Episiotomy is the term for a surgical incision of the perineum made to increase the diameter of the vulval outlet during childbirth. Although episiotomy has become one of the most commonly performed surgical procedures in the world, it was introduced without strong scientific evidence of its effectiveness.
Since the 1970s, its routine use in the UK has been challenged. Episiotomy was submitted to randomized clinical trials, and reviews of these trials by Caroli and Belizan, 2004, concluded that there is only evidence to support the selective, and not routine use of episiotomy. Adverse effects of routine episiotomies;
Episiotomy rates in the UK in 2006-2007 were reduced to 13% of women, NHS Choices website.
Benefits found by Caroli and Belizan:
Adverse Effects found by Caroli and Belizan:
There are 2 main types of incision (see Figure 1 opposite).
The incision starts midline at the frenulum of the labia minora, avoiding damage to the Bartholin’s gland. It is then directed diagonally to the left over the right side of the posterior perineum to a point midway between the anus and ischial tuberosity, avoiding the anal sphincter.
The incision starts in the midline position and is made vertically towards the anus.
Mediolateral vs. Medline
Midline incisions bleed less and are easier to repair. However the incision carries a greater risk of extension into the rectum, hence it should only be used by the experienced. After reviewing clinical trials, Caroli and Belizan (2004) concluded that there was insufficient evidence to indicate which method was superior.
The decision to perform an episiotomy must be made on an individual basis and using clinical judgement, taking the woman’s wishes and obstetric history into consideration. The woman must be given information on episiotomy and consent obtained prior to labour, because it is difficult to obtain true informed consent during labour.
Don't perform episiotomy too early because vaginal delivery may not be possible, and blood loss and discomfort are increased when mothers receive both a perineal and abdominal incision. Don't incise beyond the bony ischial tuberosities. Outlet obstruction due to bony structures is not relived by an episiotomy.
Controlled delivery of the head that allows gradual stretching of the perineal tissue can help in minimizing damage to the perineum. Perineal masage begining around the 34th week has been shown to reduce perineal damage by 6%, Shipman 1997.
2.) Carroli G, Belizan J (2004) Episiotomy for vaginal birth (Cochrane Review): In: The Cochrane Library, Issue 1 Chichester, UK: John Wiley and Sons, Ltd.
3.) Shipman M, Boniface D, Tefft M, Mcloghry F (1997) Antenatal perineal massage and subsequent perineal outcomes: a randomised controlled trial. British Journal of Obstetrics and Gynaecology 104: 787-791.
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