examined for any tears that need repair. The episiotomy incision made in the vaginal skin, muscle and perineal skin is stitched closed in layers using absorbable sutures. The vaginal skin is repaired first, then the muscle and finally the skin of the perineum. Stitching usually takes about 10-20 minutes. The incision is closed soon after delivery to prevent blood loss and reduce the chance of infection.
The median incision is easiest to make and repair, but if it has to be extended or tears it does not give any protection to the anus. The mediolateral cut is more difficult to repair but it gives the best protection against damage to the anal sphincter and best suits the purpose of the cut.
Why Do You Need an Episiotomy?
A normal vaginal delivery involves intense labor contractions and requires a pushing on the mother’s part. Time and patience is required for the labor to produce a baby. Pushing by the mother can cause tears in the vagina.
An episiotomy may be performed to prevent jagged tears which are likely:
- if your baby presents face first and not the crown of the head first
- if you have a scar from earlier tears
- if you’ve had previous surgery to repair a tear or uterine prolapse
An episiotomy may also be performed:
- if your baby is suffocating due to lack of oxygen (the umbilical cord gets “kinked” or compressed, or there appears to be umbilical cord problems and the baby needs to be delivered quickly
- if your baby is large or its head is too big
- if your baby is in distress in the birth canal
- if your baby’s shoulder gets stuck in the vagina
- if there is an emergency and there is not enough room to deliver your baby with forceps
- if your baby presents bottom first (breech) and needs more room to get out
- to prevent overstretching of the muscles which may lead to prolapse later
One of the main reasons for an episiotomy is to avoid tears since it is felt that a clean, surgical cut is easier to repair than a natural tear. Natural tears in the perineum can happen as your baby passes through the vagina. Injury to the perineum can be: