Episiotomy and Repair

Episiotomy is a surgical incision of the perineum performed by the accoucheur to widen the vaginal opening to facilitate the delivery of an infant (see the following images). It is one of the most commonly performed procedures on women worldwide. Initially described in 1742, episiotomy was introduced into the United States in the mid-19th century.[1] In 1920, at a meeting of the American Gynecological Society in Chicago, Dr Joseph DeLee first publicly advocated the routine adoption of mediolateral episiotomy for all deliveries in nulliparous women.[2]

Episiotomy was first recommended as a way of facilitating completion of the second stage of labor and reducing the maternal and neonatal trauma and morbidity associated with delivery. The purported short-term benefits for the parturient included its ease of repair compared to a spontaneous perineal laceration, decreased postpartum pain, and reduction in severe or third- or fourth-degree lacerations.

Additional long-term benefits were believed to accrue from shortening the time for which the perineum was stretched during birth, including prevention of pelvic floor relaxation, pelvic organ prolapse, sexual dysfunction, and urinary and fecal incontinence. The purported benefits to the neonate included prevention of asphyxia, cranial trauma, and cerebral hemorrhage, as well as reduction of the risk of shoulder dystocia.

Despite a lack of supporting data, episiotomy was widely adopted into obstetric practice after 1920 and came to be considered standard of care by many American obstetric care providers. By 1979, episiotomy was performed in approximately 63% of all deliveries in the United States, with higher rates among nulliparas.[3] In Great Britain in the same era, episiotomy rates ranged from 14-96% among nulliparas and from 16-71% among multiparas.[4]

In the 1970s and 1980s, however, obstetric providers began to question the routine use of episiotomy. A growing body of evidence began to emerge that demonstrated the potential consequences of episiotomy, including increased risk of extension to severe perineal lacerations, dyspareunia, and future pelvic floor dysfunction.

As a result, the use of episiotomy has decreased from its 20th-century peak. For example, the number of episiotomies performed annually in the United States fell from over 1.6 million in 1992 to 716,000 in 2003 as a more restricted use of the procedure was adopted.[5, 6]

The ability to provide evidence-based recommendations regarding the indications for and technique of episiotomy is limited by the scarcity of high-quality data. Accordingly, indications for the procedure are based largely on clinical opinion and anecdote. The best data on episiotomy focus on routine versus restricted use of the procedure.

A Cochrane review of the existing literature on episiotomy found that most studies were of such poor quality that they could not be included.[7] Their review concluded that episiotomy did not decrease rates of urinary incontinence, pain, or sexual dysfunction, and that it increased the rates of perineal laceration, suture placement and perineal repair, and wound complications.

In addition, the authors concluded that episiotomy conferred no benefits on the neonate.[7] They also found that of the 3 studies comparing midline (median) episiotomy with mediolateral episiotomy, none were of high enough quality to be included in their review; thus, they were unable to draw any conclusions about the superiority or inferiority of a given episiotomy type.

Another systematic review was published in the Journal of the American Medical Association (JAMA) in 2005.[8] This review included more studies than the Cochrane review had, but it came to identical conclusions.

In regard to short-term outcomes, the JAMA review concluded that episiotomy resulted in more pain, more need for pain medication, and more severe lacerations than no episiotomy.[8] In regard to long-term outcomes, it found that the evidence was of poor quality, that episiotomy yielded no significant improvement in urinary or fecal incontinence, prolapse, or sexual function, and that it was associated with greater dyspareunia.

The JAMA authors concluded that “[i]n the absence of benefit and with a potential for harm, a procedure should be abandoned…. Evidence does not support maternal benefits traditionally ascribed to routine episiotomy. In fact, outcomes with episiotomy can be considered worse since some proportion of women who would have had a lesser injury instead had a surgical incision.”[8]

Since the publication of the JAMA and Cochrane meta-analyses, various professional bodies, including the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynaecologists (RCOG), and the National Institute for Health and Clinical Excellence (NICE), have published consensus guidelines addressing episiotomy in current clinical practice.

An ACOG Practice Bulletin published in 2006 and reaffirmed in 2016 concluded that median episiotomy is associated with higher rates of injury to the anal sphincter and rectum than mediolateral episiotomy and recommending restricted use of episiotomy in clinical practice (level A recommendation).[9, 10]  ACOG further concluded that routine episiotomy does not prevent pelvic floor damage leading to incontinence and that mediolateral episiotomy may be preferable to midline episiotomy when clinically indicated (level B recommendation).

The ACOG Practice Bulletin further advised that data show no immediate or long-term maternal benefit of routine episiotomy in perineal laceration severity, pelvic floor dysfunction, or pelvic organ prolapse compared with restrictive use of episiotomy. The Practice Bulletin also again noted that episiotomy has been associated with increased risk of postpartum anal incontinence.[10]  The ACOG recommendations also noted that although most lacerations during vaginal delivery are first-and second-degree lacerations, more severe third-and fourth-degree lacerations that result in obstetric anal sphincter injuries (OASIS) may occur in up to 11% of women giving birth vaginally.[10]

In 2007, NICE and RCOG published similar guidelines recommending against routine episiotomy and advocating mediolateral episiotomy in clinically indicated cases.[11] The NICE and RCOG guidelines also outline the recommended technique for performing a mediolateral episiotomy.

In 2015, RCOG updated their guidelines on the Management of Third- and Fourth-Degree Perineal Tears adding the following[12, 13] :

• Evidence for the protective effect of episiotomy is conflicting
• Mediolateral episiotomy should be considered in instrumental deliveries

Major society recommendations recognize a restricted role for episiotomy to assist with difficult deliveries (eg, shoulder dystocia,[14] although dissents from this recommendation have been expressed[15] ), to facilitate delivery in the context of nonreassuring fetal status, or possibly to avoid a serious maternal laceration.[9]

Few contraindications to episiotomy exist. Episiotomy cannot be performed without consent of the patient.[16] Relative contraindications to the procedure include inflammatory bowel disease and severe perineal malformations. Episiotomy should not be performed unless vaginal delivery is considered to be possible.

Additionally, episiotomy should not be performed with operative vaginal delivery (forceps or vacuum) unless deemed necessary by the delivering provider; both procedures are associated with a significantly increased risk of severe perineal laceration.[17]

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.

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.

In an episiotomy, the perineum is incised with scissors or a scalpel as the infant’s head is crowning. Two types of episiotomy have been described: midline (median) and mediolateral (see the image below).[19] Generally, midline episiotomies are more commonly performed in the United States, whereas mediolateral episiotomies are more common in other parts of the world.

In a risk assessment based on clinical anatomy, Garner et al found that midline incisions increased the risk of direct and indirect injury to the subcutaneous portion of the external anal sphincter. Mediolateral incisions posed a higher risk of injury to ipsilateral nerve, muscle, erectile, and gland tissues.[20]

The incision is generally repaired after delivery of the placenta is completed. Repair of an episiotomy should take place in a setting that contains appropriate instruments, exposure, and lighting.

Procedure

A midline episiotomy may be performed after adequate anesthesia has been confirmed. Protecting the fetal head during the procedure is of utmost importance. Generally, the index and middle fingers are inserted into the vagina between the fetal head and the perineum. This maneuver provides space for making the incision.

A vertical incision is made in the midline of the perineum from the posterior fourchette toward the anus. Most commonly, the incision is made just before delivery of the fetal head, at the time when the perineum is thinned and stretched. At present, however, the evidence is insufficient to establish any particular time as the most appropriate for performing an episiotomy.

Repair

Repair of any perineal laceration, including episiotomy, serves the following 2 important functions:

• Hemostasis

• Tissue reapproximation for lacerated vaginal mucosa, soft tissue, and muscle

Accordingly, delivering providers must have a comprehensive understanding of perineal anatomy.

Various types of sutures have been used for episiotomy repair, and only limited evidence suggests the superiority of one material over another. Both chromic catgut and synthetic materials have been used successfully, and many providers now prefer braided standard or rapid-absorption polyglycolic acid sutures (typically Vicryl, Polysorb), given their minimally reactive nature. Additionally, monofilament sutures with more rapid absorption, such as Caproysn, may be used for perineal laceration repair.

Generally, the smallest-diameter suture that provides adequate tensile and knot strength for the surgical task should be used. In most instances, 2-0 and 3-0 sutures are suitable for reapproximation and repair of soft tissue in an episiotomy repair. For optimal visualization, repair should take place in a labor and delivery room or an operating room with appropriate lighting.

The ensuing description focuses on a standard episiotomy repair without extension, which is equivalent to a second-degree perineal laceration. A thorough examination of the perineum should always be performed to evaluate for extension to a third- or fourth-degree laceration. Further information regarding repair of third- and fourth-degrees lacerations is available in several standard obstetric references.[18, 21, 22, 23]

The repair is initiated by placing a suture approximately 1 cm proximal to the apex of the laceration within the vagina. The suture is secured with a knot, and the repair is continued in a continuous fashion (locked or nonlocked) to the level of the hymenal ring. The vaginal mucosa and submucosal tissue must be sufficiently reapproximated with the continuous suture, and all dead space must be closed. Careful attention must be directed to preventing sutures from passing deep enough to traverse the rectal mucosa.

Next, the hymen is reapproximated with the suture in a nonlocked fashion. This suture is then tucked through the hymenal ring posterior to the perineal body for the remainder of the repair. At this point, the muscular tissue of the perineal body is reapproximated; this includes an interrupted “crown stitch” of the bulbocavernosus muscles and interrupted or running sutures of the transverse perineal muscles.

The suture is then run posteriorly to the posterior apex of the incision to reapproximate the remainder of the perineal body. This is followed by a subcuticular skin closure run anteriorly to the introitus. Finally, the suture is secured with a knot inside the hymenal ring.

Procedure

As with a midline episiotomy, the data are insufficient to determine the optimal time for performing a mediolateral episiotomy. Most surgeons recommend making the incision immediately before delivery. The index and middle fingers are placed into the vagina between the fetal head and the perineum.

An incision is begun at the posterior fourchette and continued downward at an angle of at least 45° relative to the perineal body. The angle of the incision may approach 90° (perpendicular to the posterior fourchette) if the perineum is significantly stretched by the fetal head, so that upon relaxation of the perineum the angle will approach 45°. The incision can be performed on either side and is generally 3-4 cm in length.

The anatomic structures involved in a mediolateral episiotomy include the vaginal epithelium, transverse perineal muscle, bulbocavernosus muscle, and perineal skin. A deep or large mediolateral episiotomy may expose the ischiorectal fossa.

Repair

First, the delivering provider should examine the extent of the laceration after delivery, carefully evaluating for possible extension to third- or fourth-degree laceration. Either 2-0 or 3-0 sutures (of the same materials as used for midline episiotomy) may be used for the repair.

With 2 fingers placed in the vagina for retraction, the apex of the episiotomy site is identified, and a suture is secured approximately 1 cm proximally. The submucosal tissue and vaginal mucosa are reapproximated in a continuous fashion (either nonlocked or locked). A deep episiotomy or laceration may require additional submucosal sutures for appropriate tissue reapproximation and closure of dead space.

The bulbospongiosus muscle generally must be repaired. The fascial sheath of the muscle on both sides of the incision should be repaired in an interrupted fashion before closure of the skin, which is performed with a subcuticular stitch. Sutures should be placed perpendicular to the angle of the incision to prevent anatomic distortion of the perineum and vaginal opening.

Bleeding

Bleeding is one of the most common complications of episiotomy. The perineum and surrounding tissues have an extensive vasculature, and the blood supply to these areas is increased by the physiologic changes of pregnancy and labor.

Immediately after delivery, the episiotomy site should be inspected for bleeding. Because episiotomy is usually performed at the time of crowning, it sometimes happens that an incision is made through blood vessels that have been rendered invisible by compression from the fetal head. Inspection should include an evaluation for arterial bleeding, which may require suture ligation.

Typical episiotomy site bleeding can generally be controlled with conservative measures (eg, compression) while the repair is being performed to achieve hemostasis. Because of muscle involvement, a mediolateral episiotomy may give rise to more bleeding than a midline episiotomy. Careful inspection prior to and during the repair is required to assess for hematoma formation, which can cause significant maternal morbidity in the rare instances in which deep hematomas dissect proximally toward the upper vagina and the broad ligament.

Extension to higher-order lacerations

Another common complication of episiotomy is extension to higher-order perineal lacerations. Among primiparous women, the reported risk of third- or fourth-degree lacerations is 1% without an episiotomy, 9% with a mediolateral episiotomy, and 20% with a midline episiotomy.[24] Performance of a midline episiotomy may be the biggest risk factor for extension of a laceration into the rectum.[8, 9]

Close inspection and examination of the incision after delivery is of utmost importance; failure to identify an extension or higher-order laceration can result in infection, dehiscence, fecal incontinence, or fistula formation. Various perineal techniques (eg, warm compresses) may also be used in an effort to reduce perineal trauma.[25]

Infection

Because the site of the episiotomy is heavily colonized by bacteria and frequently contaminated by fecal matter during the process of delivery, a significant risk of infection exists. Infection generally manifests within the first week following delivery. Signs and symptoms of episiotomy infection include fever, focal tenderness at the wound site, and purulent or malodorous drainage.

Most episiotomy infections are localized and respond to appropriate wound care and oral antibiotics. If an abscess forms, drainage may be required, or spontaneous wound breakdown may ensue. In rare cases, necrotizing fasciitis may occur; this can be life-threatening if not appropriately evaluated and treated.

Routine antibiotic prophylaxis is not recommended after an episiotomy or repair of an obstetric laceration. However, infection increases the risk of perineal repair breakdown, particularly for higher order (third- or fourth-degree) lacerations.[26] Because breakdown of higher order lacerations may result in incontinence of stool or flatus, sexual dysfunction, or rectovaginal fistula, the use of prophylactic antibiotics in this setting has been evaluated.

Data from a single randomized trial suggests that administration of a second-generation cephalosporin (cefoxitin or cefotetan; if penicillin allergy, clindamycin) decreases the risk of perineal wound complications.[27] However, this study had a high rate of loss to follow-up (27%), and its findings have not been replicated in other studies.

Given the lack of evidence following a meta-analysis of data from the Cochrane Pregnancy and Childbirth Group's trial register, Buppasiri et al indicated that additional data are necessary before routine antibiotic prophylaxis for third- or fourth-degree perineal tears is recommended.[28] The American College of Obstetricians and Gynecologists (ACOG) also does not recommend universal prophylaxis due to lack of evidence,[29] but the Royal College of Obstetricians and Gynaecologists (RCOG) recommends routine prophylaxis owing to the severity of the outcomes following infection.[30]

Dehiscence

Breakdown of an episiotomy repair is infrequent (< 2% of cases of higher-order lacerations) but may be a particularly challenging complication for patients and providers.[31] Dehiscence can occur with or without wound infection. Small defects may heal spontaneously without closure; however, many defects require surgical closure.

Historically, delayed closure (2-3 months after delivery) was performed. Over the past 20 years, early closure has been reported to represent an appropriate and successful approach.[32, 33, 34] . Measures such as debridement or parenteral antibiotic therapy may be necessary before wound closure.

The goals of pharmacotherapy are to prevent complications and infections and reduce morbidity.

Class Summary

Routine use of prophylactic antibiotics is not necessary. However, in the case of third or fourth-degree lacerations, the Royal College of Obstetricians and Gynaecologists (RCOG) recommends prophylactic broad-spectrum antibiotics to reduce the incidence of infection and dehiscence.

Cephalexin (Keflex)

Cephalexin is a first-generation cephalosporin that arrests bacterial growth by inhibiting bacterial cell wall synthesis. It has bactericidal activity against rapidly growing organisms. Cephalexin's primary activity is against skin flora; the drug is used for skin infections or prophylaxis in minor procedures.

Cefazolin

Cefazolin is a first-generation semisynthetic cephalosporin that by binding to 1 or more penicillin-binding proteins arrests bacterial cell wall synthesis and inhibits bacterial replication. It has a poor capacity to cross blood-brain barrier. It is primarily active against skin flora, including Staphylococcus aureus. Regimens for IV and IM dosing are similar.

Amoxicillin and clavulanate (Augmentin, Augmentin XR, Amoclan)

Amoxicillin inhibits bacterial cell wall synthesis by binding to penicillin-binding proteins. Addition of clavulanate inhibits beta-lactamase producing bacteria.

It is a good alternative antibiotic for patients allergic or intolerant to the macrolide class. It is usually well tolerated and provides good coverage to most infectious agents. Not effective against Mycoplasma and Legionella species.

Ampicillin and sulbactam (Unasyn)

This is a drug combination of beta-lactamase inhibitor with ampicillin. It interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. It is an alternative to amoxicillin when the patient is unable to take medication PO. It covers skin, enteric flora, and anaerobes. It is not ideal for nosocomial pathogens.