• 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


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


  • 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


  • 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.