An Episiotomy is a cut performed by a doctor or midwife late in second stage of labour in order to assist the delivery of the baby. This is usually performed with the use of a local anaesthetic and the cut is made at about “7 o’clock” at the centre of the back wall of the vagina so as to avoid the rectum.
It is no longer done routinely and is now only done to assist delivery in certain circumstances such as fetal distress, to prevent severe trauma or assisted delivery. An episiotomy slightly reduces the chances of a third or fourth degree tear (a rip from your fanny to your bum) and is easier to repair than a random tear. However, it may be more uncomfortable afterwards than a tear.
Often the decision about making an episiotomy is not made until last minute, depending on circumstances, but it is always done with the patient’s consent.
It is not done routinely with a Ventouse delivery, but is almost always done with a forceps delivery.
Rips or Tears
Most women will experience some form of tear or damage to the vagina and surrounding tissues during their first vaginal delivery. Most cause only temporary problems and will have no long-term effect on future health. The extent of the damage is related to many factors such as the size and position of the baby, the time spent pushing, the type of delivery, and the woman’s pelvic floor and its ability to stretch and withstand the traumas of pushing out a baby.
There are 4 degrees of vaginal tear.
1st Degree Tear- This is limited to the inside of the vagina only. This is unlikely to give any problems either at the time of delivery or later. It rarely needs stitching unless there is heavy bleeding. Healing is usually very straight forward.
2nd Degree Tear – This involves the vagina and the bridge of tissue between the vagina and the anus, called the perineum. It does not involve any damage to the rectum or the sphincters of the rectum, but may include some damage to some of the deeper muscles. It usually involves some stitching to bring together the deeper muscles and rebuild the perineum and close any defect in the vagina and skin. This stitching usually requires either local anaesthetic or gas and air, or the topping up of an epidural if one is in place. You will usually have to be in stirrups and this can take anything from 5 to 40 minutes. You can normally still hold the baby or hand it to the father.
3rd Degree Tear- This means that the tear has extended into the sphincter of the rectum. This will need to be repaired carefully to prevent any future problems with the back passage, such as incontinence. This repair is normally done under optimum conditions which are in an Obstetric Operating theatre. It may seem like a big performance at the time and a complete annoyance after a difficult birth, and may even delay bonding with your baby, but it is worth it. It is best done by an experienced doctor and may need some extra treatment afterwards to keep your motions (poos) soft and regular and a course of anti-biotics is usually given to prevent infection. You will need careful follow up appointments with physiotherapists and a post natal gynaecological team is usually advised.
4th Degree Tear- This is just like the 3rd degree tear but the tear actually goes into the rectum, repair is as above but a little more detailed and longer.
3rd and 4th degree tears happen in approximately 5% of vaginal births.
The important thing is to make a diagnosis and for the lesions not to be missed but this may mean a sometimes uncomfortable examination shortly after the birth, including often a finger up the bottom.
Vaginal tears may be associated with increased bleeding after delivery and is usually more extensive the greater the blood loss.
Most heal nicely with a good result and minimal disruption to the bowel, the bladder or sexual function. The stitches dissolve and rarely need to be removed.
Sadly however, there are sometimes complications. Infection may occur after a few days, heralded by pain, redness and sometimes a breakdown of the wound with some extra bleeding. Rarely, the wound needs re-stitching but it is usually best left to heal completely before making a decision at a later date.
Occasionally there is delayed healing which may require some extra treatment such as cautery (being cauterised) or minor surgical procedures.
By 6 weeks things should be almost back to normal. If not, you should seek advice.