Description
Episiotomy is the most common obstetric procedure performed in the second stage of labor. [1] This is done to reduce the incidence of severe perineal tears (third and fourth degrees) during labor. making a controlled incision in the perineum to widen the vaginal opening Facilitating difficult labor results in easily repairable incisions compared to uncontrolled vaginal trauma. [2]
Episiotomy was first introduced in the 18th century as a preventive measure. During the first half of the 20th century, the rate of such interventions worldwide gradually increased. Furthermore, with the increasing trend of hospital deliveries and physician involvement in normal simple procedures The number of episiotomies during birth has increased. [3] In 1977, episiotomy rates in the United States were reported to vary from 9.8% of home births to 91% of primipara births in selected hospitals, and data from the British Department of Obstetrics and Gynecology in 1984 indicated a range of rates From 14% to 96% in primiparas and from 16% to 71% in multiparas. [4] Although episiotomy has become one of the most commonly performed surgical procedures, there is no conclusive scientific evidence for its effectiveness [3]. A review (Lede 1996) [5] showed that routine use of episiotomy reduces benefits; instead, it requires more surgical perineal repair, resulting in higher medical costs and more maternal discomfort. In addition, routine use can lead to poor muscle tone, fecal and/or urinary incontinence, and decreased sexual function [5].
A meta-analysis comparing conventional versus restrictive episiotomy showed that restrictive episiotomy was associated with less trauma to the posterior perineum, less need for sutures, and fewer healing-related complications. [3] World Health Organization (WHO) and other professionals Since the 1990s, society has recommended restrictions on routine episiotomy. The prevalence of episiotomy varies worldwide, with declining rates in developed countries but higher rates in less industrialized and developing countries. [6]
Indication
Episiotomy is recommended during difficult vaginal delivery to control and avoid potential perineal lacerations during delivery.
It is done in conditions such as:
- Complicated vaginal delivery (breech shoulder dystocia forceps vacuum) [7]
- Incision-related scarring in the genital area [7]
- Poor healing or 4th degree tear and fetal distress [7]
- Perineal tearing appears to be inevitable when perineal tissue is poorly elastic [8]
- Or based on the traditional view of perineal length research, Asian women have shorter perineal lengths than Caucasians, which increases their risk of tearing[8]
Opinions vary about the benefits of this procedure.
The benefits for the mother are:[9][3]
- Reduced likelihood of third-degree perineal tears
- Improve sexual function by preserving muscle relaxation in the pelvic floor and perineum
- Reduces the risk of fecal and urinary incontinence
- Easier to repair and heal better than a laceration as it is a straight and clean cut
Benefits for the baby:
It also suggests that episiotomy increases the APGAR score of the baby, reduces the prolongation of the second stage of labor, and may also reduce the possibility of fetal shoulder dystocia. In some cases, perineal stiffness can lead to fetal asphyxia, traumatic brain injury, cerebral hemorrhage, and mental retardation [9][3].
Types of Episiotomy
Episiotomy
Although seven different incisions are described in the literature, the two main types of episiotomy are median and mediolateral. [10] Episiotomy is divided into the following types [2]: midline midline medial lateral modified midline J-shaped anterior and radical (Schuchardt incision) [10]. Medial episiotomy is preferred in the UK and most European countries, whereas midline episiotomy is most common in North America. [4] There is controversy as to which method is best for episiotomy. Study shows medial episiotomy reduces occurrence of Third degree tear. A midline episiotomy results in a deeper perineal tear than a midline episiotomy. [11].
This procedure is done with scissors or a scalpel during the last part of the second stage of labor to widen the vaginal opening and repair it with sutures. [3]
Management
Patients should be monitored for pain and urinary incontinence in the postpartum period. The sutures used to close the episiotomy will reabsorb in the tissue within 6 to 8 weeks. [2] There is no specific cure, and personal hygiene is key to healing. [12]
Medical management
- Paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain. [13]
- Laxatives are recommended after perineal repair as stool can cause the wound to dehisce. Stool softeners (such as lactulose) should be titrated to keep stools soft and not loose and are prescribed 10 days postoperatively. [13]
- Broad-spectrum antibiotics are recommended in the immediate postoperative period to reduce the risk of infection and wound healing. [13]
- During the first 48 hours, the patient is positioned to avoid pressure on the episiotomy site and help reduce perineal edema. Lie on a flat bed and on your side while breastfeeding and avoid overuse of the sitting position. Patients should also be advised to avoid activities This may increase intra-abdominal pressure for the first 6 to 12 months after delivery. [13]
- The wound should be washed and patted dry after using the toilet. Patients should inspect the wound daily using a hand mirror for any signs of wound rupture. [13]
Physiotherapy Management
- Sitz baths can help relax the pelvic floor and relieve pain.
- Ice packs help reduce swelling and can cause pain relief. [2] RCTs have shown that a single 20-minute application of cryotherapy (placing a bag of crushed ice in the perineal area) is effective in relieving perineal pain in postpartum women following episiotomy vaginal delivery. [14]
- TENS is effective for pain relief. Low-frequency Tens (5 Hz and 100 µs pulses) and high-frequency Tens (100 Hz and 100 µs pulses) applied for 30 minutes near the episiotomy site were found to be safe and effective in reducing pain, according to randomized controlled trials. [15]
- The patient will be taught Kegel exercises to train the pelvic floor muscles.
Complications
Complications include[16][2]:
- bleeding
- infection
- Urinary retention especially prolonged dysuria following instrumented delivery which may lead to urinary tract infection [17]
- prolonged wound healing,
- dyspareunia,
- pelvic floor dysfunction
- urinary fistulas, and
- inappropriate wound scarring
According to a study evaluating early complications after episiotomy in Vietnamese women, sitting pain (30.4%) was the most prominent problem, pelvic disorders such as urinary incontinence (11.4%) urinary retention (10.8%) or flatulence incontinence (8.9%) ) )be observed A significant number of participants and sexual dysfunction (40.7%) generally had problems in the areas of desire (68.9%) and pain (58.5%). [16]
Contraindications
Episiotomy may increase the risk of third- and fourth-degree tears in parous women. [2]
Clinical Significance
Opinions vary regarding the suitability of episiotomy. Conventional wisdom holds that routine episiotomy reduces the pressure of the fetal head on the pelvic floor tissues and prevents third- or fourth-degree perineal lacerations. Also, it is considered easy to sew because Open wounds are smoother than spontaneous wounds [8]. However, published reports claim no such benefit of episiotomy, and extensive research underscores that routine use of episiotomy should be abandoned [18]. According to the American College of Obstetricians and Gynecologists (ACOG) guideline “The best available data do not support the casual or routine use of episiotomy. [19] In fact, episiotomy is inherently a birth trauma. It does not reduce the incidence of severe perineal lacerations. On the contrary, research shows it increases Risks of complications include perineal tearing, perineal pain (compared with no tearing), puerperal infection, postpartum hemorrhage and later dyspareunia. Therefore, clinicians must ensure that the benefits of intervention outweigh the risks during the decision-making process. visible In recent years, many obstetricians have begun to limit the use of episiotomy. [9][18][2]
References
- ↑ Langrová P, Vrublová Y. Relationship between episiotomy and prevalence of urinary incontinence in women 2-5 years after childbirth. small. 2014;90:98.
- ↑ Jump up to:2.0 2.1 2.2 2.3 2.4 2.5 2.6 Barjon K, Mahdy H. Episiotomy. InStatPearls [Internet] 2021 Jul 31. StatPearls Publishing.
- ↑ Jump up to:3.0 3.1 3.2 3.3 3.4 3.5 Carroli G. Mignini l. Episiotomy for vaginal birth (Cochrane Review). The Cochrane Collaboration and published in The Cochrane Library. 2009.
- ↑ Jump up to:4.0 4.1 Ruderman J, Carroli JC, Reid AJ, Murray MA. Episiotomy: Differences in practice between family physicians and obstetricians. Canadian Family Physician. 1992 Nov;38:2583.
- ↑ Jump up to:5.0 5.1 Lede RL, Belizán JM, Carroli G. Is routine use of episiotomy justified?. American journal of obstetrics and gynecology. 1996 May 1;174(5):1399-402.
- ↑ Woretaw E, Teshome M, Alene M. Episiotomy practice and associated factors among mothers who gave birth at public health facilities in Metema district, northwest Ethiopia. Reproductive Health. 2021 Dec;18(1):1-1.
- ↑ Jump up to:7.0 7.1 7.2 Kartal B, Kızılırmak A, Calpbinici P, Demir G. Retrospective analysis of episiotomy prevalence. Journal of the Turkish German Gynecological Association. 2017 Dec;18(4):190.
- ↑ Jump up to:8.0 8.1 8.2 Yang J, Bai H. Knowledge, attitude and experience of episiotomy practice among obstetricians and midwives: a cross-sectional study from China. BMJ open. 2021 Apr 1;11(4):e043596.
- ↑ Jump up to:9.0 9.1 9.2 Izuka EO, Dim CC, Chigbu CO, Obiora-Izuka CE. Prevalence and predictors of episiotomy among women at first birth in Enugu, south east Nigeria. Annals of medical and health sciences research. 2014;4(6):928-32.
- ↑ Jump up to:10.0 10.1 Kalis V, Laine K, De Leeuw JW, Ismail KM, Tincello DG. Classification of episiotomy: towards a standardisation of terminology. BJOG: an international journal of obstetrics & gynaecology. 2012 Apr;119(5):522-6.
- ↑ Sooklim R, Thinkhamrop J, Lumbiganon P, Prasertcharoensuk W, Pattamadilok J, Seekorn K, Chongsomchai C, Pitak P, Chansamak S. The outcomes of midline versus medio-lateral episiotomy. Reproductive Health. 2007 Dec;4(1):1-5.
- ↑ Faruel-Fosse H. Post-delivery care after episiotomy. Journal de Gynecologie, Obstetrique et Biologie de la Reproduction. 2006 Feb 1;35(1 Suppl):1S52-8.
- ↑ Jump up to:13.0 13.1 13.2 13.3 13.4 Goh R, Goh D, Ellepola H. Perineal tears-A review. Australian journal of general practice. 2018 Jan;47(1/2):35-8.
- ↑ Beleza AC, Ferreira CH, Driusso P, Dos Santos CB, Nakano AM. Effect of cryotherapy on relief of perineal pain after vaginal childbirth with episiotomy: a randomized and controlled clinical trial. Physiotherapy. 2017 Dec 1;103(4):453-8.
- ↑ Pitangui AC, Araújo RC, Bezerra MJ, Ribeiro CO, Nakano A. Low and high-frequency TENS in post-episiotomy pain relief: a randomized, double-blind clinical trial. Brazilian journal of physical therapy. 2014 Jan;18:72-8.
- ↑ Jump up to:16.0 16.1 Huy NV. Pelvic floor and sexual dysfunction after vaginal birth with episiotomy in vietnamese women. Sexual medicine. 2019 Dec 1;7(4):514-21.
- ↑ Khan NB, Anjum N, Hoodbhoy Z, Khoso R. Episiotomy and its complications: A cross sectional study in secondary care hospital.
- ↑ Jump up to:18.0 18.1 Živković K, Živković N, Župić T, Hodžić D, Mandić V, Orešković S. Effect of delivery and episiotomy on the emergence of urinary incontinence in women: review of literature. Acta Clinica Croatica. 2016 Dec 11;55(4).
- ↑ M Amorim M, Coutinho IC, Melo I, Katz L. Selective episiotomy vs. implementation of a non-episiotomy protocol: a randomized clinical trial-Reproductive Health-Vol. 14-ISBN: 1742-4755-p. 55.