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

Repair

• Examine 360 degrees for other non-hemostatic lacerations that require sutures
• Use 2-0 or 3-0 vicryl rapide or similar
• Start an anchoring stitch 1 cm above apex within vaginal mucosa
• Continuous locking sutures along vaginal mucosa/submucosa
• Once at the hymen/perineal muscles, tie suture, but don't cut continuous end
• Bury the knot within the perineum

Sources

• Lappen et al. Episiotomy and Repair Technique. Updated Feb 27, 2014. http://emedicine.medscape.com/article/2047173-technique#showall