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

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

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