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An episiotomy is a surgical incision into the perineum, the area between the bottom
of the vaginal opening and the anus, in order to increase the size of the vaginal opening during childbirth. If
it is done as part of gynecologic surgery, it's called a perineorrhaphy. As discussed in recent threads on this
forum, episiotomy is controversial. However, it's sometimes necessary, and, in any event, sometimes a tear (also
called a perineal laceration) will occur during childbirth regardless of whether an episiotomy is cut.
After an episiotomy or tear, the doctor or midwife should inspect the vagina, cervix, perineum, and anus to make
sure there are no other damaged areas. If pain is a problem, the area should be injected with
novocaine, or, if
necessary, the patient should be offered an IV shot of strong painkillers. In some cases a large tear of the cervix
and/or vagina requires repair under epidural or general anesthesia in the operating room. Most women, however,
have a 2nd-degree tear of the vagina, which can be repaired right in the delivery room. A 1st-degree tear is a
thin line through the perineal tissue. This is less common than a 2nd-degree tear, which goes a little deeper.
3rd-degree tears actually cut into or through the round sphincter muscle that surrounds the anus. This muscle helps
"hold it in" so identification and repair of injuries to this muscle may prevent fecal incontinence.
A 4th-degree tear goes into the rectal tissue, and must be repaired correctly to prevent a hole forming between
the vagina and rectum, called a fistula, where gas and feces can pass into the vagina. I have seen women who delivered
at home or in an otherwise unattended setting who have a cloaca, where the rectum and vagina are essentially one
opening! This can be repaired surgically even years later. Despite what some may say, even the best doctors and
midwives will encounter 3rd- and 4th-degree tears, as childbirth is a traumatic event to the tissues of the vagina
and perineum.
Repair of an episiotomy is generally straightforward. Do a good exam, identify the tissue edges, then sew with
suture that lasts at least a few weeks. (Chromic catgut is a common episiotomy suture that lasts about 2-3 weeks).
Errors can be made by doing a hasty repair, or, more commonly, not having good enough visualization of the area
to be repaired. Poor lighting, excessive bleeding, a moving target, or, in some, cases, an uncooperative patient
(i.e. someone high on crack cocaine who doesn't want to sit still) can all make it hard to repair the area. If
the area is not approximated correctly, or even if a stitch pulls through later, the edges of the wound may not
heal correctly. Some women heal "too well" and form granulation tissue, which can create spotting and
pain. In other cases a trigger point is formed, usually right at the 6 o'clock position at the bottom of the vagina,
which can cause extreme pain with insertion of a tampon, finger, or penis.
Sadly, many women do not report this to their doctors. Maybe they are concerned about hurting their doctor's feelings,
or maybe they are embarrassed, or busy with their newborn. Regardless, episiotomy pain can almost always be fixed.
If it's a fistula, surgical repair will solve the problem. If it's a slightly tender episiotomy, ice packs, numbing
cream, sitz baths, and wearing loose clothing may help. Breastfeeding moms may benefit from a low-dose estrogen
cream, as breastfeeding decreases the amount of estrogen in the vaginal tissues. In cases where there is a bunching
up of tissue, or there are knots or other abnormalities, outpatient surgical revision of the area may help. Most
patients feel it's better to go through more surgery and have a 6-8 week recovery than have a lifetime of painful
intercourse. In cases where trigger points are identified, injections may be helpful. In some cases a combination
approach may help, such as removing the excess tissue, the doing injections later if necessary. Again, however,
this is often not that hard to fix for an experienced gynecologist. If someone has not obtained relief from the
basic treatments, then more intensive treatment is often indicated. Gynecologists are used to dealing with patients
with painful intercourse, so you should get attention to this problem from your doctor. If not, find another.
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