Episiotomy & Rotation and Extraction


An episiotomy is a surgical incision made from the vagina toward the rectum to enlarge the vaginal outlet. The incision is usually midline (straight), but can be mediolateral (angled to the side). (See Figure 8.8.) Caregivers most often perform episiotomies when the baby’s head begins to stretch the perineum. At this time, a natural anesthesia is in effeet, and the woman may not feel the incision. However, a local aesthetic is necessary for the repair of the epi- siotomy following delivery. Most caregivers give the local prior to making the incision.

Figure 8.8. The two types of episiotomy are midline and mediolateral.

Caregivers perform episiotomies to expedite birth in cases of fetal distress or during a prolonged second stage if the woman is exhausted and the perineum is taut. Some doctors do them routinely because they feel that a straight incision is easier to repair and heals better than a jagged tear. Recent studies refute these sentiments, however. While women who deliver with intact perineums recover the fastest, those who have episiotomies heal just about the same as women with spontaneous tears. Also, some doctors feel that an episiotomy prevents tearing, but once a cut is made, the incision is more likely to tear further. In addition, if an episiotomy is not performed and tearing occurs, the tearing may be superficial in nature, whereas an episiotomy cuts into muscle. For these reasons, the American College of Obstetricians and Gynecologists does not recommend episiotomies in uncomplicated deliveries.

Another reason many doctors offer for performing an episiotomy is to avoid loss of vaginal tone and control, which could result in prolapsed organs and a decrease in sexual pleasure for both partners. Other caregivers say that practicing Kegel exercises during pregnancy and following birth strengthens the vaginal muscles and eliminates this problem naturally. Additionally, some experts feel that severing of the perineal tissue during an episiotomy permanently weakens it.

Occasionally, caregivers overstitch the repair to “tighten up” a woman. This overstitching is also known as the “honeymoon stitch.” However, stitching too tightly can result in painful intercourse.

You can decrease your chances of having an episiotomy in several ways. Most importantly, talk to your caregiver about your desire not to have one. Ferforming perineal massage beginning around the thirty-fourth week of pregnancy may also help. (For instructions, see “Perineal Massage”) Many caregivers feel that perineal massage not only stretches the perineal tissues, but also prepares a woman emotionally for some of the physical sensations of birth. While you are pushing during delivery, some caregivers perform perineal massage and apply hot compresses to stretch the perineal tissues. Listen to your caregiver’s directions and push gently to allow the baby to slowly stretch the birth canal. Avoid the lithotomy position during delivery. With your legs apart and your feet in stirrups, your perineum is taut and is more likely to tear.

Lithotomy position

An episiotomy takes several weeks to heal. You may experience soreness and itching. Try sitting on pillows or air rings, taking sitz baths, and applying anesthetic pads, creams, and sprays to help alleviate some of the discomfort.

Rotation and Extraction

Forceps and the vacuum extractor are two obstetrical tools that are used to rotate a baby to a more advantageous position for birth and to help a baby move down the birth canal. They are used when the baby’s head resists rotating from a posterior or transverse position, when a woman’s pushing ability is diminished because of anesthesia or fatigue, or when a baby is in fetal distress. Before employing either of these instruments, many doctors administer a regional anesthetic and/or perform an episiotomy.



Forceps are large, curved metal tongs whose two blades are inserted into toe vagina and placed on either side of the baby’s head. The blades are then locked into place and used to manipulate or extract the baby. Forceps can bruise a baby’s soft head and facial tissue, but they can be an alternative to cesarean section if birth is imminent.

The dangerous high forceps procedure, in which the forceps are applied before the baby’s head is engaged in the pelvis, is not used today, replaced by cesarean delivery, which is safer for both the woman and the baby. The midforceps procedure, in which the forceps are used at zero to above plus-two station, presents some risk to both the maternal tissue and toe baby, and should be performed only by an experienced doctor. Low forceps are used when the head is felt at plus-two or more station and the head is not rotated more than 45 degrees past the midline. Outlet forceps, the most common procedure, are applied when the scalp is visible between contractions. They are used to aid in toe final expulsion of the baby, and they carry the least risk to the woman and baby.

Vacuum Extractor

Cap of vacuum extractor.

A vacuum extractor is a caplike device that is attached to the baby’s head using suction. The suction cup fits over the top portion of the baby’s head and helps ease the infant out through the contours of the birth canal. The doctor can adjust toe amount of suction that he uses. As a safety factor, the suction is released from the baby’s head if the doctor applies too much tension. The use of a vacuum extractor could result in caput succedaneum, a cephalhematoma, lacerations, or abrasions of the scalp.

The advantages of the vacuum extractor over forceps include less trauma to the bladder and vaginal tissues, and lowered risk of extending an episiotomy. The use of anesthesia is not always necessary with the vacuum extractor. In rare cases, the vacuum extractor can be applied before the cervix is completely dilated to avoid a cesarean section if fetal distress indicates the need for immediate delivery.

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