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Do some health professionals use episiotomies more than others?

Yes and no! Because obstetricians perform ventouse extractions and forcep deliveries it is assumed that doctors cut more episiotomies than midwives. Research does not always bear this out though! Many obstetricians are proud of getting an intact perineum, with some even using forceps without episiotomy wherever possible. Great variance is noted also between health professionals depending on when and where the health professional was trained. I trained at a fairly radical midwifery school, where the hospital computer system allowed a print out of how many episiotomies were performed by whom each year – it made for interesting reading! One highly respected midwifery sister had an episiotomy rate of 93%. In 21 years I have performed only 19 episiotomies and birthed over 2000 babies. Generally, midwives do not like having to do episiotomies. We do our own suturing usually and that takes time – especially at 0300 hrs!

How can I avoid an episiotomy or stitches?

There are no hard and fast rules here. Sometimes it depends on the position of baby’s head – and how you are built. The research is not absolutely clear about the use of heat and/or water, or handling of the perineum during second stage. Some studies show that immersion in warm water reduces lacerations, whereas other studies show the opposite. Most women tell me that the hot flannels feel good if they are not in water. I believe that the tissue appears to have greater flexibility after application of hot flannels. Midwives are all taught ‘not to poke the perineum’. A ‘hands off’ or ‘hands on’ the perineum did not prove either was hugely better. (Personally, I tend to leave hands off as much as possible and get a good intact perineum rate.) Working with your caregiver during the second stage helps. She will tell you when and how to push, when to pant and not push. What has been shown to help in studies is the use of perineal massage from week 34 to term. Ask your midwife how to do this or look in any active birth book. Midwife’s tip – use a vit E capsule or wheatgerm oil to massage in. Vit E is great for old scar tissue or damaged skin. The other vital thing is your positioning during birth. GET OFF YOUR BACK OR BOTTOM! If you are sitting on any part of the skin of your bottom then there is not as much tissue available to stretch up with the fetal head, you are more liable to sustain tears then. Be active – it’s in your interests to be so. Kneeling, squatting or lying on your side with the upper leg supported are all good positions to avoid tears.

What is the difference between a laceration and an episiotomy?

There is little difference. A large laceration (tear) may extend into difficult places to suture and be extremely uncomfortable, just as an episiotomy may be uncomfortable. Episiotomies are classified as second degree incisions, meaning that they involve the skin and the muscle layer beneath. Lacerations are classified as to first (skin only), second (skin and the muscle layer) or third degree (involving anal sphincter tissue). Where the anal sphincter is completely torn through, with the laceration going into bowel tissue it is classified as a fourth degree tear. Note - I have seen more third and fourth degree tears from too small an episiotomy extending than from anything else. A laceration can therefore be very small – just a skin split, to multiple, deep and difficult to suture. Obstetricians appear to prefer episiotomy repair as the edges are straight and tend to be controlled. Retrospectively, it is viewed that difficult lacerations may possibly have been be prevented by the use of an episiotomy sometimes.

Aiding recovery

• Take arnica post birth to aid the bruising.

• Use icepacks for 5 minutes at a time to reduce swelling.

• Use the shower head on cold to run over your bottom after your shower.

• Keep the sanitary pads in the freezer.

• Take regular analgesia (Panadol).

• Wear cotton pants only.

• Try to leave everything off and get air to the perineum (lay on an old towel for at least half an hour daily, preferably in sunlight).

• Use a cool hairdryer to dry after showering if you cannot bear to pat dry. Pump bottles with tepid water and a capful of Hypercal solution to rinse off after passing urine feels good too.

• A dob of Vaseline over labial tears stops urine from stinging when you wee and prevents itchiness on the skin surface as you heal.

• Keeping clean, dry, and regular changing of sanitary pads is good.

• Breast feed lying down.

• Pelvic floor muscle exercises reduce swelling and pain, increases blood supply to the damaged area and aids healing. DO THEM!!!

• Eat healthily. Prevent constipation - plenty of water and kiwi fruit.

• REST is healing. Tell the visitors that sleep IS more important!

Stitches: To suture or not to suture - that is the question...

There is considerable evidence emerging that women feel less pain, use less analgesia, feel better in themselves about having birth trauma, resume love making and have less infection in the area when a tear is left to heal up on its own. The place most women tear is in the midline area of the perineum, this area naturally gets pushed back together by our buttocks and has a poor nerve supply. If your caregiver advises that sutures may not be required, she would first assess the depth and area of the tear. If there is bleeding it needs to be sutured.  If anything ‘structural’ has been damaged, suturing may be advised. Trials in the UK consistently found better results when deeper layers had been sutured to prevent blood loss and structural damage, but the skin layer left open to heal over in its own time. Women were given the choice of closure of the skin or not, and shown the damaged area with a mirror first, before deciding. Another option (but rarely used in NZ) is the use of surgical glue, ‘Histoacryl’. This is a special type of supaglue! Women report a high level of satisfaction where Histoacryl has been used. It is quick and comfortable and is associated with much less swelling.

FAQ

Are my stitches dissolvable?

We would never be so cruel to use anything else! Different suture materials take from 12 to 35 days or more to lose tensile strength and break down. You may see bits of stitches on the shower floor for several weeks afterwards.

But my friend had to have stitches removed – will I?

Women sometimes complain that stitches are pulling as the suture material dries out. If the area has healed – about 5 days – then snipping through the stitch reduces the  tension.

Are all stitches underneath the skin surface now days?

Most caregivers suture the perineal skin surface with all knots and stitches below the skin surface as it is believed to be more comfortable and to reduce infection. The back wall of the vagina usually has sutures on it’s surface and a ‘de-tensioning’ knot left just inside (where you don’t feel it) so we can snip through if it is too tight after a few days.

What is the average number of stitches used?

Please ask about the quality, not the quantity! Due to different surgical techniques that are taught, I can use just a single continuous stitch if I want to, so if you want to skite and say, “Only 1 stitch”, feel free to do so!

Final Words

Debrief with your caregiver if your perineum has been a trial to you the first time, ask her advice about next time.

Remember the majority of second time around mums get away without having any stitches, so don’t let a painful experience the first time put you off having another baby.

Ask for a referral to an obstetrician (free if less than 6 weeks after birth) where poor healing or infection has occurred. Often extra scar tissue or granulation tissue can be fixed without necessarily having an operation and give you swift relief.