It is impossible in principle to predict what will be the process of childbirth for a particular woman in labor. Despite all the advances in medicine, on a preliminary assessment of risk factors, some processes during childbirth are subject exclusively to the forces of nature. The doctor and the woman in labor have no choice but to accept this. There are many ways to help your baby be born if labor is difficult. One of them is episiotomy. In this article we will tell you what it is, how it is performed and what consequences such an operation can have.
Features:
Episiotomy is one of the most common small operations in obstetrics. Its name comes from the Greek word "epision", which means "female external genital organs." The second part of the word means "dissection". In fact, this is the principle of this surgical intervention.
Episiotomy is a perineal incision. Obstetricians take such a measure when there is a high risk that a spontaneous rupture of the perineum will occur at the birth of a baby.
This measure is forced and necessary. It helps prevent serious consequences not only for women's health, but also for the health of the baby. A timely dissection of the perineum reduces the likelihood of a child receiving a severe cranial or traumatic brain injury during birth.
The dissection is carried out during the second stage of labor, with attempts, the birth of the fetal head. Anatomically, the female perineum is designed in such a way that it is possible to expand it surgically if the passage of the baby's head is very difficult. If the incision is made in time, then it will be possible to avoid a rupture, which is more difficult to heal, it can result in unpleasant consequences - prolapse of the pelvic organs, their loss, as well as heavy bleeding, which will be very difficult to cope with.
Medicine knows four types of episiotomy:
- mid-lateral (an incision with surgical scissors is made from the middle to the right or left side diagonally so that the end point of the incision is no closer than two and a half centimeters from the anus;
- perineotomy, which is also called a median episiotomy (the dissection is perpendicular to the anus from top to bottom, not leading to the anus itself);
- lateral (incision at an angle of 45 degrees a couple of centimeters away from the center of the labia);
- J-shaped (start cutting from the center of the labia bridle with a transition to the lateral direction).
The location of nerves, blood vessels, some glands in the perineum, as well as the speed and characteristics of the healing of incisions after childbirth have made the use of the first two types of perineal incision more widespread.
Lateral episiotomy is considered undesirable due to the long and difficult healing of sutures, the J-shaped one is also used extremely rarely, since for all its complexity it is not considered justified and can easily be replaced by a median-lateral or median episiotomy.
Application history
In the history of different peoples and countries, there are references to the dissection of the perineum of women during difficult and prolonged childbirth. In ancient China, a red-hot piece of iron was used for this, in some tribes of Australia - thin and sharp shells and stones with pointed edges.
This tradition has come down to modern doctors. In various countries, for a long time, dissection of the perineum was considered a normal practice and it was carried out not only if there was evidence, but also just in case, just in case, to speed up labor.
Since 1960, most European physicians have decided to abandon this approach, and only Poland, the United States, Australia and Bulgaria have decided to remain committed to episiotomy. The share of fanaticism with which obstetricians there cut the perineum of women is different - in the United States, according to statistics, up to 36% of women in labor undergo surgery, and in Australian clinics with perineal dissection, up to 90% of all births take place.
Episiotomy is recognized by doctors all over the world as a rather effective way to avoid perineal tears, to exclude severe pain syndrome when spontaneous tears in different directions are received, to prevent postpartum urinary incontinence and sexual dysfunction. At the same time, it is the surgical incision of the perineum itself that can cause all these problems. Due to this fact, the attitude to the operation today is very, very ambiguous.
In 2010, the WHO conducted a study and concluded that the absence of incisions, even if the birth is slow, is more preferable, since a woman without sutures on the perineum recovers faster, and the risk of complications is lower.
There have been no direct recommendations to prohibit episiotomy, but The World Health Organization recommends that elective episiotomy be abandoned limiting only to emergency cuts in situations where there is simply no other way out.
Who is it for?
According to the clinical guidelines of the Russian Ministry of Health, episiotomy is not recommended for routine use. This means that the doctor cannot dissect a woman's crotch at his discretion without evidence. Even if the woman in labor has previously had perineal tears, her dissection should not be routine.
The indications for the incision of the female perineum in childbirth are currently significantly limited by the World Health Organization, the Ministry of Health of Russia fully supports the restrictions. This is stated in the clinical guidelines set out in a letter dated May 6, 2014 N 15-4 / 10 / 2-3185. These recommendations are fundamental for all health care providers who deliver.
Letter dated May 6, 2014 N 15-4 / 10 / 2-3185
Surgical intervention is performed when it is necessary to minimize the likelihood of spontaneous rupture during pathological childbirth.
Such indications include a large fetus, the head diameter of which does not correspond to the throughput of the vagina, pelvic or other abnormal presentation of the fetus, if at the same time the woman categorically refused a cesarean section and insisted on independent physiological childbirth.
Also, an episiotomy is carried out, if necessary, use tools - apply obstetric forceps or a vacuum extractor, which is impossible if you do not expand the entrance to the vagina artificially.
Dissection is recommended if a woman has poorly healed scars on the genitals resulting from severe ruptures in previous births, as well as after surgical repair of the vagina or female circumcision (and this happens in obstetric practice). If the scars are thin and heterogeneous, the risk of rupture increases tenfold.
Not so long ago, incisions were made for indications such as high perineum or stiffness. Today, the Ministry of Health recommends not considering such concepts as indications for mandatory episiotomy.
A rigid perineum may need an incision only if the head is not born within an hour. And the concepts of “high risk of rupture” and “threat of rupture” do not exist in obstetrics at all. And therefore, cutting a woman's crotch just because the obstetrician thought that a rupture was likely is not worth it.
In practice, the list of indications is somewhat wider. The dissection of the perineum can be carried out for women who are forbidden to push for a long time and strongly, for example, with myopia. This is done to speed up labor with minimal effort. At the same time, there is a safer delivery option for a woman in labor - a cesarean section, one of the indications for which is myopia.
The dissection of the perineum is also carried out in the case of intrauterine oxygen starvation of the fetus, which is detected already during childbirth. In this case, the doctor needs to quickly make a decision - to dissect the perineum or decide on an emergency caesarean section. It all depends on the condition of the baby.
Episiotomy is also used for dystocia of the child's shoulders - when they are wider than the head. This does not solve the problem, but the obstetrician after cutting gets more space for the necessary manipulations.
Technique
After the decision to perform an episiotomy has been made, the perineum is treated with an antiseptic solution before dissection. The woman may be given an epidural if the catheter is already in the spinal canal, or local anesthesia with lidocaine. Often, the dissection is performed without anesthesia. If the tissues of the perineum are tense, the woman will not feel acute pain during dissection.
It is possible to perform a dissection only when the attempt is at the maximum stage of its development, and the head is visible from the vagina by 3-4 centimeters. It is impossible to dissect the perineum outside the attempt.
Surgical scissors are used for cutting. One branch of them is introduced in the direction of the intended incision, when the woman is calm and relaxed, without trying. Then the obstetrician waits for the start of the contraction and, at the peak of the push, makes an incision with a quick movement.
It is not possible to calculate the length of the incision by eye to a millimeter, therefore the obstetrician makes it of an arbitrary length. It is believed that an incision less than three centimeters in length is ineffective and dangerous - the perineum does not expand significantly, but a small incision can begin to spontaneously tear further.
Epiziorrhaphy or perineorrhaphy is the suturing of the incision and restoration of tissue integrity. They are carried out after the child is born, the afterbirth leaves and the doctor will examine the cervix in connection with its possible ruptures and injuries. Even if the perineum was cut without anesthesia, then before suturing it is customary to carry out infiltration anesthesia - to inject lidocaine or another analgesic directly into the tissues to be sutured.
The choice of material for suturing and the technique of performing sutures affects the characteristics of wound healing, regardless of how the perineum was cut. Suturing can be performed with silk sutures that do not dissolve. They will need to be removed after healing.
This method (Jute technique) involves the application of sutures resembling eights, passing through all layers of tissue. Such stitches are quite often inflamed and infected in the postpartum period.
Suturing can be layered and gradual. First, the integrity of the posterior wall of the vagina is restored. Then the muscles are sutured. Immersion seams are made using a self-absorbable material. A continuous cosmetic seam is made outside. Upon completion, the perineum is again treated with an antiseptic solution.
Recovery and care tips
The place where the incision is made, in all respects, is not too convenient for it to be easy and simple to carry out the necessary care in the postpartum period. After the caesarean section, the suture is isolated from the rest of the body with a sterile bandage. It is not possible to impose this on the perineum - a woman needs to go to the toilet, wash herself, it is necessary to ensure the unhindered discharge of postpartum discharge - lochia. None of this implies dressings.
The lochia themselves, which are secreted from the genital tract, are a welcome breeding ground for pathogenic bacteria. That is why there is a possibility of infection in the area of postoperative sutures and for the same reason seams require careful maintenance.
The perineum is often tense - when moving, walking, pulling urge during bowel movements, because the risk of seam divergence is quite high. If the postpartum woman does not follow all the doctor's recommendations, complications can be very serious. The most common questions of women after an episiotomy need detailed and detailed answers.
How to sit?
After childbirth, in which doctors were forced to dissect the perineum, it is impossible to sit, since this will most likely lead to divergence of the stitches. How long the ban on such a pose will last depends on how large the wound is sutured in the perineal region. Usually women are not advised to sit down for 2-2.5 weeks. If the incisions were deep and lengthy, the postpartum woman could theoretically sit down no earlier than 3-4 weeks later.
You cannot sit down, but you can sit down with support on the thigh from the side opposite to the direction of the incision. If the episiotomy was performed towards the left, you need to sit down with support on the right thigh.
Eating, drinking tea and feeding the baby at this time is recommended either while standing or lying on its side. There are no restrictions on lifting weights for women after physiological childbirth with episiotomy, but you should still limit yourself to the weight of the baby and not strain unnecessarily. You need to walk and stand with caution, not to allow a sharp change in body position, in which the muscles of the perineum will strain.
How long does healing take? Care of seams
The duration of the healing period of the stitches depends directly on how carefully and correctly they will be processed. If there were no complications at the early postpartum stage, there was no inflammation, the healing of the wound edges occurs within 5-6 days. If the stitches were applied using threads that do not dissolve on their own, it is customary to remove them after a week. If pathologies and complications of the suture are identified, the healing time may increase indefinitely.
To promote faster healing, a woman should remember a few simple but important rules for caring for sutures:
lining in the hospital, and then the gaskets need to be changed regularly - preferably every 2-3 hours;
at the end of defecation or urination, each time you need to carefully wash the genitals in a bidet with warm water and immediately change the pad;
you need to wash with your palm in the direction from the pubis to the anus, and not vice versa (this will help to exclude the introduction of intestinal bacteria into the wound area);
you can wash with a weak solution of potassium permanganate (this will dry out the area of the wound surface);
it is impossible to wipe the crotch with the seams with rubbing or sharp movements; it is better to use sanitary napkins and apply them with gentle blotting movements;
in the maternity hospital, the seams are treated every day with brilliant green, the midwife does it, but at home a woman can ask for help with the treatment of her husband or one of her close female relatives.
If in the maternity hospital there are pronounced problems with the appearance of the seams, edema appears, signs of inflammation, physiotherapy methods, such as laser therapy, ultrasound, may be recommended. Pain medications may be recommended for the woman to relieve pain.
Sometimes circumstances develop in such a way that a good suture, which is not in doubt among the doctors in the hospital, unexpectedly diverges or becomes inflamed after discharge. The reason in most cases lies in the loss of vigilance by the puerpera - on discharge, some of the excess of happiness simply forget how to get into the car correctly, as a result the seams are damaged.
The road home must go for a happy mom in the back seat of a car in a reclining state with support on the hip on the healthy side. This must not be forgotten.
You shouldn't take a bath in the first month. You should confine yourself to showers and washing. If there is no bidet, then you need to wash yourself with running water from a jug or ladle. It is forbidden to wash in a basin with standing water.
The rate of suture healing depends on hemostasis. therefore the diet must necessarily contain foods that have a positive effect on blood density. It is not recommended to eat bakery products, flour, fatty and fried foods. Constipation should not be allowed, therefore, if it is difficult to empty the intestines, it is worth using an enema, microclysters or laxatives allowed for nursing mothers.
To make the scar more even, women are advised to use special means, for example, Kontraktubex gel, one month after the episiotomy. It has a moderate effect on collagen production and prevents the appearance of an ugly and rough colloidal scar.
Physical activity and sports
Every young mother wants to get in good shape as soon as possible after giving birth - to lose weight, get rid of a tummy, which does not immediately return to its former form. Therefore, the question of whether episiotomy affects sports is quite relevant for women in childbirth.
In general, the regimen of physical activity of women who have undergone such a surgical intervention is not much different from the regimen for ordinary women in childbirth, who did without perineal dissection.
Two weeks after giving birth, it is allowed to perform general strengthening gymnastics, which will include simple and calm exercises, without stretching the legs and squats. After two months, you can do fitness, swimming, yoga.
A postpartum bandage will help get rid of the abdomen, which will gently support the abdominal muscles.
Possible complications and consequences
Do not forget that episiotomy, with all its simplicity in execution, is still a surgical intervention, and therefore various complications are also not excluded after it.
Even in the generic process, the surgical incision can be aggravated by its subsequent spontaneous divergence up to the ascertaining of the fact of a 3-4 degree perineal rupture. In this case, not only ruptures of the skin can occur, but also ruptures of muscle tissue, as well as injuries of the intestinal sphincter, intestinal wall. In the most difficult situations, a vaginal-rectal fistula can form.
Consolidation at the seam is considered to be rather disturbing. The situation when a bump appeared on it must also be taken seriously. This may be a manifestation of improper joining of the wound edges, complicated by the healing of individual layers during layer-by-layer healing.
A suture that takes a long time to heal usually has one or more complications. The following symptoms are considered dangerous:
suppuration in the suture area;
green, gray, brown or yellow discharge from the genital tract or from the area of the postoperative suture;
putrid or fishy odor;
increased pain;
asymmetrical arrangement of the labia in relation to each other;
swelling of the seam, redness, if they persist for a long time;
high fever, feeling of weakness, chills, dizziness;
any problems with urination - soreness, difficulty passing urine;
violation of the integrity of the seam.
The seam divergence is manifested by the appearance of blood and blood discharge from the suture area. After removing the remnants of the threads, if they were not self-absorbing, the unhealed areas of the wound heal on their own, growing together by the method of secondary tension. Sometimes sutures are applied again if the first ones have parted, but only on the condition that healing has not occurred on most of the wound.
If you suspect a divergence of the stitches, you must definitely contact your gynecologist.
The wound can become inflamed due to contact with pathogenic or opportunistic bacteria, which live in large numbers in the intestines and perineum. The thought of possible inflammation should be allowed if the swelling and soreness in the suturing area does not disappear for a long time. The appearance of pus is a sure sign of infection. You also need to see a doctor at the antenatal clinic. In this case, the wound in the perineum is washed, the purulent contents are removed, if necessary, a drainage outlet is installed. Treatment requires the use of antibacterial agents, which is not always combined with breastfeeding.
Asymmetrical labia, a lump on the scar can be a manifestation of hematomas. If they are small, antibiotic treatment is also recommended, but if the hematomas are solid and deep, sometimes it is necessary to resort to surgical help to remove the hematomas.
Dyspareunia is one of the most talked about consequences of episiotomy in women. This term covers the pain that a woman can experience in the vagina during sexual intercourse. It is recommended for a woman to refrain from sexual intercourse up to one and a half months after giving birth with a dissection of the perineum. Then the relationship is not forbidden, but it may not be too pleasant for the woman herself.
A woman and her partner cannot have any effect on dyspareunia. Neither gels nor lubricants can significantly ease the discomfort. Correctly selected poses will help to reduce them somewhat. After six months, dyspareunia usually disappears.
Prevention
To avoid episiotomy during childbirth, it is recommended for a woman to perform exercises during pregnancy that increase the elasticity of the muscles of the perineum - Kegel exercises. Also, a light external massage with any neutral oil can help a woman - they massage the genitals for 5 minutes a day. The blood supply improves, the elasticity of the muscles increases.
During childbirth, a woman should strictly follow the instructions of an obstetrician or doctor and push only when there is an appropriate command.
Slower passage of the baby through the birth canal reduces the risk of rupture and the likely need for an episiotomy. Correct breathing should be used, it is taught in courses for expectant mothers.
Reviews
According to women, it is quite difficult to process a seam at home. It is especially difficult for women whose postpartum period fell on hot summer weather - the seam heals more difficult, requires constant "airing" and drying with green paint.
About a third of women complain of discomfort during sex. But they argue that the trouble is limited to the feeling of tension on the skin during frictions. Neither the excitement nor the orgasm of the perineal dissection has a great influence.
In the first weeks with seams in an intimate place, according to reviews, it is very scary to go to the toilet. Women are afraid to push, resulting in constipation.
In general, women who have undergone such an operation claim that dissection is better than rupture, although recovery from an episiotomy requires endurance, patience and strict adherence to all medical recommendations.
You will learn even more about episiotomy in the following video.
