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EPISIOTOMY

Procedure and
Repair Techniques

The American College of


Obstetricians and Gynecologists
W O M E N S H E A LT H C A R E P H Y S I C I A N S
EPISIOTOMY
Procedure and
Repair Techniques
RALPH W. HALE, MD
FRANK W. LING, MD

The American College of


Obstetricians and Gynecologists
W O M E N S H E A LT H C A R E P H Y S I C I A N S
Episiotomy: Procedure and Repair Techniques represents the knowledge and
experience of experts in the field and does not necessarily reflect College policy.
Methods and techniques of clinical practice that are currently acceptable and used
by recognized authorities are described in this publication. These recommenda-
tions do not dictate an exclusive course of treatment or of practice. Variations tak-
ing into account the needs of the individual patient, resources, and limitations
unique to the institution or type of practice may be appropriate.

Library of Congress Cataloging-in-Publication Data

Hale, Ralph W., 1935


Episiotomy : procedure and repair techniques / Ralph W. Hale, Frank W. Ling.
p. ; cm.
Includes bibliographical references.
ISBN 978-1-932328-29-5 (alk. paper)
1. Episiotomy. I. Ling, Frank W. II. American College of Obstetricians and
Gynecologists. III. Title. [DNLM: 1. Episiotomy. WQ 415 H163e 2007]

RG971.H35 2007
618.85--dc22
2006036891

Copyright 2007 by the American College of Obstetricians and Gynecologists, 409


12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved.
No part of this publication may be reproduced, stored in a retrieval system, posted
on the Internet, or transmitted, in any form or by any means, electronic, mechani-
cal, photocopying, recording, or otherwise, without prior written permission from
the publisher.

ISBN 978-1-932328-29-5

12345/10987
CONTENTS

Preface v

Introduction 1
Indications 3
Types of Episiotomy 4
ACOG Position 5

Basic Anatomy of the Perineum 3


External 3
Internal 6

Midline Episiotomy 8
Procedure 8
Repair 11

Mediolateral Episiotomy 16
Procedure 16
Repair 16

Complications 19
Bleeding 19
Infection 19
Pain and Dyspareunia 20
Extension 21
Other Complications 21

Perineal Laceration 21
Periurethral Tears 21
Vaginal Tears 23
Perineal Tears 23

References 24

iii
Preface

Episiotomy is the most common operative procedure that most obste-


tricians will perform in their lifetime. Because it is so common and
considered minor surgery, teaching students or interns the principles
and techniques usually is left to the most junior of residents. As a
result, the Residency Review Committee for Obstetrics and Gynecology
(RRC) asked the American College of Obstetricians and Gynecologists
(ACOG) to prepare a teaching aid for all residents, but especially those
with the least experience. The result is this monograph.
As with most surgical procedures, there are many approaches and
modifications to episiotomy. However, the principle is the same. It
does not matter if your preference is 4-0 chromic catgut suture or 3-0
polyglycolic suture. What matters is how, where, and when you suture.
It is hoped that this monograph will be a guide to your approach to
episiotomy.
Many Fellows of ACOG participated in the development of this
monograph, and it would be impossible to name them all. However,
special thanks go to Frank Ling, MD, Howard Blanchette, MD, John
Hauth, MD, and Gary Hankins, MD. A very special thank you goes to
Tamara Tin-May Ho Chao, MD, resident member of the RRC, for her
insightful comments.
Finally, this document would not have been possible without the
support of the ACOG Development Committee. Countless members of
ACOG donate to the Development Fund annually to allow ACOG to
expand its activities and further our educational endeavors. This
monograph is just one example of how those donations can have a
major impact.

Ralph W. Hale, MD
ACOG Executive Vice President

v
Introduction

The first use of an episiotomy to facilitate the delivery of an infant is


lost in the past. Whether ancient midwives or birth attendants used
primitive knives has been questioned for years. Perhaps they did or per-
haps they did not. What is known, however, is that intentional incision
of the perineum was not practiced as a routine procedure until the 20th
century.
Treatises on management of the perineum as the fetal head
emerges at the time of delivery focused on protecting against tears
and lacerations. In the 1700s, the usual description of a delivery of
the infants head concentrated on preserving the intact perineum by
allowing a slow, controlled dilation and delivery by exerting pressure
on the perineum (1).
In 1828, Ferdinand von Ritgen described a similar maneuver for
easing the head over an intact perineum (2). His procedure, which he
modified to use extension rather than flexion of the head, also was
designed to prevent trauma to the perineum while facilitating the deliv-
ery (3). This was accomplished by placing the examiners fingers on the
perineal body and gently pushing the head from flexion to extension.
This maneuver is still performed in deliveries today and is known as the
Ritgen maneuver.
Although procedures for increasing the size of the vaginal outlet
may have been used in the United States by Native Americans, immi-
grant midwives, or others, the first reported use was in Virginia in 1852
(4). However, there is little evidence that it gained any regional or wide-
spread acceptance as part of a vaginal delivery.
In 1893, Karl August Schuchardt, preparing to perform a vaginal
approach to excision of a large cervical cancer, performed a medio-
lateral incision of the perineum to obtain additional exposure (5). He
reported on this procedure to increase exposure in the same year. In his
report, he described incision in the mediolateral tissue and muscles
with much the same anatomical detail we would use today. Although

1
2 Episiotomy

he never used the word episiotomy, the procedure would be called


gynecologic episiotomy today.
J. B. Delee usually is credited with popularizing the use of the epi-
siotomy when he became the champion for the use of forceps to pro-
tect the fetal head during delivery (6). He felt strongly that use of the
forceps always should be accompanied by an episiotomy to prevent
damage to the pelvic floor. Because of Delees stature in the field of
obstetrics, his premise rapidly became accepted by U.S. obstetricians.
As more and more women gave birth in hospitals rather than
homes, episiotomy became the rule rather than the exception. The
lithotomy position, especially if extreme, actually accentuated the tight-
ening of the perineal opening and further contributed to the perceived
need for a surgical approach to increase the vaginal opening. This pro-
cedure, which began as a mediolateral approach, slowly evolved in the
United States during the 1950s and 1960s to predominantly a midline
procedure.
The purpose of the procedure, which was explained to residents
year after year, was to facilitate the second stage of labor. It also was
reported to reduce perianal trauma, pelvic floor dysfunction and pro-
lapse, urinary and fecal incontinence, and sexual dysfunction. Benefits
to the fetus were a shortened second stage and less potential trauma to
the fetal head.
In the 1970s and 1980s, however, obstetricians began to question
the validity of the concept of protecting the perineum and the benefits
related to routine episiotomy. In 1981, the National Childbirth Trust
in London published a study that questioned the use of episiotomy as
a routine procedure (7). This led to further review and questioning of
routine use of episiotomy for vaginal delivery given that there was little
evidence to support the reported benefits.
Today, episiotomy is still the most common surgical procedure
performed by most obstetricians; however, it is much less common
than in the 20th century. In 2003, 716,000 episiotomies were per-
formed in the United States, whereas 11 years earlier, more than 1.6
million episiotomies were performed (8, 9) (see table). It most often
is used in women who are having their first child and less frequently
used with later children.
Episiotomy 3

Episiotomies Performed in the United States


Year No. Rate per 10,000 Population/Female

2003 716,000 24.7


2002 780,000 53.2
2001 843,000 58.2
2000 944,000 66.4
1999 1,048,000 74.4
1998 1,220,000 87.3
1997 1,183,000 85.7
1996 1,294,000 956.6
1995 1,410,000 1,050.3
1994 1,512,000 1,136.1
1993 1,562,000 1,184.4
1992 1,611,000 1,235.1

Data from DeFrances CJ, Hall MJ, Podgornik MN. Advance data from Vital and Health Statistics.
Hyattsville (MD): U.S. Dept of Health and Human Services, Centers for Disease Control and
Prevention, National Center for Health Statistics; 2005. No. 359. Advance Data available at:
http://www.cdc.gov/nchs/products/pubs/pubd/ad/ad.htm. Retrieved June 8, 2004.

Indications
Today, the indications for episiotomy are based primarily on the clini-
cal situation at the time of delivery and, therefore, vary greatly
depending on the opinion of the obstetrician. In general, an episioto-
my is indicated when shortening of the second stage of labor and
expediting the delivery of the infant is indicated. Situations that may
fall in this category are clinical circumstances such as a nonreassuring
fetal heart rate pattern, shoulder dystocia, or operative vaginal delivery.
Another indication is the potential for a significant spontaneous lacer-
ation at the time of delivery, which may occur with a short perineal
body, a previous laceration, or a very large infant. However, two recent
studies have not shown that episiotomy provided perineal protection,
4 Episiotomy

facilitated operative delivery, or improved neonatal outcome (10, 11).


Current review and opinion suggest that evidence-based criteria are
insufficient for establishing recommendations; therefore, clinical judg-
ment remains the best guide (12).

Types of Episiotomy
The two basic types of episiotomy in use in the United States today are
the median and the mediolateral (Fig. 1). The median is also com-
monly referred to as the midline and is the most frequently used epi-
siotomy in the United States. However, it is also associated with a
greater risk of extension. This extension may include the anal sphincter
(third degree) or the rectum (fourth degree) (13) (see box).
A mediolateral episiotomy, which is an incision at least 45 degrees
from the midline, is less frequently performed in the United States, but
is more commonly found in other countries. This episiotomy is
favored in those countries because it reduces the risk of third- and

Extension of Episiotomy

First-degree tear: A superficial laceration of the mucosa of the vagina,


which may extend into the skin at the introitus. It
does not involve deeper tissues and may not
require repair.

Second-degree tear: A first-degree laceration that involves the vaginal


mucosa and perineal body. It may extend to the
transverse perineal muscles and requires a suture
repair.

Third-degree tear: A second-degree laceration that extends into the


muscle of the perineum and may involve both the
transverse perineal muscles as well as the anal
sphincter. It does not involve the rectal mucosa.

Fourth-degree tear: A laceration involving the rectal mucosa.

Note: Some definitions are limited to the three levels of tear and will combine
the first- and second-degree tears as only one level.
Episiotomy 5

Head of baby Fig. 1. Midline and mediolateral episiotomy.


(Pilliteri A. Maternal and child nursing.
4th ed. Philadelphia [PA]: Lippincott,
Williams & Wilkins; 2003.)
Mediolateral

Midline

fourth-degree extensions (14). Disadvantages of the mediolateral epi-


siotomy are reported to be a more difficult repair, increased blood loss,
and increased postpartum discomfort (15).

ACOG Position
The American College of Obstetricians and Gynecologists has conclud-
ed: The best available data do not support liberal or routine use of
episiotomy. Nonetheless, there is a place for episiotomy for maternal
or fetal indications, such as avoiding severe maternal lacerations or
facilitating or expediting difficult deliveries (16). Further information
is available in Practice Bulletin Number 71, Episiotomy (16).

Basic Anatomy of the Perineum


Before performing and repairing an episiotomy, it is essential that the
obstetrician have a thorough knowledge of the anatomy of the per-
ineum and adjacent structures. A lack of knowledge of this area can
lead to failure to adequately perform and repair the incision.

External
The external genitalia are seen in Figure 2. The most critical area of the
perineum is the distance from the vestibular fossa to the anus. This
area is frequently referred to as the pudenda or perineal body, and it
averages 34 cm in length in nonpregnant women. It will vary signifi-
cantly from woman to woman, and it will expand as the head begins
to emerge. The midline episiotomy is made in this anatomical area and
this is where the mediolateral episiotomy begins.
6 Episiotomy

Mons pubis
Anterior commissure of
labia majora
Prepuce of clitoris
Pudendal cleft (groove or
space between the
labia majora)
Glans of clitoris
Frenulum of clitoris
External urethral orifice
Labium minus
Labium majus
Openings of paraurethral
(Skenes) ducts
Vestibule of vagina
(cleft or space surrounded
by labia minora)
Vaginal orifice
Opening of greater
vestibular (Bartholins) gland
Hymenal caruncle
Vestibular fossa
Frenulum of labia minora
Posterior commissure of
labia majora
Perineal raphe
(over perineal body)
Anus

Fig. 2. External genitalia. (Netter RH. Atlas of human anatomy. 4th


ed. Philadelphia [PA]: Saunders Elsevier; 2006. Netter illus-
trations used with permission of Elsevier Inc. All rights
reserved.)

Internal
Underlying the skin are the muscle and fascial supports of the per-
ineum (Fig. 3). A midline episiotomy will extend from the vaginal ori-
fice caudad toward the anus. The incision will be in the central point
of the perineum and usually extends to the transverse perineal mus-
cles, of which there are two: superficial and deep. The two muscles are
in such close approximation that they usually are not identifiable as
two separate entities. Because they also intertwine with the anal
Episiotomy 7

Bulbospongiosus muscle Clitoris Suspensory ligament of clitoris


with deep perineal (investing
or Gallaudets) fascia
partially removed Ischiocavernosus muscle

Bulb of vestibule
Superficial perineal space
(pouch or compartment)
Perineal membrane

Ischiopubic ramus
with cut edge of Greater vestibular
superficial (Bartholins) gland
perineal (Colles)
fascia Bulbospongiosus
muscle
(cut away)
Perineal
membrane
Superficial
transverse
Ischial perineal
tuberosity muscle

Sacro-
tuberous Perineal
ligament body

Gluteus
maximus
muscle

Ischioanal fossa
Coccyx Obturator
fascia
Urethra
Tendinous arch of
Crus of levator ani muscle
clitoris Sphincter urethrae
muscle Inferior fascia of
Ischio- pelvic diaphragm (cut)
pubic
ramus Perineal membrane Levator ani muscle
(cut and reflected)
External anal sphincter muscle
Compressor urethrae
Bulb of muscle
vestibule Anococcygeal (ligament) body
Sphincter urethrovaginalis
muscle

Vagina
Greater vestibular Deep transverse
(Bartholins) gland perineal muscle
Perineal membrane

Fig. 3. Muscle and fascial supports of the perineum. (Netter


RH. Atlas of human anatomy. 4th ed. Philadelphia [PA]:
Saunders Elsevier; 2006. Netter illustrations used with
permission of Elsevier Inc. All rights reserved.)
8 Episiotomy

sphincter, they often are mistaken for the sphincter itself. They extend
laterally from the midline to the ischial tuberosity, and near the lateral
vaginal edge their fascial covering is also next to the bulbospongiosus
muscle.
The bulbospongiosus is the main muscle that is incised when mak-
ing a mediolateral episiotomy. This muscle extends from the pubic
rami, circumscribes the vaginal opening, and then spreads slightly as it
terminates just above the transverse perineal muscles. Lateral to the
bulbospongiosus muscle is the superficial perineal compartment,
which is usually filled with fatty tissue. The Bartholins gland, vestibu-
lar bulb, and multiple veins are also in this compartment.
The blood supply to this area is seen in Figure 4. The internal
pudendal artery, a branch of the anterior trunk of the internal iliac
artery, is the main supplier of the perineum. Its branches are the per-
ineal, labial, and hemorrhoidal arteries. The venous drainage follows
essentially the same patterns as the arteries. However, in the paravagi-
nal area, varicosities are not uncommon during pregnancy.
The area is innervated by the pudendal nerve and its branches as
seen in Figure 5. The pudendal nerve is a branch of sacral 2, 3, and 4.
Occasionally, a cutaneous branch of the inferior anal nerve can inner-
vate the area around the anus. When this occurs, the traditional pu-
dendal block anesthesia will not be adequate for performance of an
episiotomy, and local infiltration will be needed.

Midline Episiotomy
Procedure
Before performance of the episiotomy, adequate pain relief is needed.
This can be obtained by use of local infiltration, pudendal nerve block,
or conduction analgesia, such as an epidural or saddle block. Once
pain relief is ensured, the procedure can commence. It is important to
make certain that the fetal head is protected during the episiotomy. For
that reason, a scalpel or other blade should be used only if scissors are
not available.
Initially, the index and middle finger should be inserted into the
vagina between the perineum and the fetal head. The perineum is then
Episiotomy 9

Posterior Dorsal artery of clitoris


labial artery
Deep artery of clitoris
Ischiocavernosus
muscle Bulb of vestibule
Compressor urethrae muscle
Bulbospongiosus
muscle Artery to bulb of vestibule
Superficial Greater vestibular (Bartholins) gland
perineal space
Deep transverse perineal muscle
Perineal
membrane Internal pudendal (clitoral) artery
Perineal membrane (cut)
Perineal
artery Perineal artery (cut)
Superficial Superficial perineal (Colles)
transverse fascia (cut and reflected)
perineal to open superficial perineal space
muscle
Internal pudendal artery
Perineal in pudendal canal (Alcocks)
artery Inferior rectal artery
Internal
pudendal
artery in
pudendal
canal Round ligament Branches
(Alcocks) of
Tubal
uterine
Ovarian artery
Inferior
rectal artery
External anal sphincter muscle

Note: Deep perineal (investing or


Gallaudets) fascia removed from
muscles of superficial perineal space

Ovarian vessels

Tubal branches of ovarian vessels


Uterine vessels

Ureter

Vaginal branches of uterine artery

Vaginal artery

Levator ani muscle

Perineal membrane

Internal pudendal artery

Perineal artery

Superficial perineal space

Superficial perineal (Colles) fascia

Fig. 4. Blood supply of the perineum. (Netter RH. Atlas of


human anatomy. 4th ed. Philadelphia [PA]: Saunders
Elsevier; 2006. Netter illustrations used with permis-
sion of Elsevier Inc. All rights reserved.)
10 Episiotomy

Anterior labial nerve


(from ilioinguinal nerve)

Dorsal nerve of clitoris

Posterior labial nerves

Superficial Branches
of perineal
Deep nerve

Perineal branch of
posterior femoral
cutaneous nerve

Dorsal nerve of
clitoris passing
superior to
perineal membrane

Perineal nerve

Pudendal nerve in
pudendal canal
(Alcocks) (dissected)

Inferior clunial
nerves

Gluteus maximus
muscle (cut away)

Sacrotuberous ligament

Perforating cutaneous nerve

Inferior anal (rectal) nerves

Anococcygeal nerves

Fig. 5. Innervation of the perineum. (Netter RH. Atlas of


human anatomy. 4th ed. Philadelphia [PA]:
Saunders Elsevier; 2006. Netter illustrations used
with permission of Elsevier Inc. All rights reserved.)
Episiotomy 11

incised vertically extending toward, but not into, the transverse perineal
muscles (Fig. 6). Although in some women a raphe or dimpling can be
seen, the incision should be made as close to the midline as possible. A
question often arises as to when to perform the episiotomy. Some rec-
ommend before the head is fully crowning; others suggest only just
before expulsion when the perineum is thinned and stretched. Both
approaches have advantages and disadvantages and rely on the clinical
judgment of the obstetrician. In general, it is better to perform the epi-
siotomy later to avoid excessive blood loss and complete the delivery
shortly thereafter.
After completion of the delivery, it is critical to inspect the incision
site carefully to determine the extent of the episiotomy and any possi-
ble tears or extensions. In primiparous women, the reported odds ratio
is +22.08 that midline episiotomies will extend beyond the initial inci-
sion into and through the transverse perineal muscles and the anal
sphincter (third degree) or into the rectal mucosa (fourth degree) (17).
In another study, 14.9% of midline episiotomies resulted in an exten-
sion (18).

Repair
Surgical repair of an episiotomy is a reapproximation of separated vagi-
nal mucosa, soft tissue, and muscle so that each part is paired with its
counterpart (Fig. 7, AF). A complete knowledge of perineal anatomy is
necessary if this is to occur (see Basic Anatomy of the Perineum).

Fig. 6. Midline episiotomy. (Beckman


CRB, Ling FW, Laube DW, Smith
RP, Barzansky BM, Herbert WN.
Obstetrics and Gynecology. 4th ed.
Baltimore [MD]: Lippincott,
Williams & Wilkins; 2002.)
12 Episiotomy

The choice of suture is based on the extent of the repair. If the rectal
mucosa is to be repaired, the suture should be no larger than 4-0. The
standard suture material is chromic catgut, but synthetic material also
is used by many obstetricians. The needle should be small and tapered
for the mucosa, and a larger suture may be preferable for the soft tissue
and muscle. Use of two different suture sizes and needles certainly is
acceptable.
For the sake of inclusion, this description will begin with a rectal
extension and proceed upward. Obviously, if no extension occurred, the
repair will begin at the appropriate lowest point of episiotomy.
If the rectal mucosa is involved, the apex should be identified. A
suture is then placed approximately 1 cm above the apex. This suture
should extend through the submucosa, but usually not the mucosa
itself. It is placed 1 cm above the apex to ensure that any retracted ves-
sels are ligated. The mucosa is then closed in a running or locking fash-
ion with 4-0 suture to join the two mucosal edges (Fig. 7A). The suture
should not penetrate the mucosal layer but bring the submucosa
together. Sutures should be placed no more than 0.5 cm apart, and the
running nonlocking suture should continue to the anal sphincter and
perineal body.
Next, the anal sphincter should be identified. The two edges usually
will be retracted laterally, and an Allis clamp may be necessary to iden-
tify the cut edges and bring them together in the midline (Fig. 7B).
When repairing the anal sphincter, it is important to suture the fascial
sheath and not just the muscle. This repair is best accomplished with
several interrupted sutures around the muscle rather than one large fig-
ure eight. The repair is strengthened by the sheath, not the muscle.
Some obstetricians recommend that it is best to first apply the bottom-
most suture at the 6 oclock position, then the most internal suture at
the 9 oclock position, then at the top or most superior part of the
muscle, followed by a 3 oclock placement, which is the most superfi-
cial and easiest. Because the transverse perineal muscles also are sepa-
rated, they can be repaired in a similar fashion. The 12 oclock anal
sphincter suture usually will include a portion of the lower capsule of
Episiotomy 13

the transverse muscular tissue. Some obstetricians advocate use of 2-0


suture for these capsule repairs because it will give support for a longer
time and thus increase the healing capability. This is a personal choice,
and there is no evidence to suggest which size suture is best.
Now the underlying rectal fascial layer should be closed (Fig. 7C).
This gives a second layer over the rectal mucosa and helps to further
support the extension. In addition, it also closes some of the potential
dead space between the vaginal mucosa and the rectum. Some do
this layer before sphincter repair and incorporate the 6 oclock sphinc-
ter suture at the inferior end of this second-layer rectal repair. Through-
out these procedures, the obstetrician should be checking carefully for
any bleeding vessels and appropriately ligate them to prevent future
hematomas.
At this point, the procedure has reached the level of repair that is
needed for a midline episiotomy without extension or a secondary lacer-
ation repair. A suture is placed approximately 1 cm above the apex of
the vagina (Fig. 7D). The suture is then continued in a running or run-
ning locking fashion to the hymenal ring. Care should be taken to avoid
deep suturing that could extend through the submucosal tissue into the
rectum. Careful attention should be directed to ensuring the submucos-
al tissue is incorporated in the running suture (Fig. 7E). The size of
suture for this portion of the repair usually is 3-0, although, for the
novice surgeon, 2-0 is easier to use. The needle should be noncutting.
At the hymen, careful approximation of the two edges can be
obtained by bringing the outer portion together. The running suture is
then continued to the squamomucosal junction.
When this area is reached, it is important to assess the perineal
body and submucosal areas. If there is a deep defect, interrupted
sutures may be needed to approximate the sides to prevent dead space.
Finally, the skin is ready for closure (Fig. 7F). This can be done by a
continuous subcuticular extension of the suture that has been brought
to the squamomucosal area; it also can be closed with a separate 3-0 or
4-0 subcuticular repair.
14 Episiotomy

Fig. 7. Repair of midline episiotomy. A. Closure of the


rectal mucosa. B. Closure of the anal sphincter.
C. Second layered closure of the rectal mucosa
using the rectovaginal fascia. D. Anchor stitch
placed 1 cm beyond the most superior extent of
the episiotomy. E. Use of one suture for closure.
F. Completion of repair using a subcuticular
suture. (Hankins GDV, Clark SL, Cunningham FG,
Gilstrap LC. Operative obstetrics. New York [NY]:
McGraw-Hill; 1995. Reproduced with permission
of The McGraw-Hill Companies.)

B
Episiotomy 15

F
16 Episiotomy

Mediolateral Episiotomy
Procedure
A mediolateral episiotomy requires the same pain prevention as noted
for a midline repair. The debate about when to perform the episiotomy
is also the same. Most surgeons recommend these procedures be done
just before delivery because mediolateral episiotomies tend to bleed
more than midline procedures.
Once the decision is made, the fingers are inserted into the vagina
between the head and the perineum. An incision is then made at
approximately a 45-degree angle from the midline to the perineal body
(Fig. 8). The apex should be in the exact midline of the perineum, not
lateral to the midline. This incision can be on the left or right side
depending on the preference of the obstetrician. Some authorities sug-
gest that repair of an incision on the patients left side is mechanically
easier for a right-handed surgeon. It is important to use large, straight
sharp scissors to allow the incision to be made in a single cut. The inci-
sion will extend approximately 4 cm into the perineum and may reach
the ischioanal fossa. If the incision is not deep enough, there will be
little relaxation, and a second incision to extend the first will be neces-
sary. Although not prohibited, a second incision increases the risk of a
zigzag line upon healing. Optimal timing of the episiotomy usually is
when the vertex is crowning. Before crowning, there is the risk of exces-
sive bleeding because the vessels are not compressed.

Repair
Immediately after the delivery, the obstetrician should examine the
extent of the episiotomy. Upward extension of the vaginal incision
should be evaluated carefully, especially if a forceps delivery occurred.
Once this evaluation is completed, the repair should begin (Fig. 9,
AD). Any arterial bleeding should be managed to prevent subsequent
hematoma formation.
Two fingers are placed in the vagina for traction and to spread the
incisional edges. A suture of 2-0 or 3-0 material is then placed approxi-
mately 1 cm above the apex. This will prevent retracted vessels from
bleeding and disrupting the repair. A running suture using a noncutting
needle is then used to close the vaginal mucosal and submucosal areas
(Fig. 9A). It may be necessary to place additional interrupted sutures in
the submucosal space if inadequate tissue is obtained with the mucosal
Episiotomy 17

Fig. 8. Mediolateral episiotomy. (Hankins GDV,


Clark SL, Cunningham FG, Gilstrap LC.
Operative obstetrics. New York [NY]:
McGraw-Hill; 1995. Reproduced with
the permission of The McGraw-Hill
Companies.)

stitch. Once the introitus is reached, it will be necessary to close the


supporting tissue (Fig. 9B). There is usually no attempt to reapproxi-
mate the hymen in this approach. Several more interrupted sutures will
be necessary to close the remainder of the tissue. Because the incision is
in a lateral direction, the medial tissue will be lower than the distal
edge, and careful approximation is necessary to avoid subsequent dis-
tortion of the vaginal opening. Placing sutures diagonally rather than
horizontally will help maintain appropriate anatomical approximation
(Fig. 9C). It is usually not necessary to use more than six interrupted
sutures, and less is better than more.
Before closing the skin and underlying tissue, the bulbospongiosus
muscle usually will need to be repaired because it extends into the inci-
sion site (see Basic Anatomy of the Perineum). The upper end of the
muscle, if transected, will have retracted and will need to be identified and
reapproximated. Sutures should be placed in the fascial sheath and not
the muscle. Once this repair is complete, the underlying tissue and skin
can be reapproximated. Diagonal, not horizontal, sutures should be used.
The skin itself is best approximated with a subcuticular stitch (Fig. 9D).
18 Episiotomy

Fig. 9. Repair of mediolateral episiotomy.


A. Placement of the first suture at the
vaginal apex. B. Approximation of the
vaginal mucosa. C. The vaginal wound is
sutured to the approximate level of the
posterior commissure. D. Approximation
of the perineal skin edges. (Hankins GDV,
Clark SL, Cunningham FG, Gilstrap LC.
Operative obstetrics. New York [NY]:
McGraw-Hill; 1995. Reproduced with
the permission of The McGraw-Hill
Companies.)

D
Episiotomy 19

Complications

Bleeding
One of the most frequent complications of episiotomy is bleeding. The
area surrounding the perineum has extensive vasculature, which has
been accentuated secondary to the effects of pregnancy. During the sec-
ond stage of labor, pressure of the fetal head has compressed many of
these vessels, so they are not readily visible until after the episiotomy is
performed and the infant is delivered. The episiotomy site should be
inspected immediately after delivery and before placental expulsion. At
that time, compression with a sterile gauze sponge should control most
bleeding. However, if a small artery is bleeding, it may require clamp-
ing and ligation. Once the repair begins, incorporation of the tissue in
the suture usually will be sufficient. However, careful attention must be
paid to episiotomy sites that continue to bleed to avoid the formation
of a hematoma. If a hematoma does form, it increases the risk of infec-
tion and causes increased pain. Small hematomas can be treated with ice
packs and analgesics. Larger ones may need to be drained or evacuated.
A mediolateral episiotomy will bleed more than a midline episio-
tomy. Because this incision is more likely to involve muscle, the risk of
heavy bleeding is increased. Arterial bleeding from muscle usually
comes from a vessel that is retracted deep into the muscle so ligation is
often difficult. Because the ischioanal fossa area is adjacent to the
mediolateral site, careful hemostasis is essential to prevent formation of
deep hematomas, which can dissect upward into the upper vagina and
broad ligament. In rare instances, a hematoma can spread into the
anterior abdominal wall through a defect in Colles fascia connection
to the pubic rami.

Infection
The area of the episiotomy is heavily colonized by bacteria naturally
and frequently is contaminated by fecal matter during the delivery
process. Therefore, the risk of infection is very high. However, the
womans own defenses will help prevent most episiotomies from being
20 Episiotomy

infected. The obstetrician also can help by gently irrigating the area
using sterile saline or water, with or without the use of an antiseptic. If
infection does occur, rapid treatment is essential to avoid necrosis,
breakdown of the site, and sepsis. Necrotizing fasciitis can occur, and
its presence can be life threatening. Some physicians recommend irri-
gating with an antibacterial solution for fourth-degree extension. If an
examining finger is placed in the rectum during the repair, the sur-
geons gloves should be changed once the closure is complete to reduce
contamination during the remaining repair. Antibiotic therapy is not
indicated in the absence of infection. The use of sitz baths and stool
softeners may be helpful and reduce the need for pain medication.

Pain and Dyspareunia


Pain in the site of the episiotomy is not uncommon. Although women
without episiotomies have perineal pain, those with episiotomies will
often have pain that is more localized and lasts longer. If the patient
experiences severe pain, it is important to examine the site to rule out
hematoma or infection. These two complications can greatly increase
the pain level. Most pain related to a midline episiotomy will respond
to mild analgesics and resolve in 35 days. Pain from a mediolateral
episiotomy may last longer. The pain will be most noticeable during
ambulation.
A concern for many women is the first episode of intercourse after
giving birth. For some women, the episiotomy site will be tender.
Almost 40% of women have dyspareunia following an episiotomy (19,
20). The association of dyspareunia appears to be stronger with medio-
lateral incisions than with midline incisions, but there are no good
comparisons. There is some evidence that third- and fourth-degree
extensions will result in greater pain with intercourse (17). The type of
suture material used in the repair also may be a factor, and the use of
certain synthetic polyglycolic sutures has been shown to be associated
with earlier resumption of intercourse (21). Dyspareunia also is related
to the couples relationship both before and after the delivery. When a
woman experiences dyspareunia, it should be evaluated and not auto-
matically assumed to result from the episiotomy.
Episiotomy 21

Extension
A common complication of a midline episiotomy is extension into the
rectum. Careful exploration of the incision is necessary to ascertain if
this occurred. Once the transverse perineal muscles and the anal
sphincter tear, the rectal mucosa must be inspected carefully for
involvement. At the time of the episiotomy, the perineum is stretched
and thinned, which may result in iatrogenic extensions. Failure to rec-
ognize the extension can lead to infection, fistula formation, and even
breakdown of the episiotomy.

Other Complications
Rare, but more serious complications are dehiscence, fistula formation,
and anal incontinence. These conditions are beyond the scope of this
monograph but should be kept in mind as potentially serious compli-
cations.

Perineal Lacerations
Although not related to the episiotomy, during the process of child-
birth, tears may occur in multiple areas of the vaginal and paravaginal
area (Fig. 10). In most instances, they are minor and require no specific
therapy. However, it is important to examine the vagina and peri-
urethral areas carefully to determine if tears have occurred.

Periurethral Tears
Small tears and abrasions are seen frequently in the periurethral and
clitoral area after delivery. This is especially true when delivery occurs
without an episiotomy. These tears are usually 11.5 cm in length and
do not bleed. However, if the tears are bleeding, they should be
sutured. Very small, usually 4-0 suture is preferable. Secondary swelling
can occur, causing difficult voiding, and should be evaluated as part of
the immediate postpartum examination. Some women will report
dysuria, but careful questioning will reveal that urine touching the site
of the laceration is the cause of the discomfort and not true dysuria.
22 Episiotomy

1st degree 2nd degree perineal


perineal laceration plus
laceration tear of clitoris

3rd degree
perineal High vaginal
laceration and laceration
labial tear

C D
Fig. 10. Obstetric lacerations. A. First-degree perineal laceration. B. Second-
degree perineal laceration plus tear of clitoris. C. Third-degree perineal
laceration and labial tear. D. High vaginal laceration. (Netter RH. Atlas of
human anatomy. 4th ed. Philadelphia [PA]: Saunders Elsevier; 2006. Netter
illustrations used with permission of Elsevier Inc. All rights reserved.)
Episiotomy 23

Vaginal Tears
As the fetal head descends through the vagina, passage over the ischial
spines and through the outlet can compress the vaginal mucosa and
cause abrasions and tears. These tears can be extensive, especially in the
presence of a small pelvis with prominent spines and a large baby. They
are also more common with forceps deliveries.
After delivery of the infant, with or without an episiotomy, the vagi-
nal vault should be examined. Specific areas to be examined include
the paracervical areas, over the spines, and near the outlet. Minor abra-
sions that are not bleeding do not require suturing, even if they are
extensive. The most difficult to repair and the most serious are those
tears in the deep vaginal areas. They should be sutured even if they are
not bleeding at the time of exploration. A running, locking suture of
2-0 or 3-0 is best because the tissue often is edematous and friable. The
suture should begin at least 1 cm above the apex of the tear because
vessels may have retracted, and continued bleeding can result in a
hematoma extending up into the broad ligament. It is important to
inspect the cervix to ascertain that the vaginal tear is not in reality an
extension of a cervical tear. If it is a cervical tear, usually at 3- or 9-
oclock positions, it should be repaired if it is actively bleeding, extends
into the vagina, or is longer than 12 cm in length.

Perineal Tears
Tears in the perineum may occur when an episiotomy is not performed
or is performed late in delivery. These tears may appear jagged and
irregular in appearance (see Fig. 10). However, they should be repaired
by the same method that is used when repairing a similar episiotomy.
Smaller tears in the perineal skin may occur during a delivery. These
tears usually do not need to be repaired unless they are bleeding. Once
the legs are removed from the lithotomy position, the tears will come
together and no further therapy is needed. If active bleeding is
observed, one or two small sutures may be needed.
24 Episiotomy

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