When should an episiotomy be performed according to the American College of Obstetricians and Gynecologists (ACOG)?

From the Guidelines

Episiotomy should not be performed routinely but rather restricted to specific clinical situations where there is a clear maternal or fetal benefit, as recommended by the American College of Obstetricians and Gynecologists (ACOG) 1. These situations include cases of shoulder dystocia, operative vaginal deliveries that require additional space, fetal distress requiring expedited delivery, or when severe perineal trauma appears imminent. The decision to perform an episiotomy should be made based on clinical judgment at the time of delivery, considering the specific circumstances of each individual case. Key points to consider when deciding to perform an episiotomy include:

• The type of episiotomy to be performed, with a mediolateral incision generally preferred over a midline incision in situations where there is high risk for extension to the anal sphincter, as it carries a lower risk of extending into the rectum 1.
• The potential risks and benefits of episiotomy, including the increased risk of third and fourth-degree perineal lacerations, postpartum pain, dyspareunia, and pelvic floor dysfunction associated with routine use 1.
• The importance of a restrictive approach to episiotomy, as recommended by ACOG, in order to minimize the risk of complications and promote a positive birth experience 1.

From the Research

Episiotomy Performance According to ACOG

• The American College of Obstetricians and Gynecologists (ACOG) recommends that episiotomy should be performed by indication only, and not routinely 2, 3.
• Accepted indications for episiotomy include:
  • Shortening the second stage of labor when there is suspected fetal hypoxia 2.
  • Preventing obstetric anal sphincter injury in vaginal operative deliveries, or when obstetric sphincter injury occurred in previous deliveries 2, 4.
• The mediolateral or lateral episiotomy technique should be used 2, 5.
• Labor ward staff should be offered regular training in correct episiotomy techniques 2.
• Pain relief needs to be considered before episiotomy is performed, and epidural analgesia may be insufficient 2.
• After childbirth, the perineum should be carefully inspected, and the anal sphincter palpated to identify possible injury 2, 4.

Technique and Indications

• The use of a proper surgical technique is fundamental to obtain better results, especially in relation to the angle of incision, the distance from the vaginal introitus, and the correct timing for performing the procedure 6.
• Episiotomy may be indicated in instrumental deliveries to avoid obstetric anal sphincter injury (OASIS) 4.
• Training in perineal protection in obstetrics is recommended 4.
• Manual control of the expulsion and perineal support reduce the risk of perineal injury 4.