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15 Things To Know About Episiotomies

We all know that every pregnancy and birth is different and that for a great many mothers, birth is rarely easy or straightforward. It seems that everyone has an opinion on what women ‘should’ be doing and it seems that people have no boundaries when it comes to asking about another woman's birth story. It’s also not uncommon for people to simply ask you ‘did you get cut or tear?’ If you’re having a v-birth, it seems that one of the biggest decisions you will have to make is whether to have an episiotomy or not and risk a natural tear - just typing this makes me squirm!

But, first things first, what are we actually talking about? According to the Mayo Clinic , an episiotomy is an incision, or cut, made in the perineum (which is the birth canal) during the second stage of labor. It can be performed by a midwife or an obstetrician and is used to enlarge the opening to allow the baby to pass through and may speed up delivery or be used when the baby is in distress and needs to be born quickly.

The cut is repaired with stitches after the birth. Whilst a generation ago these were really common so it is likely that your mother and grandmother had this procedure done as a matter of routine, it is now far less common and lots of experts believe that in most cases, it is unnecessary. And that’s probably a good thing because there are so many things that can go wrong with an episiotomy in the immediate aftermath of birth and surprisingly, sometimes the symptoms don’t even appear until later in life.

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15 Persistent Risk Of Infection

Not surprisingly, infection is one of the biggest risks for a woman after she has had an episiotomy. Not only is the perineum a particularly delicate and sensitive area, add to the mix a hospital stay where even the cleanest of hospitals have germs everywhere and the odds of getting an infection increase exponentially. As your body is recovering from giving birth, it can be difficult to identify which (if any) pains are normal and what might indicate that something more serious is going on.

The National Health Service in the United Kingdom lists some signs to look out for an infection; they include red and swollen skin, persistent pain, discharge of pus or liquid or an unusual smell. Even though it can be embarrassing to raise this issue with your nurse, doctor or healthcare practitioner, it’s really important that if you suspect something is wrong, you speak up to prevent the infection from getting any worse.

14  Excessive Blood Loss

It is normal to experience some degree of bleeding after giving birth; however it is important that you and your medical team monitor your blood loss to ensure that you do not experience either a primary or secondary post partum haemorrhage. The Royal College of Obstetricians and Gynaecologists in the United Kingdom suggests that this means monitoring for up to twelve weeks after birth. Although rare, a heavy bleed or hemorrhage can pose serious problems and even be life threatening, and having an episiotomy can increase the chances of significant blood loss immediately after giving birth, especially when combined with other risk factors including induction of labor, retained placenta or having a big baby of around nine pounds or more.

The risk is further heightened if the episiotomy is performed incorrectly or in fact does not prevent a tear, but actually makes the opening much larger than needed or tears into the anus.

13 Tearing All The Way

An episiotomy is a precise procedure in a very delicate area and there is always the potential for things to go wrong, including a cut which actually tears the rectum. The perineum is the muscle structure between the v-opening and the anus which contains all of the connective tissue and in some cases the procedure can tear all the way to the rectum causing significant problems for continence. This sometimes requires extensive follow up surgeries in an effort to repair the damage, and in the worst of cases, the damage can never be reversed resulting in a lifetime of problems.

In addition to a difficulty in controlling bowel movements, known as anal incontinence, a rectal tear can even inhibit a woman’s ability to control gas, which, apart from being uncomfortable, can also be embarrassing, and cause emotional problems for women.

12 Lifetime Of Incontinence

For lots of women, a common but unwelcome side effect of having children is some degree of urinary incontinence. This can begin in pregnancy as the baby grows, the uterus enlarges and causes pressure on the bladder sometimes making coughing, sneezing or laughing risky activities! However, we now know that if a woman has an episiotomy during childbirth, she is more likely to have anal incontinence, in addition to urinary incontinence, as a direct result of the damage caused to the muscles and ligaments of the perineum when it is cut.

Whilst the increased risk is well documented, there is currently no way of knowing if, how or to what extent the nerves and muscles are damaged which could lead to incontinence. Aside from being an inconvenient and potentially embarrassing issue, this could cause more extensive and longer term health issues both physically and psychologically.

11 Repair Surgery May Be Needed

If there is one thing worse than having an episiotomy, it has having at least one subsequent repair surgery but perhaps more, which often involve re-cutting the same site, re-stitching and then trying to avoid infection whilst recovering and hoping that this time, it will work - and all while having a new baby or young child to care for. As there is no way of being sure whether the surgery has ‘worked’ until after recovery, it is possible that a woman may have to endure a number of operations and sadly, may never regain continence, feeling or not experience pain ever again.

There are a few reasons why a woman may need to undergo repair including a failed first attempt, ripped stitches during healing or scar tissue which has healed in a manner which makes every day activities uncomfortable or painful for the woman. There are always risks with surgery, but having to undergo several procedures at the same site increase a multitude of risks.

10 Living With Pain

If you’ve had an episiotomy and managed to avoid an infection, ripped stitches, excessive bleeding and further repair surgery, you actually might not be off the hook just yet. Some women have reported living with the after effects and pain of this procedure for years to come, and some, the rest of their lives. During recovery, women may even find the simple act of sitting down painful and many report fear of resuming sexual intercourse due to pain and discomfort.

Anecdotally, woman have shared that sometimes if the wound has not healed properly or changed the shape of their perineum, they can continue to experience pain and unpleasantness when having their period as the consequences of a birth intervention. One mother even shared that her scar was still sore almost three years later, sometimes still bled and had impacted so much on her marriage that it left her feeling depressed and isolated. Other long term side effects of having an episiotomy include ongoing back pain and abdominal pain impacting on a woman’s ability to live her life freely.

9 Side Effects Of Antibiotics

If the site of the procedure becomes infected, which is indeed common, a woman will most likely be placed on antibiotics which can seriously interfere with her health and potentially that of her new baby if she is breastfeeding. In addition to the wound becoming infected, a woman who has just given birth is at increased risk of developing a urinary tract infection and also hospital superbugs like staphylococcus which can be particularly serious and have long term implications.

In the period immediately after birth, a woman’s body is recovering from the intense period of pregnancy and the physically demanding job of childbirth and is at an increased risk of infection, especially if she has had any interventions such an episiotomy. Some people can have severe reactions to antibiotics such as vomiting, diarrhea, cramping, a rash or even an allergic reaction. If a new mother is breastfeeding her baby, the baby may also experience some of these symptoms.

8 Life Long Scar Tissue

In many cases, it is the scar tissue which forms as the wound is healing that can be the cause of a great deal of the pain and discomfort that women experience. This scar tissue can become hard and painful and cause problems such as painful intercourse and difficulty with toileting. In some cases, the scar tissue can cause the v-opening to become tighter than it was before giving birth but rather being a bonus, this can actually cause health issues and may even make subsequent v-births difficult.

Women’s Health and sports medicine physical therapist Dr Ginger Garner advises that women who are experiencing pain as a result of their perianal scar could try to alleviate the problem with a massage to loosen the scar tissue and try to regain function.

7 Stitches Can Be Torn Off

One of the most common problems to arise after having an episiotomy during childbirth is that of ripped stitches and yes, it is as painful and as potentially serious as it sounds. In the period immediately after childbirth, any woman, regardless of any birth interventions, can expect to experience pain, swelling and bruising. This is further complicated by a procedure such as a cut and subsequent repair to the affected area. A case of torn stitches may increase the risk of infection as the wound is open and if untreated, could have implications for long term health in terms of incontinence, menstrual and sexual health.

And the scary thing is, is that it is so easy to tear stitches in the aftermath of birth just doing regular activities like going to the toilet, moving suddenly and even bending to pick up or put down your new baby. Although it is a relatively simple procedure to repair the stitches, some mothers may not even know that they have torn a stitch and have to act on ‘gut feeling’ or attempting to investigate the wound for themselves, which is absolutely easier said than done.

6 It Can Tear Anyway

To cut or tear? This is perhaps the single biggest question that women who are giving birth need to ask themselves at some point. In the past, there has been a commonly held belief that it is better, perhaps safer, for a doctor or midwife perform a planned, controlled incision rather than experience an opportunistic tear, which can be unpredictable and indeed severe.

But having an episiotomy does not necessarily guarantee that a woman won't experience a tear in addition to the cut. Once the integrity of the perineum is compromised by an incision, it is actually more likely to tear further, therefore increasing the risk of complications and perhaps even extending as far as the rectum. This area is already quite fragile in the first place, so it is really something you want to risk?

5 It Can Be Performed Without Consent

The American Journal of Obstetrics and Gynecology reported that the rate of episiotomies performed is, thankfully, on the decline but that more than half of the women who gave birth in 1979 would have experienced this procedure as a matter of necessity. In 2017, times have changed and women are now more educated and empowered about their choices in the birthing suite and in most cases would need to give consent to have this procedure performed.

In an emergency situation, a medical practitioner may have to perform an episiotomy in the best interests of the baby and the mother even if it was not in the birth plan and is against the mother’s wishes. There have also been reports of women who’s birth partner, husband or even in one case, mother, gave permission for this to take place instead of the birthing mother.

4 The Cut Can Go Wrong

There is risk with any medical procedure and that should not be discounted even if it is something recommended by your doctor or something he or she has done a thousand times before. Even if you are planning an intervention free birth, sometimes things can go wrong or a situation may arise in which you need a procedure for your health or one that is best for your child.

Although an episiotomy is generally considered a routine medical method, it is not without risk and women need to be aware of the risk. If it is performed too quickly, cut too far, in the wrong direction or not repaired properly, there are serious implications for the birthing mother. It could lead to a greater likelihood of having to undergo subsequent repair surgeries and lead to a longer period of healing and recovery and of course, many of the other issues we’ve discussed in this post.

3 Symptoms Get Worse Later In Life

Even if a woman feels that her scar has healed quite well and she has managed to ‘escape’ her episiotomy fairly unscathed, the process of aging may mean that she will experience symptoms and complications later in life. As we age, hormonal changes and muscle weakness can mean that a previously stable condition can deteriorate and cause problems they haven’t experienced before either constantly and in an acute state or intermittently impacting on their life.

These symptoms can be painful and embarrassing for women to acknowledge and talk to their health professional about, and the nature of this condition means that it is difficult for a doctor to be able to tell what is ‘wrong’ from looking at the physical site and therefore relies on the testimony of the woman which can be a frustrating experience.

2 Increased Pressure On Moms

Sometimes it can feel like birth is a competitive sport and some people choose to keep things to themselves in case they would be judged by other mothers. One of the most hot topics in any mothers' groups is sharing birth stories and at times, it can feel like a competition of war stories or a battle to prove who had the most natural and intervention-free birth. The pressure on new mothers is intense in the first place and in addition to this, women may not feel comfortable sharing their health issues associated with the recovery and repair.

All too often mothers feel pressure to have ‘the perfect birth’ which we all know, is not necessarily possible and that as long as the mother and baby are healthy in the end, that is all that matters. Mothers can feel pressure from all sides – if the doctor or midwife would like to perform one, they may feel pressured or intimidated into making a decision, or consenting to a procedure that they otherwise would not.

1 Overcoming Body Image Issues

It has been well documented that a woman’s body undergoes radical changes and transformations during pregnancy and after childbirth, and many new mothers wonder if what is happening to them is ‘normal’ or whether their body will ever be the same again. The internet is chock full of mothers reaching out on message boards, forums and discussion threads to other mothers seeking advice and reassurance.

This relationship between mothers and their new, postpartum bodies is further complicated when they have experienced a surgical intervention during birth which has left them ‘feeling’ different. This can result in mothers feeling unhappy with how they look or feel ‘down there’, leading to low self esteem and possibly even depression and anxiety. It can further cause problems in their romantic relationships particularly with intimacy if the body they are left with is drastically different to the one prior to childbirth or don’t feel comfortable during sexual intercourse.

Sources: Mayoclinic.org, rcog.org.uk, obgyn.ucla.edu, Gingergarner.com, Bottomlineinc.com

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