What is the recommended management for vaginal repair after a delivery surgical cut, also known as an episiotomy (perineal incision)?

Management of Vaginal Repair After Episiotomy

The recommended management for vaginal repair after episiotomy involves using continuous non-locking suturing techniques with delayed absorbable suture material, as this approach minimizes pain and optimizes healing. 1

Principles of Repair

Preparation

• Ensure adequate anesthesia (regional, general, or local when appropriate)
• Establish good visualization and exposure
• Place Foley catheter before initiating repair
• Perform surgical-site vaginal preparation with povidone-iodine or chlorhexidine gluconate (if allergic to iodine) 2
• Administer prophylactic antibiotics before repair for complex lacerations:
  • First-generation cephalosporin (cefazolin 2g)
  • Second-generation cephalosporin (cefoxitin 2g)
  • For penicillin allergy: clindamycin 1

Suturing Technique for Second-Degree Tears/Episiotomy

1. Place anchor suture above the apex of the laceration in vaginal epithelium
2. Use continuous, non-locking suture (3-0 or 4-0 delayed absorbable such as polyglactin or poliglecaprone) to close:
   • Vaginal epithelium
   • Underlying muscularis
   • Rectovaginal fascia to the level of the hymenal ring 2, 1
3. Transition into the axial plane, parallel to the perineal muscles
4. Reapproximate the bulbocavernosus and transverse perineal muscles in a running, continuous, nonlocking fashion
5. For perineal skin closure, choose one of these options:
   • Continuous, non-locking, subcuticular technique (preferred)
   • Leave skin unsutured
   • Close with skin adhesive 2
6. Anchor the suture and knot behind the hymen 2

Postoperative Care

Pain Management

• First-line: acetaminophen and NSAIDs 1
• Ice packs for local relief
• Opiates only if necessary 2, 1

Wound Care

• Sitz baths twice daily until first wound check
• Daily cleaning under running water, especially after bowel movements 1
• Hygiene advice should be given to all women who had an episiotomy or perineal tear 3

Bowel Management

• Stool softeners (polyethylene glycol 4450 or mineral oil) twice daily for six weeks to achieve soft stool consistency 2, 1

Follow-up and Complications

Follow-up

• Clear documentation of repair technique
• Early follow-up within two weeks 1

Management of Complications

• For broken down perineal wounds, suturing is preferred for large dehisced wounds 3
• Infection of perineal scar requires oral broad-spectrum antibiotics and local nursing 3

Important Considerations and Pitfalls

Avoid These Common Mistakes

• Using interrupted transcutaneous sutures for skin closure
• Using locking sutures (can cause tissue edema and necrosis)
• Inadequate antibiotic prophylaxis for complex lacerations
• Insufficient bowel management postoperatively
• Inadequate follow-up 1

Evidence-Based Improvements

• Continuous suturing techniques are associated with less short-term pain than interrupted sutures 4
• Polyglycolic acid sutures with subcuticular technique show better long-term results with less pain and disabilities in the early puerperium compared to catgut 4
• Cold therapy can help with perineal pain and wound healing 5

By following these evidence-based recommendations for episiotomy repair, providers can minimize complications such as pain, infection, and wound breakdown, ultimately improving patient outcomes and quality of life during the postpartum period.