What is the recommended management for a first-degree episiotomy (perineal incision)?

Management of First-Degree Episiotomy

For first-degree episiotomy repair, the recommended approach is either no suturing or use of skin adhesive rather than traditional suturing, as these methods are associated with less pain, shorter procedure time, and similar functional and cosmetic outcomes. 1

Assessment and Diagnosis

• After all vaginal deliveries, perform a systematic evaluation of perineal trauma including visual inspection, thorough perineal examination, and digital rectal examination 1
• First-degree episiotomy involves injury to the perineal skin and vaginal epithelium only, without involvement of perineal muscles 1
• Ensure adequate lighting and patient positioning for proper assessment of the wound 1

Management Options

Non-Surgical Management

• If the wound is hemostatic (not actively bleeding), consider leaving the wound unsutured 1
• Benefits include:
  • Shorter procedure time 1
  • Less pain during recovery 1
  • Reduced need for analgesia 1
  • Decreased dyspareunia 1
  • Improved breastfeeding rates at 3 months postpartum 1

Skin Adhesive Closure

• Apply skin adhesive after ensuring the wound is clean and dry 1
• Benefits compared to traditional suturing:
  • Significantly shorter procedure time (2.29 vs 7.88 minutes) 1
  • Less need for local anesthetic 1
  • Shorter time to become pain-free (3.18 vs 8.65 days) 1
  • Higher patient satisfaction 1
  • Lower pain scores at 3 months postpartum 1

Traditional Suturing (if needed)

If suturing is required (due to active bleeding or wound characteristics):

• Use continuous non-locking suturing technique rather than interrupted sutures 1
• Choose monofilament sutures (e.g., poliglecaprone/MONOCRYL) which cause less bacterial seeding and may reduce infection risk 1
• Consider rapidly-absorbing sutures to reduce the need for postpartum suture removal 1

Perioperative Considerations

• Ensure adequate anesthesia before repair - local anesthesia is usually sufficient for first-degree repairs 1
• Prepare the site with antiseptic solution (povidone-iodine or chlorhexidine gluconate if allergic to iodine) 1
• Antibiotics are not routinely recommended for first-degree episiotomy repair unless there are signs of infection or contamination 2

Postoperative Care

• Maintain good perineal hygiene with gentle cleansing after toileting 3
• Manage pain with:
  • Acetaminophen and NSAIDs 3
  • Sitz baths (moist heat application) 4
  • Cold packs for the first 24-48 hours 4
  • Dry heat application (infrared lamp therapy) if available 4
• Use stool softeners to prevent constipation and reduce strain on the perineal area 3
• Monitor for signs of infection: erythema, edema, pain, purulent discharge, wound dehiscence, and systemic symptoms 3

Complications and Management

• If infection develops:
  • Obtain wound cultures before initiating antibiotics 3
  • Consider surgical drainage for infected wounds 3
  • Initiate antibiotics for infections with systemic symptoms 3
  • Recommended regimens include metronidazole plus ciprofloxacin, levofloxacin, or ceftriaxone 3
• For wound dehiscence:
  • Early repair of episiotomy dehiscence (after adequate wound cleansing and antibiotics) is safe and effective 5
  • Without repair, healing by secondary intention results in prolonged morbidity 6

Follow-up

• Schedule early follow-up within two weeks to assess healing 3
• Evaluate for complete healing before resuming sexual activity 3
• Consider referral to specialized postpartum perineal clinic for complicated cases 1

Common Pitfalls to Avoid

• Failing to perform a thorough assessment to correctly identify the degree of episiotomy 1
• Unnecessary suturing of hemostatic first-degree episiotomies, which increases pain and recovery time 1
• Overlooking signs of infection which can lead to wound dehiscence 3
• Using interrupted sutures rather than continuous technique, which is associated with more pain 1