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 procedureNot 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 babyThere may be other reasons for your health care provider  to recommend an episiotomy.

Risks of the procedureAs 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 intercoursePeoples 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 procedureAn 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 procedureAfter 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 baby’s 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 painYour 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 baby’s head has settled deep into your pelvis.

From a few weeks to a few hours before labor begins

Increase in vaginal discharge (clear,

Show. A thick mucus plug has accumulated at the cervix during

Several days before labor begins

pink, or slightly bloody)

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

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 30–70 seconds.

Change with movement

Contractions may stop when you walk or rest, or may even stop with a change of position

Contractions continue, despite movement

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 before…menstrual 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 FibroidsDifferent fibroids develop in different locations in and on the uterus.

Intramural FibroidsThese 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 Women’s Health, they are the most common type of fibroid and are found in about 70 percent of women of childbearing age (HHS, 2008).

Subserosal FibroidsSubserosal 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 FibroidsWhen 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: CausesWhat Causes Fibroids?It is unclear why fibroids develop, but several factors may influence their formation.

HormonesEstrogen 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 HistoryFibroids may run in the family. If your mother, sister, or grandmother has a history of this condition, you may develop it as well.

PregnancyPregnancy 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 FactorsWho 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: DiagnosisHow 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:UltrasoundAn 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 MRIThis in-depth imaging testing produces pictures of your uterus, ovaries, and other pelvic organs.

Part 7 of 8: TreatmentHow 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.MedicationsMedications 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.SurgerySurgery 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 sectionCesarean 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 laborFetal 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

ContraindicationsThere 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: Surgeon–Physician who performs the surgical procedureSurgeon assistant–Physician who works alongside the surgeon as needed to aid with the surgical procedureCirculating nurse–RN outside the sterile field who supervises the equipment, sponge count, personnel, supplies, and sterile field and also documents the procedureScrub nurse–RN at the operating table, part of the sterile field, who assists the surgeon and anticipates his/her needsSurgical technologist–An allied healthcare professional who functions as a scrub nurse but without administering medicationsAnesthesiologist/nurse anesthetist–Physician/nurse who administers anesthesia and monitors the patient throughout the surgical procedure

OR aide–Aide who obtains equipment and supplies from outside the operating room, as needed