Most are done in 2 ways:

1. Medio-lateral episiotomies are either a right or left side vaginal cut. This will engage more muscles, have deeper tissues involved, it take longer to heal.
2. Midline episiotomies are intended to be a cut straight down cut to the anus, but avoiding the anal sphincter and rectum.  This is less extensive and generally heals faster.

How much time needed to heal an episiotomy?

Typically episiotomies heal within about 10 to 14 days depending on the degree of the laceration and other variables.

A 1st-degree incision is just a slight cut that does not go all the way into the perineal muscle.  A 2nd-degree incision, a little deeper, is a common practice that cuts into the perineal muscle but not completely through the muscle.  A 3rd-degree incision actually cuts through this muscle, but not through the round sphincter muscle that is next to the anus. As the repair of injuries to this muscle may prevent fecal incontinence, it is of extreme importance to have a skilled and experienced physician such as Dr. Morice do the repair. A 4th-degree tear is a severe tear extending into the rectal tissue and possibly involving periurethral and labial areas.  It must be repaired appropriately to prevent a hole forming between the vagina and rectum.  If not done properly, the hole may convert to a fistula, where gas and feces can pass into the vagina. This can be repaired surgically even years later, however can be avoided by a good surgical repair by an experienced and skilled physician.

Long-lasting pain from an episiotomy may result from:

1. A hasty repair.
2. Not having sufficient visualization of the area repaired during the repair.
3. Excessive bleeding.
4. A moving target (a patient who constantly moves while doing the repair).

Outcomes after episiotomy include:

1. Severity of perineal laceration related to continued pain
2. Fecal or urinary incontinence.
3. Pelvic floor outcomes such as pelvic floor relaxation or prolapse

What measures should be taken during episiotomy?

1. Skillful repair in order to minimize pain and assist healing.
2. Postpartum inspection if any complaints to discover any other damaged areas of the vagina, cervix, perineum or anus.
3. For immediate reduction in pain, injection with numbing medicine in the area or IV administration of pain medicine as needed.
4. Kegel exercises to increase blood flow to the area may improve healing.

What are the risks and benefits associated with episiotomy?

The following risks are frequent;

1. If the area is not approximated with good surgical technique, the wound edges may not heal easily.
2. Tight suture healing leads to formation of granulation tissue, spotting, and pain in some cases.
3. A poorly healed end may be formed after an episiotomy, usually at the 6 o’clock position at the base of the vagina.  It causes severe pain with placing of a tampon, finger, or penis.
4. Significant increase in maternal blood loss is another risk.
5. A deep or extensive episiotomy may lead to intrapartum hemorrhage (excessive blood loss).
6. The risk of an anal sphincter injury is increased with the most commonly performed midline episiotomy.
7. The risk of poor wound healing is increased in a breast-feeding mother due to a decrease of estrogen levels in breast-feeding moms.
8. Vaginal discomfort and pain due to vaginal dryness caused by decreased estrogen levels in breast-feeding moms.
9. The amount of pain in the first several postpartum days is mostly underestimated.

Benefits include that episiotomies reduce anterior vaginal lacerations, which carry nominal morbidity.

Prevention of intracranial hemorrhage or intrapartum asphyxia, as well as birth trauma, is the main advantage of an episiotomy.

What is the greatest risk encountered during episiotomy?

Mediolateral and, to a minor degree, mid-line episiotomies considerably increase the quantity of blood loss at delivery.  Blood loss and possible anal sphincter damage are the greatest risks during episiotomy.  The most severe and underestimated is the anal sphincter damage, particularly with the midline episiotomy.  The rate of recurrence and severity varies from case to case. To determine the risk factors for anal sphincter injury during episiotomy, a great deal depends on variables such as vacuum assistance delivery of the newborn or delivery with forceps, as well as individual obstetric factors such as fetal weight, maternal pelvis and medical conditions, and the position of the fetus.