Procedure and

Repair Techniques

The American College of Obstetricians and Gynecologists

WOMEN ’ S HEALTH CARE PHYS IC I ANS

EPISIOTOMY

Procedure and

Repair TechniquesRALPH W. HALE, MD

FRANK W. LING, MD

The American College of Obstetricians and Gynecologists

WOMEN ’ S HEALTH CARE PHYS IC I ANS

EPISIOTOMY

Episiotomy: Procedure and Repair Techniques represents the knowledge andexperience of experts in the field and does not necessarily reflect College policy.Methods and techniques of clinical practice that are currently acceptable and usedby 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 limitationsunique 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 andGynecologists. III. Title. [DNLM: 1. Episiotomy. WQ 415 H163e 2007]

RG971.H35 2007618.8’5--dc22

2006036891

Copyright © 2007 by the American College of Obstetricians and Gynecologists, 40912th 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, postedon the Internet, or transmitted, in any form or by any means, electronic, mechani-cal, photocopying, recording, or otherwise, without prior written permission fromthe publisher.

ISBN 978-1-932328-29-5

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iii

CONTENTS

Preface v

Introduction 1Indications 3Types of Episiotomy 4ACOG Position 5

Basic Anatomy of the Perineum 3External 3

Internal 6

Midline Episiotomy 8Procedure 8Repair 11

Mediolateral Episiotomy 16Procedure 16

Repair 16

Complications 19Bleeding 19

Infection 19

Pain and Dyspareunia 20

Extension 21

Other Complications 21

Perineal Laceration 21Periurethral Tears 21

Vaginal Tears 23

Perineal Tears 23

References 24

v

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, MDACOG Executive Vice President

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 infant’s 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 examiner’s 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

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 Delee’s 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.

2 Episiotomy

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

Episiotomy 3

IndicationsToday, 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,

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 andPrevention, 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.

Episiotomies Performed in the United States

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 EpisiotomyThe 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

First-degree tear: A superficial laceration of the mucosa of the vagina,which may extend into the skin at the introitus. Itdoes not involve deeper tissues and may notrequire repair.

Second-degree tear: A first-degree laceration that involves the vaginalmucosa and perineal body. It may extend to thetransverse perineal muscles and requires a suturerepair.

Third-degree tear: A second-degree laceration that extends into themuscle of the perineum and may involve both thetransverse perineal muscles as well as the analsphincter. 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 combinethe first- and second-degree tears as only one level.

4 Episiotomy

Extension of Episiotomy

Episiotomy 5

Fig. 1. Midline and mediolateral episiotomy.(Pilliteri A. Maternal and child nursing.4th ed. Philadelphia [PA]: Lippincott,Williams & Wilkins; 2003.)

Head of baby

Midline

Mediolateral

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 PositionThe 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.

ExternalThe 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 3–4 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 oflabia majora

Prepuce of clitoris

Pudendal cleft (groove orspace between thelabia majora)

Glans of clitoris

Frenulum of clitoris

External urethral orifice

Labium minus

Labium majus

Openings of paraurethral(Skene’s) ducts

Vestibule of vagina(cleft or space surroundedby labia minora)

Vaginal orifice

Opening of greatervestibular (Bartholin’s) gland

Hymenal caruncle

Vestibular fossa

Frenulum of labia minora

Posterior commissure oflabia majora

Perineal raphe(over perineal body)

Anus

Fig. 2. External genitalia. (Netter RH. Atlas of human anatomy. 4thed. Philadelphia [PA]: Saunders Elsevier; 2006. Netter illus-trations used with permission of Elsevier Inc. All rightsreserved.)

InternalUnderlying 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

Suspensory ligament of clitoris

Bulb of vestibule

Perineal membrane

Greater vestibular(Bartholin’s) gland

Bulbospongiosusmuscle(cut away)

Superficialtransverseperinealmuscle

Perinealbody

ClitorisBulbospongiosus musclewith deep perineal (investingor Gallaudet’s) fasciapartially removed

Superficial perineal space(pouch or compartment)

Ischiopubic ramuswith cut edge ofsuperficialperineal (Colles’)fascia

Perinealmembrane

Ischialtuberosity

Sacro-tuberousligament

Gluteusmaximusmuscle

Obturatorfascia

Tendinous arch oflevator ani muscle

Inferior fascia ofpelvic diaphragm (cut)

Levator ani muscle

External anal sphincter muscle

Anococcygeal (ligament) body

CoccyxIschioanal fossa

Crus ofclitoris

Ischio-pubicramus

Bulb ofvestibule

Greater vestibular(Bartholin’s) gland

Perineal membrane

Urethra

Sphincter urethraemuscle

Perineal membrane(cut and reflected)

Compressor urethraemuscle

Sphincter urethrovaginalismuscle

Vagina

Deep transverseperineal muscle

Ischiocavernosus muscle

Fig. 3. Muscle and fascial supports of the perineum. (NetterRH. Atlas of human anatomy. 4th ed. Philadelphia [PA]:Saunders Elsevier; 2006. Netter illustrations used withpermission of Elsevier Inc. All rights reserved.)

Episiotomy 7

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 Bartholin’s 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

ProcedureBefore 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

Round ligamentTubalOvarian

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

Posteriorlabial artery

Ischiocavernosusmuscle

Bulbospongiosusmuscle

Superficialperineal space

Perinealmembrane

Perinealartery

Superficialtransverseperinealmuscle

Perinealartery

Internalpudendalartery inpudendalcanal(Alcock’s)

Inferiorrectal artery

External anal sphincter muscle

Note: Deep perineal (investing orGallaudet’s) fascia removed from muscles of superficial perineal space

Ovarian vessels

Tubal branches of ovarian vessels

Branchesofuterineartery

Inferior rectal artery

Superficial perineal (Colles’)fascia (cut and reflected)to open superficial perineal space

Perineal artery (cut)

Internal pudendal (clitoral) artery

Deep transverse perineal muscle

Greater vestibular (Bartholin’s) gland

Artery to bulb of vestibule

Compressor urethrae muscle

Bulb of vestibule

Deep artery of clitoris

Dorsal artery of clitoris

Internal pudendal arteryin pudendal canal (Alcock’s)

Perineal membrane (cut)

Fig. 4. Blood supply of the perineum. (Netter RH. Atlas ofhuman anatomy. 4th ed. Philadelphia [PA]: SaundersElsevier; 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

Deep

Branches of perinealnerve

Perineal branch ofposterior femoralcutaneous nerve

Dorsal nerve ofclitoris passingsuperior toperineal membrane

Inferior clunialnerves

Gluteus maximusmuscle (cut away)

Pudendal nerve inpudendal canal(Alcock’s) (dissected)

Perineal nerve

Sacrotuberous ligament

Anococcygeal nerves

Inferior anal (rectal) nerves

Perforating cutaneous nerve

Fig. 5. Innervation of the perineum. (Netter RH. Atlas ofhuman anatomy. 4th ed. Philadelphia [PA]:Saunders Elsevier; 2006. Netter illustrations usedwith 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, A–F). A complete knowledge of perineal anatomy is

necessary if this is to occur (see “Basic Anatomy of the Perineum”).

Fig. 6. Midline episiotomy. (BeckmanCRB, Ling FW, Laube DW, SmithRP, 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 o’clock position, then the most internal suture at

the 9 o’clock position, then at the top or most superior part of the

muscle, followed by a 3 o’clock 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 o’clock 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 o’clock 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 therectal mucosa. B. Closure of the anal sphincter.C. Second layered closure of the rectal mucosausing the rectovaginal fascia. D. Anchor stitchplaced 1 cm beyond the most superior extent ofthe episiotomy. E. Use of one suture for closure.F. Completion of repair using a subcuticularsuture. (Hankins GDV, Clark SL, Cunningham FG,Gilstrap LC. Operative obstetrics. New York [NY]:McGraw-Hill; 1995. Reproduced with permissionof The McGraw-Hill Companies.)

A

B

Episiotomy 15

C

D

E

F

16 Episiotomy

Mediolateral Episiotomy

ProcedureA 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 patient’s 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.

RepairImmediately 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,

A–D). 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 withthe permission of The McGraw-HillCompanies.)

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

B

C

D

Fig. 9. Repair of mediolateral episiotomy.A. Placement of the first suture at thevaginal apex. B. Approximation of thevaginal mucosa. C. The vaginal wound issutured to the approximate level of theposterior commissure. D. Approximationof 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-HillCompanies.)

A

Complications

BleedingOne 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.

InfectionThe 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

woman’s own defenses will help prevent most episiotomies from being

Episiotomy 19

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-

geon’s 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 DyspareuniaPain 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 3–5 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 couple’s 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

ExtensionA 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 ComplicationsRare, 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 1–1.5 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 degreeperineallaceration

2nd degree perineallaceration plustear of clitoris

3rd degreeperineallaceration andlabial tear

High vaginallaceration

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

B

C D

A

Episiotomy 23

Vaginal TearsAs 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-

o’clock positions, it should be repaired if it is actively bleeding, extends

into the vagina, or is longer than 1–2 cm in length.

Perineal TearsTears 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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12. Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J Jr, Lohr KN.Outcomes of routine episiotomy: a systematic review. JAMA 2005;293:2141–8.

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15. Thacker SB, Banta HD. Benefits and risks of episiotomy: an interpretive review of theEnglish language literature, 1860-1980. Obstet Gynecol Surv 1983;38:322–38.

16. Episiotomy. ACOG Practice Bulletin No. 71. American College of Obstetricians andGynecologists. Obstet Gynecol 2006;107:957–62.

17. Klein MC, Gauthier RJ, Robbins JM, Kaczorowski J, Jorgensen SH, Franco ED, et al.Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction,and pelvic floor relaxation. Am J Obstet Gynecol 1994;171:591–8.

18. Bodner-Adler B, Bodner K, Kaider A, Wagenbichler P, Leodolter S, Husslein P, et al:Risk factors for third-degree perineal tears in vaginal delivery, with an analysis of epi-siotomy types. J Reprod Med 2001;46(8):752–6.

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21. Leroux N, Bujold E. Impact of chromic catgut versus polyglactin 910 versus fast-absorbing polyglactin 910 sutures for perineal repair: a randomized, controlled trial.Am J Obstet Gynecol 2006;194:1589–90; discussion 1590.