What are the indications for an episiotomy?
Diagrams and pictures of episiotomy and episiotomy repair are available
moondragon - Please note that we would recommend a continuous
subcuticular suture to close the vaginal skin.
An episiotomy is a surgical incision through the
perineum made to enlarge the vagina and assist childbirth.
Prior to an episiotomy, lignocaine is injected into the
subcutaneous tissues of the perineum and vagina. A right mediolateral
cut is then made and pressure on the fetal head is maintained so that
the delivery is slow and the head remains flexed, minimizing the
possibility of the incision extending.
At one time it was believed that episiotomies reduced
the incidence of anal sphincter tears. There is, however, little good
evidence to support this and there is certainly no evidence to support
routine episiotomy in all deliveries as a preventive measure against
third- or fourth degree tears. Episiotomy rates are falling (Figure 1.)
Figure 1. Falling Episiotomy Rates. A study
involving 34,048 vaginal births at Thomas Jefferson University Hospital
in Philadelphia, Pa, which showed a reduction in episiotomy rates from
69.6% in 1983 to 19.4% in 2000
Midline episiotomy in particular does not protect the
perineum or sphincters during childbirth and may impair anal continence.
If an episiotomy is to be performed at all, a right (or less commonly
left) posterolateral episiotomy is preferred (Figure 2).
Figure 2. A right medio-lateral
- To protect the premature baby's head from undue pressure during
- To allow more space for the application of forceps.
- To protect the baby's head if the perineum is tight and
unyielding or is delaying the birth of the baby.
- To speed up second stage.
How is it done?
The mother is asked to lie back so that a clear view of the perineum can
- Local anaesthetic is injected in several places close to where
the tissues will be cut.
- If the cut is made when the skin is numb from stretching, then
no anaesthesia may be needed until stitching begins.
- When the head is crowning, the doctor or midwife makes a
surgical cut, using scissors, from the base of the vagina either out
to the side (lateral) or down towards the anus (midline).
Occasionally a J-shaped incision is made, to the side.
How is an episiotomy repaired?
These newer materials result in
less short-term pain and less analgesic requirements than older
materials such as catgut and non-absorbable sutures. Good perineal
hygiene after delivery is likely to aid healing, and the use of ice
packs. The perineum is infiltrated with 1%
lignocaine unless an epidural is in situ or there has been a pudendal
block or perineal infiltration prior to delivery. The apex of the
vaginal incision or tear is identified and the first suture placed above
this level.An episiotomy repair is demonstrated by
Figures 3-5.Repair should be with
an absorbable synthetic material (Dexon or Vicryl), using a continuous
subcuticular technique to minimize short- and long-term problems.
Figure 3. The vaginal mucosal suture
commences from just above the apex of the incision and the perineal
musculature has an inverted suture.
Figure 4. The muscle is closed with a
Figure 5. The vaginal skin is closed with
a continuous subcuticular suture.
A tear may be less painful than an episiotomy and may
also heal better.
Classification of spontaneous perineal tears:
- First degree Injury to the vaginal epithelium and
vulval skin only.
- Second degree Injury to the perineal muscles, but
not the anal sphincter.
- Third degree Injury to the perineum involving the
anal sphincter complex.
- Fourth degree Injury to the perineum involving the
anal sphincter complex and rectal mucosa.
Repairing a third or fourth degree tear.
This should ideally be by an experienced clinician, in
theatre, with good analgesia, good lighting and the appropriate
instruments. The anal mucosa should be repaired using interrupted
dissolving sutures, with the knot of each suture in the lumen of the
bowel. The internal sphincter is then identified and its ends
approximated and sutured with a monofilament suture such as
polydioxanone (PDS). Next, the ends of the external anal sphincter are
identified and either approximated or overlapped, again with the
monofilament suture. The rest is as described for episiotomy repair.
Antibiotics, laxatives and fibre are important to allow healing. If
secondary breakdown occurs, it may be necessary to perform a
defunctioning colostomy before re-repairing.
Women delivering in the Swedish setting had a 23 times higher risk of
OASR compared to Italy. An association between obstetric anal sphincter
rupture and birth weight, gestational age,
instrumental vaginal deliveries and duration of second stage was found.