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Episiotomy

Last updated Feb. 25, 2018

Approved by: Maulik P. Purohit MD MPH

Blausen.com staff. "Blausen gallery 2014

An Episiotomy (or Perineotomy) is a minor surgical procedure to widen the opening of the vagina during childbirth.


Background Information:

What are the other Names for the Procedure?

  • Perineotomy

What is Episiotomy surgical procedure?

  • An Episiotomy (or Perineotomy) is a minor surgical procedure to widen the opening of the vagina during childbirth
  • Earlier, it used to be routinely performed. But nowadays, experts believe that the procedure should not be done on a routine basis, as there are a number of complications associated with it. Hence, the incidence of the procedure, is in decline

What part of the Body does the Procedure involve?

An Episiotomy procedure involves the vagina and the area between the vagina and the anus, called the perineum.

Why is the Episiotomy surgical procedure Performed?

An Episiotomy is performed for the following reasons:

  • During childbirth: This surgical procedure allow an easier passageway of the infants and decrease possible injury to the mother’s vagina, urethra, bladder, and rectum
  • Use of this procedure may also allow for a faster delivery, of the baby
  • Indications for performing an Episiotomy:
  • If the baby's head or shoulders are too big for the mother's vaginal opening
  • If labor is prolonged and stressful for the baby and the pushing time needs to be reduced
  • If baby is in the breech position (the feet or buttocks of the child exiting first) and there is a problem during delivery
  • If forceps or vacuum extractor are used to help get the baby out

What are some Alternative Choices for the Procedure?

The procedure is not performed for every woman during childbirth, since many do not need a cut to facilitate labor.

What are the Recent Advances in the Procedure?

The routine use of episiotomy has been on the decline; hence, there are no recent advances in this procedure.

What is the Cost of performing the Episiotomy surgical procedure?

The cost of Episiotomy procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

  • It is normal for a patient to feel uncomfortable and confused by the information regarding an Episiotomy procedure and on what needs to be done
  • If the patient needs further reassurance or a second opinion, a physician will almost always assist and also recommend another physician, if required
  • They can also choose to approach another physician independently. Besides, if the procedure has many alternatives, the patient may take a second opinion to understand and choose the best one

What are some Helpful Resources?

http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000482.htm

http://www.babycentre.co.uk/a165/episiotomy

http://www.nhs.uk/conditions/pregnancy-and-baby/pages/episiotomy.aspx

Complete Guide to Symptoms, Illness & Surgery; Written by H Winter Griffith, M.D.; Revised and updated by Stephen Moore, M.D. and Kenneth Yoder, M.D.; The Berkley Publishing Group, 5th Edition, New York, 2006

Prior to Episiotomy surgical procedure:

How is the Episiotomy surgical procedure Performed?

  • An Episiotomy is typically performed under local anesthesia during the second stage of labor, as the baby is close exiting and there is a tear towards the urethra
  • With the individual in a lithotomy position (lying flat on the back (supine) with feet raised), a surgical cut is made on the skin and the underlying muscle in the perineum, between the posterior vaginal wall and the anus
  • The cut can be straight (median episiotomy) or diagonal (medio-lateral episiotomy)
  • The cut is then closed with sutures following delivery

Where is the Procedure Performed?

An Episiotomy procedure is usually performed at the birth unit, during labor.

Who Performs the Procedure?

An Episiotomy surgical procedure may be performed by any of these medical personnel, with assistance from an anesthesiologist:

  • Obstetrician
  • Gynecologist
  • Family doctor
  • Midwife

How long will the Procedure take?

An Episiotomy takes less than 5 minutes to perform.

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the surgical procedure and helps avoid unnecessary complications.

  • Provide a complete list of medications you are currently, taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
  • If you are allergic to any specific medication or food items
  • If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
  • If you or your family members, have a history of bleeding disorders, or if there is a tendency to bleed more than normal
  • If you have diabetes, high blood pressure, chest pains, or have previously suffered from a heart attack
  • If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
  • If you have a history of frequent bone fractures (this may affect bone-healing, if bones are involved as part of your procedure)
  • A list of all previous surgical procedures you have undergone, like for example: Removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.

What Preparations are needed, prior to the Procedure?

  • The physician may evaluate the individual’s medical history to gain a comprehensive knowledge of the overall health status of the patient including information related to the medications that are being currently taken
  • Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time, before the procedure is performed
  • Blood tests may be performed to determine if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
  • Do inform the physician if you are allergic to any local anesthetics, lidocaine, etc.
  • Avoid application of any cosmetics, deodorant, or topical medicines on the area, prior to the procedure
  • It is advisable to quit smoking and the use of any nicotine based products, for a while, before the surgery
  • Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
  • The patient must avoid eating or drinking at least 8 hours prior to the surgical procedure, depending on when the procedure is arranged
  • For persons suffering from diabetes, it is important that the blood sugar stays within the normal range; if not their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines
  • A physician will request your consent for the Episiotomy procedure using an Informed Consent Form.

What is the Consent Process before the Procedure?

A physician will request your consent for the Episiotomy procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is your approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

You must sign the forms only after you are totally satisfied by the answers to your questions. In case of minors and individuals unable to personally give their consent, the individual’s legal guardian or next of kin, shall give their consent for the procedure.

What Tests are needed, before the Episiotomy surgical procedure?

Routine blood tests and other tests that is necessary, as determined by the physician for a successful labor.

What are some Questions for your Physician?

Some of the basic questions that you might ask your physician are as follows:

  • What is an Episiotomy (Perineotomy)?
  • Why is this procedure necessary?  How will it help?
  • Is there an emergency?
  • Who are the medical personnel involved in this procedure?
  • Where is the procedure performed?
  • What are the risks while performing the procedure?
  • What are the complications that might take place, during recovery?
  • How long will it take to recover?
  • How many such procedures have you (the physician) performed?
  • Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
  • What are the costs involved?

During the Episiotomy surgical procedure:

What kind of Anesthesia is given, during the Procedure?

Injection of local anesthesia is administered for this procedure.

How much Blood will you lose, during the Procedure?

The blood loss from the procedure is usually minimal.

What are the possible Risks and Complications during the Episiotomy surgical procedure?

There are general factors that increase the risk of getting complications during surgery and they include:

  • Obesity: generally greater the degree of obesity greater the surgical risk.
  • Smoking: longer the smoking history (in pack years smoked) greater the surgical risk
  • Advancing age: generally greater the age results in higher surgical risk  
  • Poorly controlled diabetes as evidenced by a high hemoglobin A1c and high fasting glucose
  • Poorly functioning kidney as evidenced by increased BUN (blood urea nitrogen) and creatinine in the blood
  • Poorly functioning liver as evidenced by increased blood liver function tests
  • Hypertension (increased blood pressure) especially if poorly controlled
  • Poor nutritional status (malnutrition with mineral and vitamin deficiencies)
  • Poor lung function as evidenced by abnormal lung function tests
  • History of bleeding disorders
  • Long standing illness such as autoimmune disorders and chronic infections
  • Poor immune system due to a variety of causes
  • The possible risks or complications that may arise during the surgery are:
  • Excessive bleeding
  • Infection surrounding the surgical would
  • Anesthetic complications
  • In rare cases, accidental injury to the sphincter or rectum

What Post-Operative Care is needed at the Healthcare Facility after the Episiotomy surgical procedure?

At the healthcare facility, usually there is no requirement for any post-procedure care, unless any complications arise. 

After the Episiotomy surgical procedure:

What are the possible Risks and Complications after the Episiotomy surgical procedure?

The possible risks and complications that may arise after an Episiotomy are:

  • Infection surrounding the surgical wound
  • Injury to the anal sphincter resulting in fecal incontinence
  • Injury to the perineum resulting in pelvic floor weakening
  • Painful intercourse for few months
  • Perineal pain

What is the Prognosis after the Surgery?

The prognosis is good in experienced hands and when done in select indications (mentioned previously).

When do you need to call your Physician?

Do contact your physician if you notice any of the following symptoms:

  • Worsening pain and swelling surrounding the surgical wound
  • Bleeding or fluid drainage around surrounding the surgical wound
  • The occurrence of any symptom that causes uneasiness, such as nausea, vomiting, and constipation
  • Swelling surrounding the abdominal area
  • Signs of an infection
  • Fever
  • Dizziness
  • Headache
  • Muscle aches
  • Fever
  • Feeling sick
  • Complications associated with prescription medications used in treatment

What Post-Operative Care is needed at Home after the Episiotomy surgical procedure?

At home, the following post-operative care is recommended, after an Episiotomy procedure:

  • Resume regular/daily activities, as early as possible (under advice by the physician). This aids in a faster recovery
  • Keep the wound clean and dry
  • Clean the surgical area with warm water after urination, or bowel movement
  • Take hot baths several times a day to relieve pain (per advise from the physician)
  • Take stool softeners to prevent constipation
  • Avoid taking nonprescription medications, such as aspirin. However, individuals may take acetaminophen to relieve pain, if required
  • Immediately for a few weeks after the surgery, have a diet consisting of foods high in fiber.  As you increase your fiber intake, also increase your fluid intake
  • Resume driving only after a period of 10-14 days after leaving the healthcare facility (as advised by your physician)
  • Avoid sex till complete healing has taken place; which is usually for a period of around 4-6 weeks (under advise by the physician)

How long does it normally take to fully recover, from the Procedure?

Generally, it takes about 6 weeks to recover from an Episiotomy procedure.

Additional Information:

What happens to tissue (if any), taken out during the Procedure?

The procedure does not involve the surgical removal of any tissue.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

Since no tissue is removed during the procedure, a pathologist does not get involved in the care of the patient.

Who will you receive a Bill from, after the Episiotomy surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

  • The outpatient facility, physician’s office or hospital
  • An anesthesiologist (if anesthesia was administered)
  • Obstetrician, gynecologist, family doctor, or a midwife

The patient is advised to inquire and confirm the type of billing, before the Episiotomy procedure is performed.

Thanks and Gratitude:

We sincerely acknowledge and thank Dr. Douglas J. Jones for reviewing the article. His valuable input and feedback has helped enrich the contents of this article.

Douglas J. Jones, MD FACS
Board Certified General Surgeon and Faculty Member
University of Illinois, College of Medicine at Urbana-Champaign
506 S. Mathews Ave., Urbana, IL 61801, USA

Reviewed and Approved by a member of the DoveMed Editorial Board
First uploaded: July 17, 2013
Last updated: Feb. 25, 2018