Intervention in the natural course of childbirth: what is episiotomy and why is it needed. Episiotomy: all the pros and cons of the procedure
As is known, labor pain has wonderful property– she is quickly forgotten. Therefore, many women, remembering the birth of their child, only talk about how doctors “cut” them, as a result of which their life became more difficult in the first month after childbirth. As a rule, in this case we are talking about perineo- or episiotomy. We will tell you what these operations are, why they are needed and, most importantly, what a woman can do to avoid them or make these injuries less painful.
What is the perineum?
The pelvic floor, or perineum, is the internal support of our body, all of our internal organs. It consists of three layers of muscles. The muscles of the lower (outer) layer are arranged in the form of a figure eight, the rings of which encircle the vagina and anus. Middle layer represented by the triangular muscle. Finally, the upper (inner) layer forms the pelvic diaphragm. This is the paired and most powerful muscle of the pelvis, whose fibers create a real dome.
Such a complex structure and close connection of the perineum with genitourinary organs imply that this area is subject to heavy loads and plays important role in the functioning of organs located in the pelvis.
Indeed, the pelvic floor is a support for the internal genital organs, bladder and rectum. Damage or weakness of this muscle leads to prolapse or even prolapse of organs and disruption of their functions.
In addition, along with the muscles abdominal wall and the diaphragm (the muscular septum separating the chest and abdominal cavity) the pelvic floor is involved in the regulation of intra-abdominal pressure, and therefore affects the organs located in the abdominal cavity.
During childbirth, these muscles stretch in a unique way, forming a wide tube through which the baby passes. After childbirth, they contract, returning to their previous position.
Causes of breakups
Unfortunately, no matter how ideally the perineal muscles are “designed,” there are many factors that reduce their elasticity and contribute to perineal rupture. Among them:
- the woman’s age is more than 35 years, especially if this is her first birth;
- high crotch (when the distance between anus and the entrance to the vagina is more than 7-8 cm);
- developed muscles of the perineum (for example, in women who play sports professionally);
- scars on the perineum after injuries received during a previous birth or as a result of plastic surgery;
- swelling of the perineum (with weak labor, prolonged pushing);
- fast and rapid childbirth;
- insufficient protection of the perineum (reception provided by the midwife) when removing the baby’s head and shoulders;
- inappropriate behavior women in labor - during childbirth, especially during the second period, when the fetus is expelled, it is necessary to strictly follow the recommendations of the doctor and midwife who monitor the condition of the perineum.
Premature attempts, strong attempts at the moment when it is necessary to breathe through the contraction (at the moment of removal of the head and shoulders of the fetus), contribute to the appearance of ruptures.
Do not forget that the inflammatory process in the vagina (colpitis, vulvovaginitis) contributes to significantly greater trauma to soft tissues birth canal. Therefore, all women are recommended to undergo smears for vaginal flora at 36 weeks of pregnancy and, if necessary, undergo appropriate treatment.
Tears can be internal (on the cervix and inside the vagina) and external (at the exit of the vagina). Cervical ruptures most often occur at the end of the first stage of labor, when the cervix has not yet fully opened, and the fetal head has already pressed against the entrance to the small pelvis, putting pressure on bladder and rectum; at the same time there is a desire to push and thereby get rid of the pain. However, this should not be done under any circumstances, since pressure on the cervix that has not yet opened leads to its rupture.
In turn, according to the principle “the force of action is equal to the force of reaction,” the cervix puts pressure on the fetal head and leads to additional injuries to the unborn child. The fetal head should descend slowly, gradually expanding the tissues of the vagina and perineum. Any forcing can lead to vaginal injuries - abrasions and ruptures.
To prevent this from happening, you need to listen to the recommendations of the doctor and midwife and not push before the head completely fills the entire vagina and reaches the exit from the pelvis. During the birth of the head and shoulders of the fetus, the mucous membrane of the labia may be injured. This occurs during rapid extension during her birth.
Degrees of perineal tear:
I degree: the posterior commissure (a small area of perineal skin between the entrance to the vagina and the rectum) and the vaginal wall are disrupted. The perineal muscles remain unharmed.
II degree: the skin of the perineum, the walls of the vagina and the muscles up to the sphincter of the rectum are damaged.
III degree: The II degree rupture deepens, involving the sphincter of the rectum, and sometimes its wall.
When is a perineal incision necessary?
There are the following indications for perineal dissection:
Threatening perineal rupture(occurs with a large fetus, high perineum, rigidity - poor extensibility of perineal tissue, etc.). Most often, the gap begins with posterior commissure, and then moves to the perineum and vaginal walls. A breakup does not begin suddenly - it is preceded by changes appearance crotch.
Signs indicating an impending rupture include characteristic protrusion of the perineum, cyanosis, swelling, and then pallor of the skin. If obstetricians notice signs threatening break, then it is cut. This is done because the smooth edges of an incised wound heal better after suturing than jagged edges laceration.
Premature birth- to avoid pressure from the perineal tissues on the fragile bones of the premature baby’s skull.
The need to shorten the period of exile due to the condition of the mother in labor (high blood pressure, congenital and acquired heart defects, myopia, etc.).
Indications for episiotomy are the threat of rupture of the “low” perineum (when the distance between the rectum and the entrance to the vagina is small), acute subpubic angle (the angle at which the bones of the pubic symphysis meet), breech presentation of the fetus, scar changes perineum, obstetric operations (application of obstetric forceps, vacuum extractor).
Lateral episiotomy - an incision strictly to the side - is carried out only when pathological changes perineum that does not allow the use of another method of dissection (for example, for tumors) - such incisions heal less well.
Perineotomy and episiotomy are performed in the second stage of labor, when the presenting part of the fetus has sank to the pelvic floor and tension in the perineum appears, before its rupture occurs. The operation is performed by a doctor; in emergency cases, in his absence, by a midwife.
The perineotomy operation does not require pain relief, since ischemia (lack of blood supply) of the perineal tissue leads to loss pain sensitivity. Before dissection, the skin of the perineum is treated with tincture of iodine. The incision is usually made with scissors at the moment the fetal head erupts. Its length is on average 2-3 cm. Blood loss, as a rule, is small. Restoration of the cut perineum is carried out after the birth of the placenta.
Caring for seams
To identify injuries, after childbirth the doctor must examine soft fabrics birth canal. Regardless of whether it was a tear or a cut, the integrity of the tissue is necessarily restored. Whether pain relief will be used, and which one, depends on the degree of damage to the birth canal.
If a woman has only cervical ruptures, then anesthesia is not required, since there are no pain receptors in the cervix. Cervical tears are sutured with absorbable sutures (catgut or vicryl). There is no need to remove them.
If ruptures of the vagina and labia minora are detected, they are sutured, usually under local anesthesia. As with cervical ruptures, as suture material absorbable sutures are used.
If the perineum has been damaged, depending on the depth of the wound, either local anesthesia or intravenous anesthesia is given (in this case, the woman falls asleep for a short time). If epidural anesthesia was used during childbirth, then the woman is simply given an additional dose of anesthetic.
The integrity of the perineum is restored layer by layer. First, the muscles - deep and superficial - are carefully compared, then sutures are placed on the skin. If the sutures are applied with catgut, they do not need to be removed, but if with silk thread, the sutures are removed 5-7 days after birth.
IN postpartum period sutures on the perineum and labia are treated with hydrogen peroxide and a solution of potassium permanganate or brilliant green once a day. The midwife does this postpartum department. If the ruptures in the soft tissues of the birth canal were deep, then it is possible to prescribe antibacterial drugs– due to the proximity of the rectum and the possibility of infection.
For pain in the suture area, painkillers are prescribed in the first three days after birth; for swelling, the use of an ice pack is recommended.
How to behave?
If you have stitches in your perineum, follow a number of rules:
- In the absence of contraindications, a woman is allowed to walk by the end of the first day after birth, and to sit 2-3 days after the stitches are removed (that is, on the 7-10th day after birth). In maternity hospitals where women eat not in the ward, but in the dining room, high tables (something resembling a bar counter) are provided for such postpartum women.
- The baby will need to be fed while lying down.
- When breaking III degree the first days you will need to adhere to special diet(broth, tea, fruit juices, kefir), so that there is no stool for 6-7 days. On the 7th day you will be given a laxative (you cannot push): it is advisable that the act of defecation should be as easy as possible.
- Then you will be allowed to sit half-sided, on one of the buttocks - it is recommended to sit on the side where there is no incision (this can be done on the 5th day after birth), on a hard surface.
- During your stay in the maternity hospital and during the week at home, after each trip to the toilet you need to treat the perineum (rinse it with running water, dry it well). It should be remembered that the washing movements should be made from front to back, from the pubis to the rectum, to reduce the likelihood of germs entering the wound. After this, it is advisable to lie down for a few minutes without underwear so that the skin dries on its own, and then you can get dressed, but do not forget to change the pads more often (every 2 hours), since the wound should be dry.
Possible complications
Pain, swelling, wound infection, hematomas, and abscesses may occur in the area of the sutures. Whenever severe pain, feelings of pulsation and twitching, bursting in the area of the sutures, immediately complain to your doctor in order to exclude these dangerous complications.
If complications occur, the doctor will prescribe therapy, depending on the type of complication: frequent application of ice, treatment with ointments, or surgery. In the presence of cervical ruptures, especially deep ones, with a concomitant inflammatory process in the vagina after suturing, a scar deformity– a condition in which the connective tissue of scars deforms the cervix.
In the future, this defect can be corrected using a laser, and in case of deeper damage, surgical correction– cervical plastic surgery.
Tears of the vagina and labia minora heal with virtually no consequences and without visible scars. However, with ruptures in the clitoral area, sensitivity in this area may be impaired, which is subsequently restored within several months.
Healing of the perineum can proceed without complications - only a skin scar will remain. In the presence of colpitis (inflammation of the vagina), sutures on the perineum may diverge. Formation of muscle failure pelvic floor followed by prolapse of the walls of the vagina and uterus.
In such a situation, a few months after birth you will need enough complex operation– vaginal plastic surgery.
Prevention
Is it possible to avoid tears and cuts? It is impossible to answer this question unequivocally. But, as already mentioned, a lot depends on the woman herself - on her calmness and willingness to follow all the doctor’s instructions.
What can you do on your end to try to avoid cutting?
Firstly, you should Be conscious about preparing for childbirth. You simply must be aware of the flow normal birth and ways of breathing and relaxing in them. This will allow you to get as close as possible to the physiological course of childbirth and avoid artificial interference in the natural process.
Let us also note that the likelihood of ruptures increases with rapid and stimulated labor, therefore, by skillfully and in time relaxing, moving correctly and, most importantly, without fear of the unknown, you will help both yourself and your baby.
Secondly, it will help you perineal massage, which should be done regularly. Starting from any period (optimally - from the middle of pregnancy, but if there are complications during pregnancy, in particular increased tone uterus, threat of miscarriage - then after 36 weeks of pregnancy) massage the perineum with vegetable oil every day or 2-3 times a week. It is best to perform a massage after a shower or bath in a state of relaxation and comfort.
Accept comfortable position– some people like it lying down, others like it with one leg on a raised platform (for example, in a bathroom on the side). Pour 1 or 2 fingers with oil (it is better to pour it rather than dip it in oil - for hygiene reasons) and insert them into the vagina. Using pressing movements, massage it from the inside, especially towards the anus(this is where the maximum stretching will occur during childbirth).
You can try stretching the vagina to the sides. It is better to do this exercise not immediately, but when you get used to the massage: at first, stretching can be unpleasant due to inelastic tissues. The duration of the massage is at least 3 minutes.
At the same time, try to relax the vaginal muscles as much as possible - then discomfort will not be so strong (with a massage), and having learned such relaxation, you will be able to apply your skill at the moment the baby is born - then the risk of ruptures will further decrease, because there will be no “extra” tension in the perineum.
By the way, perineal massage will also help you if after childbirth the vagina becomes “too narrow” (this happens too!). To prepare a special oil for perineal massage, take a pack of St. John's wort herb and vegetable oil. Place the herb in a jar with a lid, pour oil on top and heat in a water bath for 15-20 minutes. Then put the jar in the cupboard for a week, after which it can be used.
If you haven't made a special massage oil, you can use any vegetable.
Third, systematically carry out special exercises aimed at gradually increasing the elasticity of the perineal tissues(consult your gynecologist about whether you can do such exercises and which exercises will be most effective for you).
In conclusion, I would like to say: tune in for the best; optimism and preparedness for childbirth will help you avoid surgical intervention.
Kegel exercises
Slow compressions. Tighten your perineal muscles and slowly count to three. Relax. It will be a little more difficult if, holding the muscles, hold them in this state for 5-20 seconds, then gradually relax.
"Elevator". We begin a smooth ascent on the “elevator” - squeeze the muscles a little (1st floor), hold for 3-5 seconds, continue the ascent - squeeze a little harder (2nd floor), hold - etc. to its limit – 4-7 “floors”. We go down in the same stages, pausing for a couple of seconds on each floor.
Abbreviations. Tighten and relax your muscles as quickly as possible.
Pushing. Push down moderately, as if you are having a bowel movement. This exercise, in addition to the perineal muscles, also causes tension in some abdominal muscles. You will also feel the anus tightening and relaxing.
Start training at ten slow compressions, ten contractions and ten thrusts, five times a day. The exercises should be repeated at least 25 times during the day. You can do the exercises almost anywhere - while walking, watching TV, sitting at a table, lying in bed.
When you first start exercising, you may find that your muscles don't want to remain tense during slow contractions. You may not be able to perform contractions quickly or rhythmically enough. This is because the muscles are still weak - control improves with practice. If your muscles get tired mid-exercise, rest for a few seconds and continue.
Childbirth is not only an exciting, but also a rather unpredictable process, during which the child may encounter some difficulties while moving along the birth canal. For example, the baby will be too large for the mother and will not be able to be born without injuring the vaginal tract.
In such cases, the doctor performs the birth with an episiotomy. What is it and how to prevent possible perineal ruptures during childbirth?
Episiotomy – what is it?
Episiotomy during childbirth is a kind of preventative measure, which helps, through surgery (a small and precise incision in the soft tissue of the vagina), to prevent serious breaks crotch.
Such injuries to the entrance at the birth of a baby, directly at the moment of passage of the head, are, unfortunately, not uncommon.
Lacerations, unlike incisions, are more difficult to heal because they have torn edges. After suturing, a scar appears that is quite difficult for further resorption.
Sutures after an episiotomy are easier to treat and dissolve because the precisely cut tissues are placed on top of each other, and the healing process is faster.
Types of cuts
Cut the crotch to make it easier birth process mother and child, it can be done in different ways. How many types of such an operation are there?
There are 4 types of similar surgical procedures used in medicine, the first two of which are used quite often:
- Mid-lateral - the incision is made in the middle between the opening of the anus and the ischial tuberosity. The obstetrician-gynecologist performs such an episiotomy diagonally to the right or left, depending on the situation.
- Perineotomy - sometimes also called median. The difference between a perineotomy and a simple episiotomy is that the incision in this case is made exactly in the middle from the end of the vaginal opening to the opening of the anus.
- Lateral - the incision is slightly angled and extends 1-2 cm from the end of the vagina. The lateral incision differs from the median one by a shorter distance and often occurs on the Bartholin gland, which is responsible for secreting lubricant in the vaginal passages. Because of high risk damage to this gland, this method is no longer used during childbirth.
- “J” – episiotomy in the form of the same name English letter. The incision goes straight down the middle, as in a perineotomy, and then bends from the opening of the anus to the left or right by 1.5 cm. This method is also not very popular due to the risk of damaging the muscles leading to the anus.
Indications
In Europe, such surgical intervention began to be used less and less in order to protect the mother in labor as much as possible from postpartum scars. European doctors hold in high esteem a long period of pushing, during which there are practically no ruptures of the vaginal tract.
In Russia this operation used quite often to help women who have given birth avoid serious postpartum injuries and long recovery.
A Latin America generally introduced incisions such as perineotomy and episiotomy into the category of planned ones.
In addition, there are serious indications for:
- risk of II or III degree perineal rupture;
- the risk of stopping the supply of oxygen to the fetus, in this situation it is necessary to sharply tame the period of pushing;
- the baby is too large for the mother;
- rigidity (hardness) of the perineal muscles, in which they are so inflexible that they cannot allow the baby’s head to pass through;
- There are prerequisites for instrumental birth, that is, you will have to help the baby be born using obstetric forceps. This is a rather controversial thing in gynecology, since they put pressure on the baby’s skull and lead to various diseases later, for example, paralysis. For a woman, the use of obstetric forceps also has its consequences: ruptures of the perineum and internal damage to the vagina can occur. In this situation, making an incision will be a less traumatic option for both the mother and the newborn;
- in the case of female circumcision - removal of parts of the perineum. Unfortunately, this practice still exists in a number of tribes and Islamic states. By and large, female circumcision is associated with the beliefs and religious prerequisites of a certain people, who decide in this way to cleanse a woman of “filth” and give her the opportunity to ascend after death to the divine kingdom. From a medical point of view, this simply cripples the female body, making the woman sexually inferior and interfering with the birth process;
- the fetus's heart rate slows down;
- The baby's shoulders do not pass through the crotch.
Sutures after episiotomy
The suture heals after an episiotomy within one to two months: it all depends on individual characteristics body. The sutures are removed after the incision 3–4 days after birth. All this time, the woman in labor has a pulling sensation, but it goes away after the stitches are removed.
Attention! If self-absorbable sutures are used during surgery, there is no need to remove the sutures. They will disappear on their own within 2-3 weeks.
During healing, you need to keep the seam clean and constantly treat it with a solution of brilliant green. Afterwards (approximately 4–5 days after the baby is born), there is no need to process the seam.
It is enough to keep it clean, wipe it dry and wash it with soap without additives or dyes so as not to cause allergies.
You cannot sit after an episiotomy for about a month. Moreover, this applies mainly to full squats on the seam itself and on the soft surfaces of sofas, beds and chairs. In this case, ruptures may occur, especially if a perineotomy was performed, which takes longer to heal.
Is it really impossible to sit after an episiotomy? How to continue to lead normal image life? In this case, many learn to deftly bypass the unpleasant prohibition and either sit, but at the same time control the process of squatting: when sitting, choose hard chairs and transfer your body weight to the leg opposite the side of the cut.
In addition, you can sit on your lap and on a special inflatable ring - an analogue of children's swimming rings. The fact is that due to the hole, which is located in the middle, the load on the perineum becomes less, and therefore you can sit on such an inflatable ring, as well as on the rim of the toilet bowl, already in the first hours after the operation.
Second birth
Childbirth after an episiotomy may also occur naturally. If the situation with the fetus repeats and an incision is required again, it is usually carried out along the same scar to avoid new ones.
However, often the second birth differs significantly from the first, and the baby passes on its own, without incisions of the vaginal passages.
Why such an operation is performed is now clear. How to avoid episiotomy and subsequent stitches and scars?
In fact, this operation is necessary only in emergency cases, so it does not make sense for every woman in labor to do it, and often the woman herself can withstand a long period of pushing and wait until the perineal tissue stretches enough for the baby to come out.
In addition, you can prepare well for childbirth:
- It is best to learn proper breathing during childbirth: two short inhalations and a long exhalation, during which the muscles of the perineum relax.
- Non-traditional methods have a good effect, such as preparing the vaginal passage for 9 months for the process of childbirth: rubbing special oils, such as almond oil, which helps increase tissue elasticity. One more unconventional method, helping to avoid ruptures is considered to be regular sex life during pregnancy (if there are no indications for sexual rest).
- Keeping yourself in sports shape is considered a very good prevention, for example, exercise on a fitball, gymnastics for pregnant women, swimming and other light sports, such as jogging.
Important! Any sports exercises during pregnancy can only be performed after consulting a doctor.
Useful video
Thus, opinions on the topic of whether an episiotomy is necessary during childbirth, in modern medicine divided. Some obstetricians believe that this surgical incision prevents ruptures of the female genital organs and anus, while others speak out sharply negatively, believing that any interference in the process of childbirth will slow down the natural healing of the female body.
However, in one luminary medical science converge: this operation will help avoid large blood loss in case of forced ruptures and will minimize future dysfunction of the genitourinary system.
Childbirth is a long-awaited process. Often on later During pregnancy, women eagerly await the onset of contractions, especially if this is the first birth, and ask the most various questions: how will the birth proceed, what can prevent a normal birth, will the child suffer, what is episiotomy and perineotomy? We will cover the last of these questions today.
Episiotomy (medial lateral episiotomy) is a surgical dissection of the soft tissues of the perineum and vagina.
Perineotomy is also a surgical dissection of the tissues of the perineum and vagina, but performed along the midline in the direction from the vagina to the anus.
Today, episiotomy is used very widely, and perineotomy is much less common. The fact is that episiotomy is much less likely to cause complications in the form of damage to neighboring organs. Sometimes it happens that the incision needs to be extended (large fetal head, incorrect insertion of the fetal head, extension of the fetal head). In this case, the episiotomy incision is simply continued, without increasing the risk of bleeding and without creating the danger of damage to other structures, since all manipulations occur within the skin, subcutaneous fatty tissue and muscles.
When performing a perineotomy, the incision is limited in length, and it is difficult to extend it. It also depends on anatomical features(high crotch or low). But in any case, with perineotomy, there is a risk of spontaneous prolongation of the incision, that is, with attempts, the perineal tissue is stretched and the incision is prolonged by a rupture, and there is a risk that the rupture will extend to the anus and damage to the sphincter or rectum will occur.
High crotch is anatomical structure perineum, when the distance between the entrance to the vagina and the anus exceeds 7 cm. Low perineum is the distance between the anus and the entrance to the vagina less than 2 cm.
Why is perineal dissection performed during childbirth?
Episiotomy and perineotomy are performed to widen the exit from the birth canal (vulvar ring). If indications for episio- and perineotomy are clinically identified, then its implementation can prevent negative consequences for mother and child.
Indications for dissection
Mother's side
Threat of perineal rupture during childbirth. A perineal rupture can occur in initially healthy tissues, or along an old scar (episiotomy in previous births). Women with initially dry and sensitive skin are more susceptible to this complication. systemic diseases connective tissue(scleroderma, dermatomyositis and others), diabetes mellitus and some skin diseases(for example, ichthyosis). Episiotomy is performed with pressure when there is a threat of perineal rupture. The threat of rupture of the perineum is diagnosed visually, the tissues are stretched to transparency, the skin is thin and shiny.
When conducting obstetric operations in childbirth. The application of exit obstetric forceps and a vacuum extractor, as a rule, requires an episiotomy to facilitate the extraction of the child and to avoid rupture of the perineum.
To facilitate the period of pushing in a pregnant woman with extragenital pathology. This includes cardiac pathology, hypertensive disorders and other pathologies. Episiotomy shortens the period of pushing, which reduces the burden on the mother.
Bleeding during childbirth exceeding physiological norms. In this case, it is also necessary to speed up the birth of the child and find the source of the bleeding. During bleeding, both the mother and the fetus suffer while it is connected to the mother by the umbilical cord.
Development of preeclampsia during childbirth or worsening of preeclampsia during the pushing period. rise blood pressure during childbirth, accompanied by complaints of headache in the parietal - temporal region, visual impairment such as flashing spots and luminous dots before the eyes, flashes and not relieved by taking antihypertensive drugs(dopegit, nifedipine), without effect from magnesium therapy.
These complaints indicate an increase in the severity of the condition and require early delivery. If the birth process by the time sharp deterioration the state has reached pushing, then you need to speed up the pushing period using available means.
From the fetus
Large fruit. If no indication was given for caesarean section, then an episiotomy can be performed during childbirth to reduce the risk of injury to the fetus.
Premature birth. Premature labor is usually performed under anesthesia and then an episiotomy is performed. This also reduces the risk of injury to the premature fetus.
Acute hypoxia or decompensation chronic hypoxia during childbirth, asphyxia began during labor during the pushing period. If these emergency conditions arose already in the period of pushing, when the fetal head is in the pelvis, then performing a cesarean section is technically impossible. You can reduce the risk of hypoxic damage and speed up the birth of a child by performing an episiotomy and using obstetric forceps or vacuum extractor.
Multiple pregnancy. Sometimes a multiple pregnancy is an indication for an episiotomy, especially if this is the first birth. Breech presentation of the first fetus is an indication for a cesarean section, but it happens that a woman in labor ends up in the maternity hospital with a large dilation of the cervix and labor has begun. In some cases, the operation is technically impossible. In this case, an episiotomy is performed.
Threat birth trauma fetus Birth trauma can happen to any child, not necessarily large or breech. If progress along the birth canal deviates from physiological norm, the risk of injury increases. If the baby approaches the exit of the birth canal in a different way (anterior view occipital presentation, that is, with the back of the head up, the neck is strongly bent and unbends after the birth of the head), then there is a risk of damage to the cervical spine or sticking (dystocia) of the shoulders. A competent obstetrician-gynecologist and midwife always see and control this process, so do not be alarmed that somewhere nearby there is an episiotomy kit (scissors, cotton balls), they will not make an incision unless necessary.
Some anomalies labor activity. Rapid and rapid labor, as the name suggests, occurs with high activity. The perineal tissues do not have time to adapt and gradually stretch under the pressure of the fetal head. If the obstetrician-gynecologist sees that the tissues are excessively stretched, thinned and threaten to rupture, then an episiotomy is performed. If rapid labor occur without the threat of perineal rupture, then an episiotomy “just in case” is not performed. In contrast to childbirth with a premature fetus, when tissue pressure on the fetal head should be reduced as much as possible.
Breech presentation of the fetus. Birth in breech presentation is considered pathological. Sometimes this definition is formal, especially when repeated births, and sometimes there is a need to expand the exit from the birth canal. This is done if there is a risk of difficulty passing the head through the birth canal.
Contraindications to perineal dissection
There are no contraindications to episiotomy and perineotomy.
How is an episotomy performed?
Prophylactic episiotomy is rarely performed ( premature birth, breech presentation first fetus and other individual conditions), an incision is made in the perineum with scissors at an angle of approximately 45º. Used for manipulation local anesthesia(novocaine, lidocaine).
Most often, an episiotomy is performed under pressure without anesthesia. Don’t let the lack of pain relief scare you; during childbirth, the level of pain is already very high, the stretched perineum is thin, and the manipulation itself is practically not felt separately from the general background. The pressing head of the fetus quickly presses the edges of the incision and stops the bleeding.
Perineotomy is now rarely performed, although this type of incision heals well. It is performed if the perineum has already begun to tear downwards, towards the anus.
Does episiotomy/perineotomy affect the baby?
If episiotomy/perineotomy is performed according to fetal indications, then its effect is clearly positive. If the perineal incision was performed according to indications from the mother, then the effect on the fetus is positive (preeclampsia in the mother is dangerous for the fetus) or absent (a perineal rupture will harm only the mother).
Episiorrhaphy/perineorrhaphy
Episiorrhaphy/perineorrhaphy is the suturing of an incision in the perineum after a cut or rupture. This manipulation is performed under local anesthesia(novocaine, lidocaine), sutures are usually applied with non-absorbable threads on the skin and with absorbable threads on the vaginal mucosa. Non-absorbable material (silk, caproag, vicryl, nylon) ensures strong closure of the wound edges and allows them to heal without the threat of suture dehiscence. Absorbable threads (for example, catgut, often used for suturing tears in the vaginal mucosa) ensure the strength of the suture for a maximum of 10 days, but the mucosa is rich in blood vessels, it grows together much faster than the skin.
How does the suture heal after cutting the perineum?
Sutures after episiotomy and perineotomy heal in approximately 10 to 14 days. The patient experiences discomfort and pain in the suture area, especially when walking, sitting down or going to the toilet, and this is normal.
The following should be on your guard:
Long-lasting swelling of the perineum, increasing swelling and the appearance of new pain (distension), asymmetry of the labia or perineum (possible formation of a hematoma, that is, accumulation of blood in the subcutaneous fatty tissue);
- appearance of discharge from unpleasant smell(yellowish, purulent or bloody);
- increased body temperature and general symptoms of intoxication (weakness, fatigue, weakness, aches in muscles and joints);
- urinary disturbance.
In these cases, you should immediately contact a gynecologist. IN daytime you can contact your local obstetrician-gynecologist at your consultation, in the evening and at night and on weekends and holidays contact an urgent gynecologist. With pronounced general symptoms intoxication, high fever you can call an ambulance medical care, in other cases, it is possible to independently contact the on-duty gynecological hospital.
Do not delay addressing such complaints; symptoms develop quickly. If at the beginning of the process it is possible to get by with a minor intervention, say, opening a hematoma, then in advanced cases, when the hematoma suppurates and the inflammatory process spreads, the operation will be much more traumatic.
Why cut the perineum if it threatens to rupture or rupture is already in progress?
Then what cut wound heals much better than a torn one. In the case of suturing an incised wound, it is easy to compare the edges of the wound defect and suture them as physiologically as possible, blood supply is quickly restored, and the wound heals primary intention(no suppuration and minimal swelling).
The edges of an incised wound are smooth and clear, while a lacerated one is uneven. It is physiologically very difficult to compare the edges of a lacerated wound (sometimes these are flaps of tissue, detached muscles), healing occurs more slowly, the blood supply to the damaged area is restored over a longer period of time, and the formation of cicatricial deformation of the perineum is also possible (with large ruptures, especially if the healing was complicated).
When are stitches removed?
The sutures are removed approximately 7-8 days. Most often, by this time the woman and baby have already been discharged from the maternity hospital, so you should go to your hospital to remove the stitches. antenatal clinic. If for some reason you are delayed in the maternity hospital, the stitches will be removed in the postpartum department.
Postpartum period. How to properly care for yourself?
Hygiene
You should wash yourself warm water with soap (try to soap only the skin of the perineum, without actively touching the mucous membranes), in the direction from front to back.
In the first few days (at least three days), you should wash your face every 2 hours and after each visit to the toilet, use soap 1-2 times a day, the rest of the washes are done simply with warm water in the shower.
Such frequent irrigation is necessary in order to remove lochia from the skin and sutures (postpartum bloody, and then mucous - bloody discharge), which are secreted very actively for about 1 week (this is the contraction of the uterus after childbirth, returning it to its previous size).
Lochia is nutrient medium for bacteria, therefore in warmth and in the presence of rich nutrition they multiply with high activity. After washing, wipe the perineum with gentle blotting movements; use a towel that does not leave lint (for example, a towel made of a fabric called “waffle”).
For at least two months you should not take baths, visit baths, saunas, or solariums. Thermal procedures can provoke not only suppuration of the sutures after episiotomy, but also lactostasis, mastitis and other postpartum complications.
Do not use commercial pads for at least the first days after childbirth. They are easy to use, but are equipped with air- and moisture-proof elements that create greenhouse effect and accelerate the growth and reproduction of bacteria.
Use cloth or gauze pads without cotton wool, throwing them away after use. Or change postpartum pads every 1.5 - 2 hours.
If possible, walk around the house for a while without underwear, the seams in this case dry out, you sweat less, and the injured skin of the perineum is not irritated.
Mode
You cannot sit on a hard surface or evenly on both buttocks for about 2 weeks. For the first two days it is better not to sit at all. You can feed your baby while lying down; there are comfortable positions for this. Then you can sit on a sofa or chair semi-sideways, so that the emphasis falls more on the thigh than on the buttock. Or use a special ring pillow, which can be purchased at orthopedic pharmacies.
All these precautions are necessary in order to prevent stretching of the perineum and suture separation or deformation.
You cannot lift anything heavier than your own baby for 2 months. Increases when lifting heavy objects intra-abdominal pressure and tension in the perineal tissues, the risk of seam divergence is very high.
Nutrition
For the same reason as heavy lifting, constipation should not be tolerated. This in itself is an unpleasant phenomenon, but if there are stitches it becomes dangerous.
All measures that help prevent and relieve constipation are described in the article “Constipation after childbirth”.
Sexual rest
The postpartum period is a very vulnerable state for a woman. The uterus is an open wound surface, so you can easily get infected. Your partner's flora (normal for him) may be unacceptable to you during this period. Besides inflammatory factor, dangerous and purely mechanical. When having sex, the perineum stretches and the seams may come apart.
Therefore, it is necessary to temporarily limit sexual relations, minimum term rest 6 weeks, or better 8 weeks.
Gymnastics
After the incision has healed and the sutures have been removed, you should observe protective regime(limitation heavy loads, cycling and similar influences), if the healing process is complicated, this period is longer, consult your doctor.
And then you should begin to restore the tone of the perineum by performing Kegel exercises. This complex, when performed regularly, will help restore the elasticity of tissues, help fight urination disorders (involuntary loss of urine when laughing, coughing) and prevent prolapse of the uterus and vagina in the future (during the period after menopause).
Kegel exercises
These are exercises to strengthen the pelvic floor muscles, developed by American gynecologist Arnold Kegel in 1952. And since then the complex has not undergone significant changes. The positive aspects of performing the complex are undeniable, the main thing is to do it regularly. after uncomplicated vaginal birth You can start exercising already on the 3rd day.
If there are stitches on the perineum (in this case it is not so important, after spontaneous ruptures or episiotomy), classes should begin after about 8 weeks.
If you really want to restore the tone of the perineum earlier, then consult your gynecologist; perhaps 10-14 days after the removal of the sutures you can start.
The timing is approximate, it all depends on the degree and depth of the rupture, the success of the healing of the sutures, the presence or absence of complications.
Exercise "pause".
During each urination, hold the stream of urine for 10 to 15 seconds, approximately 5 times per urination. And repeat every time you go to the toilet. Further, when you understand the strength and intensity of muscle work, you can repeat this exercise without urinating. This technique is convenient because you can perform it unnoticed by others, it does not require the allocation of separate time. Start your gymnastics with this exercise, do it for several days, and then add other techniques.
Squeeze exercise.
Squeeze the muscles of the perineum as strongly as possible and immediately release them, repeat several times at a fast pace. The more active the rhythm, the better for the blood supply to tissues. Start at a slower pace, speed it up, and then slow it down again. You should start this exercise when you have already felt your intimate muscles with the "Pause" exercise and learned how to control them.
Fixation exercise.
You need to strongly squeeze the muscles of the perineum and keep them in this state for at least 10 seconds, gradually you will increase the force of compression, which will not only help restore blood circulation in the muscles and mucous membranes, but will make your intimate life more bright.
Squats.
Squats with a straight back, feet shoulder-width apart. You need to slowly go down as low as possible and rise up just as slowly. Start small, then you won't get up the next day with sore muscles and quit at the very beginning.
Exercise "elevator".
The vagina, as part of its wall, contains muscles that are arranged in ring-shaped “floors”; you need to try to strain each “floor” in turn, each time staying in this position. Direction from top to bottom and back. This technique should be started after sufficient training experience.
Exercise "storm".
It is also based on wave-like muscle contraction, only here the pelvic floor muscles are involved. The “wave” should travel from front to back.
Prevention of perineal ruptures during childbirth
Childbirth at term is already a physiological prevention of ruptures, since hormonal background changes again, tissues and all other organs and systems prepare for childbirth, tissue stretchability becomes better.
You can also perform external intimate massage using neutral oils. It is performed daily already in full-term pregnancy, if there are no contraindications (low placentation, marginal placenta previa, etc.). As a result of the massage, the tissues gradually become more elastic and softer.
Forecast
Episiotomy/perineotomy is a routine manipulation and the prognosis for the life and health of mother and baby is favorable.
Sometimes the doctor during the birth process tells you that an episiotomy is needed, do not refuse the manipulation. If you are concerned about something or do not know enough about this issue, ask your doctor. Sometimes it's only chance prevent serious birth injury to the child or mother. After giving birth, do not forget about yourself, it is not only the baby that requires attention. Take care of yourself and be healthy!
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During pregnancy, problems often occur that can lead to a difficult birth and various surgical interventions. One of these operations, which is aimed at relieving and even saving the situation during childbirth, is called episiotomy.
What is an episiotomy? surgery, which is an incision on the lower part of the vagina, and this operation is not performed as planned, but only in a necessary situation when the life of the child or mother is in danger. There are special reasons for episiotomy:
- Incorrect presentation of the fetus.
- Too narrow crotch (this is an exclusively physiological feature of the body).
- Too large fruit, which is difficult to pass.
- Multiple pregnancy (sometimes it happens that the birth is difficult and the vagina has to be cut).
- Previous gynecological operations.
- The age of the woman in labor is 35+.
- Visible swelling of the perineum.
- Labor began quickly.
- If a woman is unable to tolerate pushing. She begins to push specifically trying to push the baby out as quickly as possible, without listening to Nathan’s doctor. This can actually lead to injury to both mother and baby.
- The distance between the vagina and anus is 7-8 cm (called a high perineum).
How is an episiotomy performed?
In the second half of the attempts, when the woman has already pushed the baby towards the “exit” with her own efforts and for some reason he cannot come out, the midwife or the doctor himself cuts through the lower wall of the vagina with scissors. Anesthesia is not used in this case, since when the vaginal wall expands during childbirth, blood vessels they become a little numb from tension and then, this is done very instantly and no more than 3-4 centimeters.The suture is placed on the perineum after the baby is born. As a rule, the vagina is sutured with so-called surgical threads; they dissolve on their own after about a couple of months and there is no need to remove the sutures.
What to do to avoid an episiotomy
Childbirth and preparation for it. A pregnant woman should go to various exercises or do them at home. This helps both the perineum and the fetus itself. Him - to accept correct position, the perineum becomes more elastic and strong.Perineal massage. Conduct it yourself and you can involve a partner (if you have one, of course). This requires:
- soak your fingers in glycerin.
- insert them into the vagina.
- move them slowly in a circle (you should be completely relaxed).
- massage for about 10 minutes every three hours.
Kegel exercises. On our website you can find the most important Kegel exercises. They will help you get a good workout before giving birth.
How to behave during childbirth . This is the most important thing and, perhaps, one of the feasible assistance for a woman who is giving birth.
- Do not push without your doctor's orders.
- Calm down and breathe very deeply.
- Don’t be nervous for no reason (you’re already giving birth, honey, why should you be nervous).
- Remember that if you push on your own, you can simply kill the child you have been carrying under your heart for a whole year (well, almost). Do you know why? you want to give birth faster because of the agony and pain, but you can’t observe the process, the baby may get tangled in the umbilical cord or, because of your attempts, simply change position and turn over on its back. Always listen to your doctor.
Healing of sutures after episiotomy
approximately 1-2 months. It depends on how they cut it and what kind of gaps there were. Especially it all depends on the woman:- Nutrition. Only light food.
- Breastfeeding. As often as possible and at the baby's request.
- None physical labor at all.
- Sleep at least 7-8 hours.
- Medicines on suture care (these will be prescribed by the doctor).
