Preprocedural Planning

Keep in mind that episiotomy does not provide protection against any adverse maternal or neonatal outcomes, including pelvic floor dysfunction, dyspareunia, and incontinence. Given the lack of proven benefit to episiotomy, routine use of the procedure should be abandoned; targeted or restricted use of episiotomy is appropriate (see Indications).

Limited data exist regarding the optimal timing and technique of episiotomy. Midline episiotomy increases the risk of third- and fourth-degree lacerations; therefore, if an episiotomy is clinically necessary, a mediolateral incision may be preferable. If an episiotomy is performed, careful attention must be directed to examine for possible extensions into higher-order lacerations, which must be appropriately repaired to avoid complications.

Patient Preparation

Adequate anesthesia is required before a midline episiotomy. Innervation to the perineum is provided by the pudendal nerve, a branch of sacral nerves S2-4. Appropriate techniques for anesthesia include local infiltration, pudendal nerve block, and neuraxial analgesia (eg, epidural or saddle block). The perianal area occasionally receives innervation from a cutaneous branch of the inferior anal nerve, and in these cases a pudendal block will not provide adequate pain relief for the procedure. Local infiltration or neuraxial anesthesia will be necessary.^[18]

Appropriate analgesia for a mediolateral episiotomy is similar to that required for midline episiotomy.

Technique

Ould F. A Treatise on Midwifery in Three Parts. Dublin: Nelson & Connor; 1742.
DeLee JB. The prophylactic forceps operation. Am J Obstet Gynecol. 1920. 1:34-44.
Thacker SB, Banta HD. Benefits and risks of episiotomy: an interpretative review of the English language literature, 1860-1980. Obstet Gynecol Surv. 1983 Jun. 38 (6):322-38. [QxMD MEDLINE Link].
Sleep J, Grant A, Garcia J, Elbourne D, Spencer J, Chalmers I. West Berkshire perineal management trial. Br Med J (Clin Res Ed). 1984 Sep 8. 289 (6445):587-90. [QxMD MEDLINE Link]. [Full Text].
DeFrances CJ, Hall MJ, Podgornik MN. 2003 National Hospital Discharge Survey. Advance data; No. 359. Hyattsville (MD): National Center for Health Statistics; 2005. Retrieved December 29, 2005. [Full Text].
Martin JA, Hamilton BE, Sutton PD, et al. Births: final data for 2003. Natl Vital Stat Rep. 2005 Sep 8. 54 (2):1-116. [QxMD MEDLINE Link].
Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst Rev. 2009 Jan 21. (1):CD000081. [QxMD MEDLINE Link]. [Full Text].
Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J Jr, Lohr KN. Outcomes of routine episiotomy: a systematic review. JAMA. 2005 May 4. 293 (17):2141-8. [QxMD MEDLINE Link].
American College of Obstetricians-Gynecologists. ACOG Practice Bulletin. Episiotomy. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 71, April 2006. Obstet Gynecol. 2006 Apr. 107 (4):957-62. [QxMD MEDLINE Link].
Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 198: Prevention and Management of Obstetric Lacerations at Vaginal Delivery. Obstet Gynecol. 2018 Sep. 132 (3):e87-e102. [QxMD MEDLINE Link].
National Collaborating Centre for Women’s and Children’s Health. Intrapartum Care: Care of Healthy Women and Their Babies During Childbirth. London: RCOG Press; 2007.
The Management of Third- and Fourth-Degree Perineal Tears. RCOG. Green-top Guideline No. 29. Available at https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-29.pdf. Published online June 12, 2015; Accessed: June 24, 2016.
Barclay L. RCOG Guidelines Update Management of Severe Perineal Tears. Medscape Medical News. Available at http://www.medscape.com/viewarticle/846503. June 15, 2015; Accessed: June 26, 2016.
Chauhan SP, Gherman R, Hendrix NW, Bingham JM, Hayes E. Shoulder dystocia: comparison of the ACOG practice bulletin with another national guideline. Am J Perinatol. 2010 Feb. 27(2):129-36. [QxMD MEDLINE Link].
Paris AE, Greenberg JA, Ecker JL, McElrath TF. Is an episiotomy necessary with a shoulder dystocia?. Am J Obstet Gynecol. 2011 Sep. 205(3):217.e1-3. [QxMD MEDLINE Link].
Varner MW. Episiotomy: techniques and indications. Clin Obstet Gynecol. 1986. 29:309.
Quilligan EJ, Zuspan F. Douglass-Stromme Operative Obstetrics. 5th ed. Norwalk, CT: Appleton-Century-Crofts; 1988. 698.
Hale RW, Ling FW. Episiotomy: Procedure and Repair Techniques. Washington, DC: American College of Obstetricians and Gynecologists; 2007.
Kilpatrick S, Garrison E. Normal labor and delivery. Gabbe S, ed. Obstetrics, Normal and Problem Pregnancies. 5th ed. Philadelphia: Churchill Livingston Elsevier; 2007. 303-21.
Garner DK, Patel AB, Hung J, et al. Midline and mediolateral episiotomy: risk assessment based on clinical anatomy. Diagnostics (Basel). 2021 Feb 2. 11 (2):[QxMD MEDLINE Link]. [Full Text].
Gilstrap LC III, Cunningham FG, VanDorsten JP. Operative Obstetrics. 2nd ed. New York: McGraw-Hill; 2002.
Graves CR. Obstetric problems. Rock JA, Jones HW III, eds. TeLinde’s Operative Gynecology. 10th ed. Philadelphia: Lippincott Williams & Wilkins; 2008. 825-41.
Toglia MR. Repair of episiotomy and perineal lacerations associated with childbirth. UpToDate, Version 19.3. August 2011.
Owen J, Hauth, JC. Episiotomy infection and dehiscence. Gilstrap LC III, Faro S, eds. Infections in Pregnancy. New York: Alan R Liss; 1990.
Aasheim V, Nilsen AB, Lukasse M, Reinar LM. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev. 2011 Dec 7. 12:CD006672. [QxMD MEDLINE Link].
Royal College of Obstetricians and Gynaecologists. The management of third- and fourth-degree perineal tears. Green-top guideline No. 29, March 2007.
Duggal N, Mercado C, Daniels K, Bujor A, Caughey AB, El-Sayed YY. Antibiotic prophylaxis for prevention of postpartum perineal wound complications: a randomized controlled trial. Obstet Gynecol. 2008 Jun. 111(6):1268-73. [QxMD MEDLINE Link].
Buppasiri P, Lumbiganon P, Thinkhamrop J, Thinkhamrop B. Antibiotic prophylaxis for third- and fourth-degree perineal tear during vaginal birth. Cochrane Database Syst Rev. 2010 Nov 10. CD005125. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
Fernando RJ, Williams AA, Adams EJ, on behalf of the Guidelines and Audit Committee of the Royal College of Obstetricians and Gynaecologists. The management of third- and fourth-degree perineal tears. London, UK: RCOG. Green-top guideline no. 29. Mar 2007. [Full Text].
Ramin SM, Gilstrap LC 3rd. Episiotomy and early repair of dehiscence. Clin Obstet Gynecol. 1994. 37:816.
Ramin SM, Ramus RM, Little BB, Gilstrap LC 3rd. Early repair of episiotomy dehiscence associated with infection. Am J Obstet Gynecol. 1992. 167:1104.
Hankins GD, Hauth JC, Gilstrap LC 3rd, et al. Early repair of episiotomy dehiscence. Obstet Gynecol. 1990. 75:48.
Arona AJ, al-Marayati L, Grimes DA, Ballard CA. Early secondary repair of third- and fourth-degree perineal lacerations after outpatient wound preparation. Obstet Gynecol. 1995. 86:294.

Media Gallery

Anatomy of the female perineum, with potential sites for episiotomy incision indicated. Image courtesy of Wikimedia Commons (Blausen.com staff in Blausen gallery 2014. Wikiuniversity Journal of Medicine. Available at: https://commons.wikimedia.org/wiki/File:Blausen_0355_Episiotomy.png).
Crowning of an infant's head, with potential sites for episiotomy incision indicated. Image courtesy of Wikimedia Commons (Blausen.com staff in Blausen gallery 2014. Wikiuniversity Journal of Medicine. Available at: https://commons.wikimedia.org/wiki/File:Blausen_0294_Delivery_Crowning.png).
Incisions for mediolateral and midline (median) episiotomy. Image courtesy of Wikimedia Commons (Available at: https://commons.wikimedia.org/wiki/File:Medio-lateral-episiotomy.gif).

of 3

Episiotomy and Repair Periprocedural Care

Preprocedural Planning

Patient Preparation

References

Tables

Contributor Information and Disclosures

What would you like to print?