Episiotomy and Repair Periprocedural Care

Updated: Apr 19, 2021
  • Author: Justin R Lappen, MD; Chief Editor: Christine Isaacs, MD  more...
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Periprocedural Care

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.