What is an episiotomy?

An episiotomy is an incision through the vaginal wall and the perineum (the area between the thighs, extending from
the vaginal opening to the anus) to enlarge the vaginal opening and facilitate childbirth.
During a vaginal birth, the health care provider will assist the fetus' head and chin out of the vagina when it becomes
visible. Once the head is out of the vagina, the shoulders are eased out, followed by the rest of the body.
In some cases, the vaginal opening does not stretch enough to accommodate the fetus. In this case, an episiotomy
may be done to help enlarge the opening and deliver the fetus. The episiotomy is usually done when the fetal head
has stretched the vaginal opening to several centimeters during a contraction. Although episiotomy was a very
common procedure in the past, more recent studies have found that routine or preventive use of episiotomy does not
benefit the health of mother or baby. The American College of Obstetricians and Gynecologists (ACOG) no longer
recommends performing an episiotomy on a routine basis. Discuss with your health care provider the best treatment
option for you and your baby.
An episiotomy may be classified into two types:

Midline or median. This refers to a vertical incision that is made from the
lower opening of the vagina toward the rectum. This type of episiotomy usually
heals well but may be more likely to tear and extend into the rectal area, called
a third or fourth degree laceration.
Mediolateral . This refers to an incision that is made at a 45-degree angle
from the lower opening of the vagina to either side. This type of episiotomy does
not tend to tear or extend, but is associated with greater blood loss and may not
heal as well.

After the delivery of the baby, the mother may be asked to continue to push during the next few uterine contractions
to deliver the placenta. Once the placenta is delivered, the episiotomy incision is sutured. If a mother does not have
regional anesthesia such as an epidural, a local anesthesia may be injected in the perineum to numb the area for
repair of a tear or episiotomy after delivery.
Other related procedures that may be used during labor and birth include caesarean delivery and external and
internal fetal monitoring. Please see these procedures for additional information.

Reasons for the procedure

Not all women will require an episiotomy, and assisting the tissues to stretch naturally may help reduce the need for
this procedure. If an episiotomy is not done, tearing of the perineal tissues may or may not occur. An episiotomy may
be used to assist in the treatment of the following conditions:

Fetal distress

Complicated birth such as a breech presentation (bottom or feet first) or shoulder dystocia
(when the fetal head has been delivered but the shoulders are trapped)

Prolonged second stage (pushing stage of labor)

Forceps or vacuum delivery

Large baby

Preterm baby
There may be other reasons for your health care provider to recommend an episiotomy.

Risks of the procedure

As with any surgical procedure, complications may occur. Some possible complications of an episiotomy may include,
but are not limited to, the following:

Bleeding

Tearing past the incision into the rectal tissues and anal sphincter

Perineal pain

Infection

Perineal hematoma (collection of blood in the perineal tissues)

Pain during sexual intercourse

Peoples who are allergic to or sensitive to medications or latex should notify their health care provider.

If the birth of the baby occurs too rapidly, an episiotomy may not be performed.
There may be other risks depending upon your specific medical condition. Be sure to discuss any concerns with
your health care provider prior to the delivery.

Before the procedure

Your physician/midwife will explain the procedure to you and offer you the opportunity to ask
any questions that you might have about the procedure.

You will be asked to sign a consent form that gives your permission to do the procedure. Read
the form carefully and ask questions if something is not clear. The consent form for an episiotomy
may be included as part of the general consent for your delivery.

Notify your health care provider if you are sensitive to or are allergic to any medications,
iodine, latex, tape, and anesthetic agents (local and general).

Notify your health care provider of all medications (prescribed and over-the-counter) and
herbal supplements that you are taking.

Notify your health care provider if you have a history of bleeding disorders or if you are taking
any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood
clotting. It may be necessary for you to stop these medications prior to the procedure.
Based upon your medical condition, your health care provider may request other specific preparation.

During the procedure

An episiotomy may be performed as part of a vaginal birth. The procedure and the type of episiotomy may vary
depending on your condition and your health care provider's practices.
Generally, an episiotomy follows this process:

You will be positioned on a labor bed, with your feet and legs supported for the birth.

If you have not been given any labor or delivery anesthesia, a local anesthetic may be injected
into the perineal skin and muscle to numb the tissues before the incision. If epidural anesthesia is
used, you will have no feeling from your waist down and no additional anesthesia will be needed for
the episiotomy.

During the second stage of labor (pushing stage), as the fetal head stretches the vaginal
opening, the physician/midwife will use special scissors or a scalpel to make the episiotomy
incision.

The baby will be delivered.

The placenta will be delivered.

The episiotomy incision will be examined for any further tearing.

A local anesthetic may be injected into the perineal skin and muscle to numb the tissues.

The perineal tissues and muscle will be repaired using sutures, which will dissolve over time.

After the procedure

After an episiotomy, you may experience incisional pain. An ice pack may be applied immediately after birth to help
reduce swelling and pain. During your stay in the hospital and at home after your babys birth, sitz baths (warm or
cold shallow baths) may relieve soreness and speed healing. Medicated creams or local anesthetic sprays applied to
your perineum may also be helpful.
You may take a pain reliever for soreness as recommended by your physician. Be sure to take only recommended
medications.
You should keep the incision clean and dry, using the cleansing method recommended by your health care provider
after urination and bowel movements. If bowel movements are painful, stool softeners recommended by your health
care provider may be helpful.
You should not douche, use tampons, or have intercourse until the time instructed by your physician/midwife. You
may also have other restrictions on your activity, including no strenuous activity or heavy lifting.
You may resume your normal diet unless your health care provider advises you differently.
Your health care provider will advise you when to return for further treatment or care.
Notify your health care provider if you have any of the following:

Bleeding from the episiotomy site

Foul-smelling drainage from the vagina

Fever and/or chills

Severe perineal pain

Your health care provider may give you additional or alternate instructions after the procedure, depending on your
particular situation.

What happens when labor begins?

Signs That You Are Approaching Labor
Sign

What It is

When It
Happens

Feeling as if the
baby has dropped
lower

Lightening. This is known as the baby

dropping. The babys head has settled
deep into your pelvis.

From a few weeks

to a few hours
before labor begins

Increase in vaginal
discharge (clear,
pink, or slightly
bloody)

Show. A thick mucus plug has

accumulated at the cervix during
pregnancy. When the cervix begins to
dilate, the plug is pushed into the vagina.

Several days
before labor begins
or at the onset of
labor

As labor begins, the cervix opens (dilates). The uterus, which contains muscle, contracts at regular
intervals. When it contracts, the abdomen becomes hard. Between the contractions, the uterus relaxes
and becomes soft. Up to the start of labor and during early labor, the baby will continue to move.
Certain changes also may signal that labor is beginning. You may or may not notice some of them
before labor begins:

What is false labor?

Your uterus may contract off and on before "true" labor begins. These irregular contractions are called
false labor or Braxton Hicks contractions. They are normal but can be painful at times. You might
notice them more at the end of the day.

How can I tell the difference between true labor and false labor?
Differences Between False Labor and True Labor
Type of
Change

False Labor

True Labor

Timing of
contractions

Often are irregular and do not

get closer together (called
Braxton Hicks contractions)

Come at regular intervals and, as

time goes on, get closer together.
Each lasts about 3070 seconds.

Change with
movement

Contractions may stop when you Contractions continue, despite

walk or rest, or may even stop
movement
with a change of position

Strength of
contractions

Usually weak and do not get

much stronger (may be strong
and then weak)

Increase in strength steadily

Pain of
contractions

Usually felt only in the front

Usually starts in the back and

moves to the front

Usually, false labor contractions are less regular and not as strong as true labor. Sometimes the only
way to tell the difference is by having a vaginal exam to look for changes in your cervix that signal the
onset of labor.
One good way to tell the difference is to time the contractions. Note how long it is from the start of one
contraction to the start of the next one. Keep a record for an hour. It may be hard to time labor pains
accurately if the contractions are slight. Listed as follows are some differences between true labor and
false labor:

What is a uterine contraction?

To completely understand what a contraction is, it is important to understand what the
uterus is! The uterus is the large muscle. A contraction of any muscle is a shortening
or reduction in size, in connection with muscles contraction implies shortening
and/or development of tension.
You have experienced uterine contractions beforemenstrual cramps are a uterine
contraction. Unlike menstrual cramps that for some women seem to continue for periods of
time without a break, labor contractions will come and go and have obvious breaks in
between.

It is normal for your uterus to contract during your pregnancy. The muscle layers of the
uterus tighten irregularly from the early weeks and throughout pregnancy. You may feel
them as early as four months but many women don't notice them until seven or eight
months. Usually, these contractions are not painful. You may notice more contractions when
you first lie down, after orgasm, if you have a full bladder, or after you walk up and down
stairs. These are normal contractions or Braxton Hicks contractions. If these contractions
become regular (i.e., every 10-12 minutes for at least one hour, they may be preterm labor
contractions which can cause the cervix to open.
Learning how to time the contractions is an important part of learning about labor and birth:
The duration of the uterine contraction is the time from the beginning of one contraction to
the end of that same contraction. During labor, the duration of the contractions will start
out short (25 to 35 seconds long) and ultimately get to 70 90 seconds long. With this
progression from shorter contractions to longer contractions, a mother can figure out if this
is real labor, or simply Braxton Hicks contractions. Braxton Hicks contractions remain
irregular and do not get progressively longer as time passes.
The frequency of the contractions is measured from the beginning of one contraction to the
beginning of the very next contraction. This not only includes the duration of one
contraction, but also the rest period between the two. So if you have a contraction at 8
pm and it lasts for 60 seconds, and then you have another contraction at 8:15 pm, the
contractions have a duration of 60 seconds and a frequency of 15 minutes.
The intensity of the contractions also changes as labor progresses. Early labor contractions
are often described as mild menstrual cramps. Contractions in later labor, have been
described by some stand-up comedians as feeling like your lower lip was stretched up over
your head! While this analogy is humorous, it is true that with normal labor, the intensity of
the contractions does increase, and this is a good sign that labor is progressing well.
This information can be helpful for you and your caregiver to decide the healthy next step if
you are in labor.

Tears are classified into four categories:[3][4]

First-degree tear: laceration is limited to the fourchette and superficial perineal skin or
vaginal mucosa

Second-degree tear: laceration extends beyond fourchette, perineal skin and vaginal
mucosa to perineal muscles and fascia, but not the anal sphincter

Third-degree tear: fourchette, perineal skin, vaginal mucosa, muscles, and anal sphincter are
torn; third-degree tears may be further subdivided into three subcategories: [5]

3a: partial tear of the external anal sphincter involving less than 50% thickness

3b: greater than 50% tear of the external anal sphincter

3c: internal sphincter is torn

Fourth-degree tear: fourchette, perineal skin, vaginal mucosa, muscles, anal sphincter, and
rectal mucosa are torn

Types of Fibroids
Different fibroids develop in different locations in and on the uterus.
Intramural Fibroids

These types appear within the lining of the uterus (endometrium). Intramural
fibroids may grow larger and actually stretch your womb. According to the U.S.
Health and Human Services Office on Womens Health, they are the most common
type of fibroid and are found in about 70 percent of women of childbearing age
(HHS, 2008).
Subserosal Fibroids
Subserosal fibroids form on the outside of your uterus, which is called the serosa.
They may grow large enough to make your womb appear bigger on one side.
Pedunculated Fibroids
When subserosal tumors develop a stem (a slender base that supports the tumor),
they become pedunculated fibroids.
Submucosal Fibroids
These types of tumors develop in the inner lining (myometrium) of your uterus.
Submucosal tumors are not as common as other types, but when they do develop,
they may cause heavy menstrual bleeding and trouble conceiving.
Part 3 of 8: Causes
What Causes Fibroids?
It is unclear why fibroids develop, but several factors may influence their formation.
Hormones
Estrogen and progesterone are the hormones produced by the ovaries. They cause
the uterine lining to regenerate during each menstrual cycle and may stimulate the
growth of fibroids.
Family History
Fibroids may run in the family. If your mother, sister, or grandmother has a history
of this condition, you may develop it as well.
Pregnancy
Pregnancy increases the production of estrogen and progesterone in your body.
Fibroids may develop and grow rapidly while you are pregnant.
Part 4 of 8: Risk Factors
Who Is at Risk for Fibroids?
Women are at greater risk for developing fibroids if they have one or more of the
following risk factors:
pregnancy
a family history of fibroids
being over the age of 30
being of African American descent
having a high body weight
Part 5 of 8: Symptoms
What Are the Symptoms of Fibroids?
Your symptoms will depend on the location and size of the tumor(s) and how
many tumors you have. If your tumor is very small, or if you are going
through menopause, you may not have any symptoms. Fibroids may shrink
during and after menopause.
Symptoms of fibroids may include:
heavy bleeding between or during your periods that includes blood clots
pain in the pelvis and/or lower back
increased menstrual cramping
increased urination

 pain during intercourse

menstruation that lasts longer than usual
pressure or fullness in your lower abdomen
swelling or enlargement of the abdomen
Part 6 of 8: Diagnosis
How Are Fibroids Diagnosed?
You will need to see a gynecologist, who will do a pelvic exam. This exam is used to
check the condition, size, and shape of your uterus. You may also need other tests:
Ultrasound
An ultrasound uses high-frequency sound waves to produce images of your uterus
on a screen. This will allow your doctor to see its internal structures and any fibroids
present. A transvaginal ultrasound, in which the ultrasound wand (transducer) is
inserted into the vagina, may provide clearer pictures since it is closer to the uterus
during this procedure.
Pelvic MRI
This in-depth imaging testing produces pictures of your uterus, ovaries, and other
pelvic organs.
Part 7 of 8: Treatment
How Are Fibroids Treated?
Your doctor will develop a treatment plan based on your age, the size of your
fibroid(s), and your overall health. You may receive a combination of treatments.
Medications
Medications to regulate your hormone levels may be prescribed to shrink fibroids.
Gonadotropin-releasing hormone (GnRH) agonists, such as leuprolide (Lupron), will
cause your estrogen and progesterone levels to drop, stopping menstruation and
shrinking fibroids.
An intrauterine device (IUD) that releases the hormone progestin, over-the-counter
anti-inflammatory pain relievers, such as ibuprophen, and birth control pills can help
control bleeding and pain caused by fibroids, but will not shrink or eliminate them.
Surgery
Surgery to remove very large or multiple growths (myomectomy) may be
performed. An abdominal myomectomy involves making a large incision in the
abdomen to access the uterus and remove the fibroids. The surgery can also be
performed laparoscopically, using a few small incisions into which surgical tools and
a camera are inserted.
Your physician may perform a hysterectomy (removal of your uterus) if your
condition worsens, or if no other treatments work. However, this means that you will
not be able to bear children in the future.

Indications of caesarian section

Cesarean deliveries were initially performed to separate the mother and the fetus in an attempt to save the
fetus of a moribund patient. They subsequently developed to resolve maternal or fetal complications not
amenable to vaginal delivery, either for mechanical limitations or to temporize delivery for maternal or fetal
benefit.
The leading indications for cesarean delivery (85%) are previous cesarean delivery, breech presentation,
dystocia, and fetal distress.[3]
Maternal indications for cesarean delivery include the following:

Repeat cesarean delivery

Obstructive lesions in the lower genital tract, including malignancies, large vulvovaginal condylomas,
obstructive vaginal septa, and leiomyomas of the lower uterine segment that interfere with engagement of the
fetal head
Pelvic abnormalities that preclude engagement or interfere with descent of the fetal presentation in
labor
Fetal indications for cesarean delivery include the following:
Situations in which neonatal morbidity and mortality could be decreased by the prevention of trauma
Malpresentations (eg, preterm breech presentations, non-frank breech term fetuses)
Certain congenital malformations or skeletal disorders
Infection
Prolonged acidemia
Indications for cesarean delivery that benefit the mother and the fetus include the following:
Abnormal placentation (eg, placenta previa, placenta accreta)
Abnormal labor due to cephalopelvic disproportion
Situations in which labor is contraindicated

Contraindications
There are few contraindications to performing a cesarean delivery. In some circumstances, a cesarean delivery
should be avoided, such as the following:

When maternal status may be compromised (eg, mother has severe pulmonary disease)

If the fetus has a known karyotypic abnormality (trisomy 13 or 18) or known congenital anomaly that
may lead to death (anencephaly)

Cesarean delivery on maternal request

Controversy exists regarding elective cesarean delivery on maternal request (CDMR). The 2013 American
College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice [4] and 2006 National
Institutes of Health (NIH) consensus committee[5] determined that the evidence supporting this concept was not
conclusive and that more research is needed.
Both committees provided the following recommendations regarding CDMR [4, 5] :
Unless there are maternal or fetal indications for cesarean delivery, vaginal delivery should be
recommended
CDMR should not be performed before 39 weeks gestation without verifying fetal lung maturity (due to
a potential risk of respiratory problems for the baby)
CDMR is not recommended for women who want more children (due to the increased risk for placenta
previa/accreta and gravid hysterectomy with each cesarean delivery)
The inavailability of effective analgesia should not be a determinant for CDMR
The NIH consensus panel on CDMR also noted the following [5] :
CDMR has a potential benefit of decreased risk of hemorrhage for the mother and decreased risk of
birth injuries for the baby
CDMR requires individualized counseling by the practitioner of the potential risks and benefits of both
vaginal and cesarean delivery

What are the types of anesthesia?

Local anesthesiaLocal anesthesia numbs a small part of the body for minor
procedures. For example, you may get a shot of medicine directly into the surgical area to block
pain. You may stay awake during the procedure.

Regional anesthesiaRegional anesthesia blocks pain to a larger part of your body. You
may also get medicine to help you relax or sleep. Types of regional anesthesia include:

Peripheral nerve blocks. This is a shot of anesthetic to block pain around a

specific nerve or group of nerves. Blocks are often used for procedures on the hands, arms,
feet, legs, or face.

Epidural and spinal anesthesia. This is a shot of anesthetic near the spinal
cord and the nerves that connect to it. It blocks pain from an entire region of the body, such as
the belly, hips, or legs.

General anesthesiaGeneral anesthesia affects your brain and the rest of your
body. You may get some anesthetics through a vein (intravenously, or IV), and you may breathe
in some anesthetics. With general anesthesia, you're unconscious and you don't feel pain
during the surgery.

Description should include the following members of the surgical team and their roles:
SurgeonPhysician who performs the surgical procedure
Surgeon assistantPhysician who works alongside the surgeon as needed to aid with the
surgical procedure
Circulating nurseRN outside the sterile field who supervises the equipment, sponge count,
personnel, supplies, and sterile field and also documents the procedure
Scrub nurseRN at the operating table, part of the sterile field, who assists the surgeon and
anticipates his/her needs
Surgical technologistAn allied healthcare professional who functions as a scrub nurse but
without administering medications
Anesthesiologist/nurse anesthetistPhysician/nurse who administers anesthesia and
monitors the patient throughout the surgical procedure
OR aideAide who obtains equipment and supplies from outside the operating room, as
needed