Episiotomy Repair After Normal Spontaneous Vaginal Delivery
Use continuous, non-locking sutures throughout all layers of episiotomy repair—this technique reduces postpartum pain, analgesic use, and need for suture removal compared to interrupted suturing. 1
Suturing Technique
The repair should proceed in a systematic layered approach using a single continuous suture:
- Anchor the suture above the apex of the laceration in the vaginal epithelium
- Close the vaginal epithelium, muscularis, and rectovaginal fascia using continuous, non-locking running sutures down to the hymenal ring
- Transition to the perineal muscles (bulbocavernosus and transverse perineal muscles) in the axial plane, continuing the same running, non-locking technique
- Close the perineal skin using continuous, non-locking, subcuticular (deep dermal) sutures back toward the hymenal ring
- Anchor and tie behind the hymen 1
Alternative for skin closure: Consider leaving the skin unsutured or using skin adhesive after closing deeper layers—this produces equivalent pain outcomes with shorter procedure time 1
Why Continuous Non-Locking Matters
This technique distributes tension evenly across the suture line, preventing the tissue edema and necrosis that occurs with locked sutures. Continuous subcutaneous suturing avoids damaging nerve endings on the skin surface, which is the primary source of postpartum perineal pain 1. Evidence from a Cochrane review of 16 studies demonstrates continuous suturing reduces pain up to 10 days postpartum (RR 0.76), decreases analgesic requirements (RR 0.70), and improves sexual function at 3 months 1.
Suture Material
Use synthetic absorbable monofilament sutures (such as poliglecaprone or polyglyconate) rather than multifilament or catgut 1. Monofilament sutures cause less bacterial seeding and lower infection risk.
Consider rapidly-absorbing synthetic sutures despite higher cost—they eliminate the need for suture removal in approximately 1 in 10 women, though they show no difference in pain or healing compared to standard synthetic sutures 1.
Anesthesia
Regional or general anesthesia is adequate for episiotomy repair 1. The procedure can be performed in the labor suite with proper lighting and visualization, though transfer to the operating room should be considered if exposure is inadequate 1.
Preoperative Preparation
Antibiotic Prophylaxis
Administer first-generation cephalosporin (cefazolin 2g) before repair 1
For penicillin allergy: gentamicin 5 mg/kg plus clindamycin 900 mg, or metronidazole 500 mg 1
Alternative: second-generation cephalosporin (cefoxitin 2g) 1
Vaginal Preparation
Use povidone-iodine for surgical site preparation, or chlorhexidine gluconate if iodine allergy exists 1
Surgical Counts
Count all instruments, sponges, and sutures before and after the procedure 1
Postoperative Care
Pain Management
- Acetaminophen and NSAIDs as first-line treatment 1
- Ice or chemical cold packs for immediate postpartum period 1
- Opiates only if needed for breakthrough pain 1
- Sitz baths twice daily until first wound check 1
Bowel Management
Stool softeners (polyethylene glycol 4450 or mineral oil) twice daily for 6 weeks postpartum to achieve toothpaste consistency stools—this prevents straining that can disrupt the repair 1
Follow-up
- Early follow-up within 2 weeks, ideally in a specialized postpartum perineal clinic 1
- Clear documentation of laceration type and repair technique 1
- Patient education on degree of injury and expected healing 1
Critical Pitfalls to Avoid
Never use locked sutures—they create excessive tension leading to tissue edema, necrosis, and increased pain 1
Avoid transcutaneous interrupted sutures on skin—they damage superficial nerve endings and significantly increase pain compared to subcuticular technique 1
Do not use catgut sutures—they are associated with more pain and higher resuturing rates compared to synthetic materials 1
Ensure adequate visualization—if you cannot see the apex clearly or achieve proper exposure in the labor suite, move to the operating room 1