Episiotomy

Episiotomy, is a surgical incision of the perineum and the posterior vaginal wall generally done by a midwife or obstetrician during second stage of labour to quickly enlarge the opening for the baby to pass through.
The incision, which can be done at a 90 degree angle from the vulva towards the anus or at an angle from the posterior end of the vulva (medio-lateral episiotomy), is performed under local anaesthetic and is sutured after delivery.

The use of a surgical incision of the perineum during childbirth was first described in 1742. It was introduced into the USA in the mid-19th Century. In 1920, at a meeting of the American Gynaecological Society in Chicago, USA, Joseph DeLee first publicly advocated the routine adoption of Medio lateral episiotomy for all deliveries in nulliparous women.

They became common practice during the 20th century, the main reason being to reduce the risk of severe perineal tears. 85% of women who have a vaginal delivery, will have some degree of perineal trauma, the majority of which will require suturing. By 1979, episiotomy was performed in approximately 63% of all deliveries in the USA, with higher rates among nulliparous women. In the UK in the same era, episiotomy rates ranged from 14 to 96% among nulliparous women and 16–71% among multiparous women. In recent years opposition to the use of episiotomy as a standard procedure has reduced the rate and its routine use is no longer recommended. Despite this, it is one of the most common medical procedures performed on women, though there is now considerable variation between countries. A review was published in JAMA in 2005. By this time the practice had declined in the USA from of over 60% to 30–35% of vaginal deliveries though the rate was as high as 99% in Eastern Europe.

In 2009, a Cochrane meta-analysis based on studies with over 5,000 women concluded that: “Restrictive episiotomy policies appear to have a number of benefits compared to policies based on routine episiotomy. There is less posterior perineal trauma, less suturing and fewer complications, no difference for most pain measures and severe vaginal or perineal trauma, but there was an increased risk of anterior perineal trauma with restrictive episiotomy”.

Levine EM et al in 2015 noted – The average episiotomy rate steadily declined from 1996-1998, 2003-2005 and 2012-2014. The rate of advanced perineal lacerations coincidentally rose during these time period comparisons. Levine EM, Bannon K, Fernandez CM, Locher S (2015) Impact of Episiotomy at Vaginal Delivery. J Preg Child Health 2:181.

It has been suggested that perineal massage during the second stage of labour can reduce the need for episiotomy.
Infrared lamp therapy is an effective method of treatment on healing of episiotomy wound among post-natal mothers.
In a study by Sabzaligol M et al. Aloe Vera gel not only relieved the pain but also increased the rate of wound healing in episiotomy.

References
1. Practice Bulletin No. 165: Prevention and Management of Obstetric Lacerations at Vaginal Delivery”. Obstetrics and Gynecology. 128 (1): e1–e15. July 2016.
2. Chang,S-R; Chen,K-H; Lin,H-H; Chao,Y-M Y.; Lai,Y-H (April 2011). “Comparison of the effects of episiotomy and no episiotomy on pain, urinary incontinence, and sexual function 3 months postpartum: A prospective follow-up study”. International Journal of Nursing Studies. 48 (4): 409–418.
3. Graham,I.D.; Carroli,G.; Davies,C.; Medves,J.M. (August 2005). “Episiotomy Rates Around the World: An Update”. Birth. 32 (3): 219–223.
4. Carroli, G, Mignini, L. “Episiotomy for vaginal birth”. Cochrane Database Syst Rev. 2009 Jan 21; (1):
5. Jiang, Hong; Qian, Xu; Carroli, Guillermo; Garner, Paul; Jiang, Hong (2017). “Selective versus routine use of episiotomy for vaginal birth”.
6. American College of Obstetricians-Gynecologists (2006). “ACOG Practice Bulletin. Episiotomy. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 71, April 2006” Obstetrics & Gynecology. 107 (4): 956–62
7. Levine EM, Bannon K, Fernandez CM, Locher S (2015) Impact of Episiotomy at Vaginal Delivery. J Preg Child Health 2:181.
8. Sabzaligol M, Safari N, Baghcjeghi N, Latifi M, Koohestani H R, Bekhradi R, et al . The effect of Aloevera gel on prineal pain & wound healing after episiotomy. cmja. 2014; 4 (2) :766-775