Episiotomy (perineotomy)

Episiotomy or perineotomy is a surgical procedure that is performed during childbirth. In this procedure, the doctor gives a cut on the perineum of the mother, the area between the vaginal opening and the anus, for smoother delivery of the baby. 

When the baby’s head is visible during normal delivery, the doctor carefully pulls the baby’s head and chin out of the vaginal opening, which is then followed by the body of the baby. However, in some cases, the vaginal opening is not completely expanded or stretched. This makes the delivery of the baby difficult. The episiotomy procedure aims to enlarge the vaginal opening to allow extra space for the head of the baby to come out easily.

Read more: Normal delivery process and tips

The doctor may perform this procedure in the following situations:

• Foetal distress: Foetal distress is a condition in which the heart rate of the baby may fluctuate between high and low points during birth due to oxygen deprivation. In such a case, an episiotomy helps to prevent the risk of injuries to the baby during childbirth. 
• Forceps or vacuum delivery: Your doctor may perform an episiotomy to widen your vaginal opening to make space for instruments such as forceps or vacuum suction. These instruments help in smoother delivery of the baby from the vaginal opening. 
• Health conditions: If you have any severe health problems such as heart disease, your doctor may perform an episiotomy to reduce the time taken for delivery, thus reducing the risk of complications. 
• Pre-term baby: If you are having the baby before the 37th week of pregnancy an episiotomy helps ease delivery process.
• Breech birth: If your baby is positioned such that his/her feet or buttocks emerge first during the delivery an episiotomy helps make space for the baby to come out. 
• Shoulder dystocia: If the baby’s shoulders are unable to come out of the vaginal opening. 
• Large size of the baby: If your baby is bigger than the normal size at birth. 
• Pushing the baby for a long time: If you are tired because of pushing the baby for several hours during labour, an episiotomy may facilitate childbirth.

An episiotomy is avoided if a safe vaginal delivery is doubtful and the procedure cannot be shifted to a C-section (such as in a trial of forceps which is done when the cervix is disproportionate for a vaginal delivery). This surgery will not be performed unless you grant consent. Some of the conditions that may add risk to this surgery (and where the procedure is done with caution) are as follows:

• Inflammatory bowel disease (this disease occurs when there is persistent inflammation in your digestive tract)
• Acute scarring in the perineal region 
• Deformity in the perineal area
• Lymphogranuloma venereum (formation of ulcers in the genital regions)
• Coagulation (clotting) disorders 

Before this procedure, you will need to be prepared in the following ways:

• You will be asked to sign a consent form granting your approval for the procedure. This will be given to you along with the other forms for hospitalisation.
• You must share all the information about your current and previous medicines including prescribed and non-prescribed medicines, herbs, vitamins and supplements with your doctor. 
• Also tell your doctor if you are allergic to any medicine or things that may be used in the hospital such as iodine, tape, or latex.
• You may need to stop the use of blood-thinning medicines such as aspirin before labour. 
• Any history of bleeding problems should be shared with the doctor.

The procedure will be performed in the following manner:

• You will be positioned on a labour bed with proper/appropriate support for your legs and feet for the delivery. This procedure will be conducted during childbirth.
• The medical team will administer local anaesthesia to numb your perineal region. If you have been given epidural anaesthesia (a medicine given in the lower back to ease the delivery and labour pain), you will not need additional anaesthesia at the surgery site. The team will increase the dose of the epidural instead. 
• During the birthing process, as you are pushing, when the doctor sees the baby’s head, he/she will make a small diagonal cut from your vaginal opening to your anus. 
• Once the baby and placenta (afterbirth, an organ that provides oxygen and nutrition to the baby while in the mother’s womb) are delivered, the doctor will check for further tearing of tissues in the perineal area. 
• The cut will be repaired with absorbable stitches.

The episiotomy procedure is quick and takes only a few minutes. After vaginal delivery, you may be discharged from the hospital after two days. No additional stay is needed for this surgery.

Once you are home, you will need to take the following care:

• You may have a stinging pain and swelling at the episiotomy site, for which your doctor may prescribe medicines like paracetamol and ibuprofen. 
• You can use ice/cool packs to reduce swelling or pain for the first few days. Apply the pack for half an hour and keep a gap of an hour before applying it again. You must also prevent the direct contact of ice with skin.
• You can sit on an air-filled valley cushion for about 30 minutes to gain relief from the pain or take sitz bath
• Avoid applying creams or spray on your perineum.
• Take a balanced diet. 
• Pour warm water over your vagina every time you go to the toilet as this will reduce discomfort. 
• Place a clean pad on the surgical site while passing stools. This will reduce the pressure on the wound. If you have hard stools, then the doctor may prescribe laxatives.
• Avoid lifting heavy objects as it can tear the stitches.
• Avoid using tampons or douches for a few weeks after the surgery. 
• You should wait for up to six weeks before resuming sexual activities. 
• It is normal to feel pain during sexual activities for at least the first few months. This may occur due to vaginal dryness. You can use water-based lubricating gels during sexual intercourse. 
• You can get pregnant even after three weeks of the delivery and when you are breastfeeding. Make sure to use contraception unless you wish to get pregnant again.

When to see the doctor?

Contact your doctor at the earliest if you experience any of the following symptoms after the surgery:

• Severe or worsening of pain in the perineal area 
• No bowel movement for four or more days
• Vaginal discharge with foul odour/smell 
• Discharge of blood clots that are larger than a walnut
• Red, swollen skin around the episiotomy area
• Fever or chills 
• Persistent pain
• Bleeding from the surgery site 

This surgery may have the following risks: 

• Pain while having sex 
• Accumulation of blood in the perineal tissue
• Tearing of the muscle and tissues that control our bowel movement 
• Swelling
• Infection 
• Bleeding

The doctor may schedule an appointment for you if you need any further treatment or special care for the episiotomy.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.