Episiotomy

1. Following repair of an episiotomy, the severity of perineal pain and associated inflammation should be assessed and the woman asked to rate the severity of pain experienced.
2. Providing there are no contraindications, 100mg diclofenac should be administered rectally and the woman offered a cool gel or ice pack for localised cooling.
3. Paracetamol, bathing and localised cooling are recommended for mild to moderate pain following an episiotomy.
4. For severe pain, tramadol or oxycodone may be prescribed in some cases, but these drugs are contraindicated in women who are breastfeeding.
5. The woman should be given advice on perineal hygiene, pelvic floor exercises, and adoption of sitting and lying positions.

Evidence base

Episiotomy

Figure 1

An episiotomy is a surgical incision intentionally made to increase the diameter of the vulval outlet to aid birth (Steen and Cummins 2016a).

An episiotomy may be advocated in certain situations, for example fetal distress or to enable an instrumental delivery, if a woman has problems associated with female genital mutilation or has severe hypertension or a cardiac condition (Steen and Cummins 2016b). It may also be considered when shoulder dystocia occurs to give the practitioner improved access to undertake manoeuvres to assist the birth of a baby (American Academy of Family Physicians 2012).

Two types of episiotomy may be performed: the mediolateral and the midline episiotomy or incision (Figure 1). A mediolateral incision minimises the risk of extension and is recommended by the National Institute for Health and Care Excellence (2014) when an episiotomy is deemed necessary.

Episiotomy repair is necessary to control bleeding, prevent infection and promote healing by primary intention (Steen 2010). The suture material and technique can contribute to the severity of perineal pain. Continuous suturing of the vagina, superficial and deep muscles, and skin layer with absorbable synthetic suture materials is recommended to repair an episiotomy since this is associated with less perineal pain and a reduced need for analgesia (Kettle et al 2012).

Pain management

Perineal pain may cause maternal distress and inadequate pain relief may lead to negative consequences for women in the short and long term (Steen 2010). Perineal pain may be alleviated by a combination of systemic and localised methods (Box 1). Diclofenac suppositories are effective in reducing perineal pain during the first 24 hours following an episiotomy, and their pain-relieving effect lasts longer than that associated with an oral analgesic (Hedayati et al 2003, Achariyapota and Titapant 2008, Shafi et al 2011).

Box 1. Episiotomy and pain relief methods

Episiotomy involves:

• Posterior vaginal wall.
• Superficial (bulbocavernosus and transverse perinei) and deep (pubococcygeus) muscles.
• Subcutaneous fat.
• Perineal skin layer.

Perineal pain may be alleviated by:

• Oral analgesics, if possible paracetamol for mild to moderate perineal pain and tramadol or oxycodone, or non-steroidal anti-inflammatory drugs for severe perineal pain.
• Bathing.
• Administration of diclofenac suppositories, effective for 24-48 hours following an episiotomy.
• Localised cooling for 20 minutes has a local pain relief effect that can last up to two hours following application. Women have reported using localised cooling for up to two weeks following an episiotomy.

Using an oral analgesic, bathing, applying localised cooling and undertaking pelvic floor exercises have been reported to be of some benefit to women experiencing perineal pain following episiotomy (Steen 2010). Paracetamol is advised for mild to moderate pain (Steen and Marchant 2007). Stronger analgesics, such as tramadol or oxycodone may be prescribed if a woman experiences severe pain, but they are contraindicated when breastfeeding as they may be passed to the infant in breast milk. In addition, a NSAID such as ibuprofen may be given as an alternative (Kamondetdecha and Tannirandorn 2008).

Women may find bathing soothing and this also helps with the breakdown and absorption of suture material (Steen 2010), which can assist healing of the episiotomy. Local application of an ice pack or a cooling gel pad is effective in alleviating perineal pain (Steen 2010), and no negative effects on healing have been reported (Steen and Marchant 2007).

Application of an ice pack for 20 minutes is effective for alleviating perineal pain and continues to be effective for approximately one hour 35 minutes to two hours (de Souza Bosco Paiva et al 2015). In addition, perineal pain relief was reported in the first 24 hours following an episiotomy when lidocaine 2% gel was applied (Abedzadeh Kalahroudi et al 2011). However, further research on healing and the long-term effects of lidocaine gel is needed.

Self-care advice

Advising women about self-care and how to ensure the perineal area is clean by taking regular baths, washing hands before and after going to the toilet, and changing sanitary pads frequently, helps to prevent infection, promote healing and decrease the risk of continuation of pain. It is recommended that women change their sitting position to reduce direct pressure on their perineum and lie down on their side to alleviate perineal pain, particularly in the first few days following repair of an episiotomy and when feeding their newborn.

It is important to advise women about eating a balanced diet and drinking plenty of fluids to promote wound healing and prevent constipation, as well as balancing wellbeing activities such as sleep (for example, sleep when the baby sleeps) and exercise.

There is evidence that women experience increased perineal pain after episiotomy compared to other perineal trauma (East et al2012). The skill of the practitioner conducting the procedure may also affect the severity of pain and the healing of perineal wounds (Kettle et al 2010). An incorrect episiotomy repair can contribute to long-term morbidity.

During the first three months following birth, approximately 23% of women reported dyspareunia (painful sexual intercourse), 19% reported urinary problems and 3-10% experienced faecal incontinence (Labrecque et al 2000). These comorbidities can influence pain levels and the perception of perineal pain. Therefore, practitioners should have the knowledge and skills to care for women following an episiotomy.

Learning points

1. Episiotomy repair is necessary to control bleeding, prevent infection and promote healing. Diclofenac suppositories are effective in reducing perineal pain for 24-48 hours following an episiotomy.
2. Advising women about self-care and how to ensure the perineal area is clean by taking regular baths, washing hands before and after going to the toilet, and changing sanitary pads frequently, helps to prevent infection, promote healing and decrease the risk of continuation of pain.

Disclaimer: please note that the information provided by RCNi Learning is not sufficient to make the reader competent to perform the task. All clinical skills should be formally assessed at the bedside by a nurse educator or mentor. It is the nurse’s responsibility to ensure their practice remains up to date and reflects the latest evidence.