View source for Episiotomy

==Episiotomy==
*Midline episiotomy - easier to heal, less painful, but can extend to anus
*Mediolateral - unlikely to extend to anus
*Anatomic structures - vaginal epithelium, transverse perineal muscle, bulbocavernosus muscle, perineal skin
*ACOG recommends restricting episiotomies, and prefers mediolateral to median (Level A, 2006)
*Current data is of poor quality in regards to benefits to mother or baby
*Procedure avoids spontaneous tearing and/or aids in difficult delivery:
**Shoulder dystocia (contentiously the only indication)
**If possible, avoid even in these situations: 
***Baby is large or in breech
***Labor is going too quickly
***Extraction instruments needed (forceps, vacuum assisted)
*Contraindications:
**IBD
**Perineal malformations

==Procedure (Mediolateral)==
*May be performed on either side
*Anesthetic to include local, [[Pudendal nerve block]], epidural if available
*Protect fetal head with operator hand, and cut along operator hand
*Begin incision at posterior fourchette, continue at angle of 45 - 90 degrees relative to perineal body
*Incise to generally 3-4 cm in length

==Complications==
*Bleeding
*Extension to higher-odre lacerations
*Infection - routine antibiotic prophylaxis not recommended by ACOG due to lack of evidence
*Dehiscence

==Repair==
*Examine 360 degrees for other non-hemostatic lacerations that require sutures
*Use 2-0 or 3-0 vicryl rapide or similar - the same suture will be used to close all tissue
*Start an anchoring stitch at apex within vaginal mucosa
*Continuous LOCKing sutures along vaginal mucosa/submucosa
*Once at the hymen/perineal muscles, tie suture, but do not cut continuous end
*Bury the knot within the perineum, and come out with the needle at the apex of the perineum
*Continue suturing perineal muscles up to skin in a NON-locking fashion
*At apex of skin, perform dermal approximations down to distal skin edge
*Return to apex of skin with a subcuticular stitch (like a monocryl skin closure) and tie knot
*Bury knot in superficial perineum/subQ and cut remaining suture from needle

==References==
*Lappen et al. Episiotomy and Repair Technique. Updated Feb 27, 2014. http://emedicine.medscape.com/article/2047173-technique#showall
*American College of Obstetrics and Gynecology. Episiotomy. ACOG Practice Bulletin #71. Obstet Gynecol. 2006. 107:957-62. 
*American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 120: use of prophylactic antibiotics in labor and delivery. Obstet Gynecol. 2011 Jun. 117(6):1472-83.



[[Category:OBGYN]]