TWO TYPES OF EPISIOTOMY: WHICH ONE IS BEST?
There are two basic types of episiotomies:
A median episiotomy is cut right down the center of the perineum, between the vagina and the rectum.
A mediolateral episiotomy is angled off to the side, into either the right or the left labial area.
Which type of episiotomy is preferable if you have to choose? Median episiotomies have been associated with less postpartum and sexual pain, less blood loss, and a lower risk of infection.
However, because it’s positioned right down the middle, the median approach confers a very substantial risk of tearing into the anal opening or rectum, somewhere between 11 and 12 percent. Mediolateral episiotomies are associated with more postpartum and sexual pain and possibly more muscle weakness, but they generally decrease the risk of anal or rectal injury to around 1 to 2 percent.
There are pros and cons to both types, and there is no obvious right choice that applies to all women. For women with a short perineum— meaning the distance between vagina and rectum is very small—a mediolateral might best help to avoid extension of the episiotomy into the anal sphincter. With a long perineum, a median episiotomy might help to avoid tearing into the labia.
Median episiotomies are more popular in North America, whereas mediolateral episiotomies have remained more popular in Europe, and doctors from both sides of the ocean have long debated which method is less traumatic.
Unfortunately, despite the fact that these procedures involve their most intimate parts, women have rarely been invited to join the debate.
“Wait a second,” I can hear you asking, “aren’t episiotomies, and all of these associated injuries, repaired before leaving the labor room?” Isn’t everything put back into place after delivery, allowing you to eventually heal back to full strength? Though you might assume so, the data argues otherwise.
First of all, it’s been found using ultrasound that even after repair of a torn anal sphincter right after delivery, separated anal muscles are still seen in up to 40 percent of these women postpartum. Secondly, according to a survey of obstetricians in the United Kingdom, less than a third of doctors reported that they felt adequately trained in repairing anal sphincter injuries that occur during childbirth.
As the problem of anal incontinence has begun to earn its long-overdue place on the women’s health-care agenda, debate has increased regarding the best techniques for repairing perineal and anal injuries in the delivery room.
Some expert surgeons specializing in obstetrical anal sphincter injury have recently begun to advocate a more meticulous surgical approach in the labor room, using overlapping repair techniques that attach the torn muscles more strongly.
In the short term, this method has been reported to lower the risk of anal incontinence, but overlapping sphincter repair is not yet included in most general obstetrical training; nor has it been proven to be the best technique over the long run. As the problem of anal incontinence continues to be addressed, you’ll undoubtedly see greater efforts being made to prevent and repair these injuries in the delivery room, whether with the overlapping repair or other innovations. For now, reducing the number of unnecessary episiotomies in our obstetrical world would probably do the most good.
When an episiotomy is avoidable, avoid it!
WHEN SHOULD YOU HAVE AN EPISIOTOMY?
Physicians trained in recent years tend to favor a relatively hands-off approach when it comes to episiotomies, compared to their predecessors, who tended to intervene with less hesitation. But even today, there are a handful of absolutely, positively justified reasons for your doctor or midwife to cut an episiotomy. For instance:
In cases of fetal distress or an abnormal fetal heart rate close to delivery, a well-timed episiotomy can shorten the time to delivery by critical minutes.
If the baby becomes stuck during delivery—particularly if the shoulders are wedged behind the pubic bone (shoulder dystocia)—an immediate episiotomy is warranted to help prevent asphyxiation of the newborn.
Sometimes an obstetrician will notice a particularly severe injury occurring in some place other than the perineum—for example, the labia, urethra, or clitoral area—and perform an episiotomy to relieve pressure and spare extensive injury that can be both painful and difficult to repair.
Clinicians would routinely include an episiotomy with each forceps or vacuum (a soft suction device used to gently pull the fetal head toward the vaginal opening) delivery, creating more room for inserting these devices. However, most physicians have abandoned the routine use of episiotomy even during these operative deliveries, using them on a more selective basis.
If you have an episiotomy, the overwhelming odds predict that you’ll do absolutely fine. But if your doctor or midwife recommends planning an episiotomy with the intent of protecting your body from injury, then it’s time to ask some questions and perhaps explore your provider’s style. According to some specialists in obstetrical injury, the most appropriate episiotomy rate should be no higher than around 20 to 30 percent for uncomplicated pregnancies. Recent trends are encouraging in this regard; one review of more than thirty-four thousand vaginal deliveries found a decline in episiotomy rate from 69.6 percent of all vaginal births in 1983 to 19.4 percent in 2000. Episiotomies will always have an important place in the labor room, but today’s research says there’s little basis for routinely cutting one in order to preserve your pelvic floor.
EPISIOTOMY: JUST THE TIP OF THE ICEBERG OF PELVIC CHANGE
In the end, episiotomies probably carry as much symbolic and emotional weight as actual medical importance. Injury to the perineum is just the tip of the iceberg of pelvic injury that can result from childbirth—the surface damage that, however significant, is often small compared with the more extensive, deeper changes that occur at its base. Before reaching the perineum, the fetus has traversed the foundation of your pelvic supports and a number of structures that will determine your postreproductive function and control. Sometimes the most important damage has already been inflicted, completely unseen.
It’s time for you, the central person in the labor room, to familiarize yourself with the parts of your body hidden beneath the iceberg’s tip.
Let’s continue unfolding the anatomy of labor and take a look at the unseen structures that are essential to your health, independence, and intimacy beyond the labor room. A little knowledge can empower you to prevent future problems and alleviate those you might already have.
Conclusion
Childbirth is a transformative journey, bringing both remarkable joys and physical challenges. Understanding the implications of decisions like episiotomies and their role in your pelvic health empowers you to make informed choices during labor and delivery. By fostering awareness and seeking thoughtful care, you can prioritize both immediate recovery and long-term well-being. With knowledge and support, you can embrace the postpartum phase with strength and confidence, paving the way for a healthier future.
Coming up Next: The Pelvic Floor After Childbirth Pt. 3
Taking care of your body after delivery is about more than just healing—it’s about understanding the changes that happened along the way. We’ve talked about episiotomies and how they can affect your recovery and pelvic health, giving you tools to make informed decisions during and after childbirth. As you continue your journey of understanding your pelvic health, the next blog will dive into the levator muscles, the unsung heroes of pelvic-floor support. You’ll learn how these muscles can be affected during childbirth and why they play such a critical role in preventing issues like prolapse and incontinence. More importantly, you’ll discover practical strategies and treatments to strengthen your pelvic floor and restore function over time. Don’t miss this next step in taking charge of your long-term health and well-being!
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