THE EPISIOTOMY

A few years ago, towards the end of an absolutely crazy 24 - hour shift in a fairly busy private maternity hospital, we received a patient in the wee hours of the morning who came to us in advanced labour. She as a 20 year old, first time mom from a community that still widely practices the female genital cut.

As the midwife settled her into bed and took her though the admission process, I noted that she appeared a little too somber for a new mom but could not quite put a finger on what was going on. I was exhausted, running on a caffeine high and had a ton of laboratory results to review in preparation for the handing-over morning ward round and so I did not give it much thought at the time.

At about 5.30a.m., the midwife told me that she had noted the absence of the fetal heart tones on the monitor; simply put, she could not pick the baby’s heartbeat. This was not good, not good at all. She was ready for my review, which was an emotional one for a young woman who was already in a lot of pain. She had not been feeling any movement from her baby the last two days but had failed to notify anyone as she did not quite understand the huge significance of this on the well-being of her unborn one. She was quite tearful when I explained that she seemed to have already lost her baby and we were not anticipating a joyful end to the labour.

As we were all grappling with the bad news, we got to the second round of things getting nasty. At examination, I discovered she had undergone the most severe form of the female genital cut. The entire clitoris and labia minora were gone. The whole vulva area was one big shiny scar that had absolutely no elasticity whatsoever. It was impossible to do a proper vaginal examination to assess how far her labour had progressed. I couldn’t help wondering just how she had gotten pregnant to begin with!

In such cases, it is usually sensible to perform a caesarian delivery to extract the baby and minimize any further injury to the mom. In this case however, we had a dilemma. Our patient hailed from a community that absolutely abhors caesarian section. It is looked upon as creating a disability in the woman and she will never be viewed as whole again. Hence getting consent for surgery was an uphill task. Secondly, she had lost her baby and the thought of nursing a surgery with nothing to show for it is a really tough call. Thirdly, she was already in advanced labour and would probably deliver before we got her on the operating table.

We took a decision to allow her to vaginal delivery. In view of her existing genital scarring, we had to give her bilateral episiotomy to widen the vagina to allow for the baby to come out. She delivered a still born baby and we spent two hours suturing her episiotomy to restore the genitals to their initial state.

So, what is an episiotomy? To most women, it is a dreaded cut which most do not have any idea what it is about. The stories about episiotomies abound and are mostly quite comically narrated by most moms. In the genital area, the thick fleshy part between the vaginal opening and the anal opening made up of muscle, is called the perineum. During delivery of the baby, the vaginal opening must widen up to allow the baby to come through. This results in stretching of the perineum. Sometimes, the stretching is too much and the perineal muscles will tear, resulting in perineal tears. The doctor or midwife may opt to prevent the tearing by going ahead giving an episiotomy which involves cutting through this muscle to widen the birth canal then stitch it up thereafter.

For many years, the episiotomy was done routinely to most mothers. It was argued that a clean straight cut is easier to repair than tears that can be jagged and difficult to align back to normal thereafter. However, consistent research has now shown that episiotomies do not necessarily improve outcomes for either baby or mother and hence should not be routinely practiced. Instead, better perineal support during delivery is advocated for to minimize tears and hence minimize need for repairs.

However, in the case of mothers with genital scarring, mothers requiring extra help during a vaginal birth such as by use of forceps or a vacuum to help extract the baby, or those with very big babies whose shoulders are stuck (shoulder dystocia), an episiotomy is unavoidable. The episiotomy is given at the height of a contraction when the mother is experiencing intense pain and may not notice it happening. Ideally, verbal consent should be sought from the mother before the episiotomy is given and a local anesthetic agent injected into the site where the episiotomy will be given to ease the pain.

Most episiotomies heal uneventfully without the need for antibiotics and with minimal pain. However, the mother must maintain strict hygiene for the duration of healing to minimize complications. Such may include infection of the wound with possible breakdown, requiring repeat repair; healing with scarring; pain during intercourse thereafter and misalignment of the genital tissues.

In the case of our patient, we were forced to make fairly big cuts on either side of vagina to avoid tearing scar tissue. The repair was difficult and exhausting for both the patient and the medical team. Subsequent deliveries will remain a challenge for her, with need to counsel her early and plan for the deliveries. She may have avoided a caesarian section this time round but she still had deep wounds to nurse, both psychologically for her tragic loss and physically in her most private body parts.

As the female circumcision debate rages on, let us spare a thought for women like this who have no comprehension of what the results of the practice entail for the woman.