What are the current guidelines for episiotomy (perineal incision) during labor and delivery?

Episiotomy Guidelines

Episiotomy should be performed selectively based on specific clinical indications only, not routinely, as selective use results in 30% fewer severe perineal/vaginal trauma cases without increasing harm to mother or baby. 1, 2, 3

Indications for Episiotomy

Episiotomy is indicated only in the following specific circumstances:

• Suspected fetal hypoxia requiring shortened second stage of labor 3
• Operative vaginal deliveries (forceps or vacuum) to prevent obstetric anal sphincter injury (OASIS) 3
• Previous obstetric anal sphincter injury in prior deliveries 3

Outside specialized maternity structures, do not perform episiotomy systematically for the sole purpose of reducing anal sphincter injury risk, as no convincing evidence supports this practice. 1

Technique Selection

Type of Episiotomy

• Use mediolateral or lateral episiotomy technique rather than midline episiotomy 3
• The incision should start within 3 mm of the midline in the posterior fourchette and extend laterally at an angle of at least 60° toward the ischial tuberosity 1
• Labor ward staff require regular training in correct episiotomy techniques 3

Pain Management Before Incision

Critical pitfall: Even with epidural analgesia in place, test the perineal skin for pain sensation before performing episiotomy, as epidural coverage may be insufficient 3

• Consider local anesthetics or pudendal block as isolated or additional pain relief methods 3
• For episiotomy repair, regional or general anesthesia is recommended for adequate pain control 1

Repair Technique

Immediate Post-Delivery Assessment

• Systematically inspect the perineum and digitally palpate the anal sphincter after all vaginal deliveries to identify possible injury 1, 3
• A rectal exam improves OASIS detection rates and should be performed routinely 1

Suturing Method

Use continuous, non-locking sutures for all layers of episiotomy repair to reduce short-term pain, dyspareunia, and suture material usage 1, 3

The recommended repair sequence:

1. Anchor suture above the apex of the vaginal epithelium laceration 1
2. Close vaginal epithelium, muscularis, and rectovaginal fascia using continuous non-locking suture to the hymenal ring 1
3. Reapproximate bulbocavernosus and transverse perineal muscles in running, continuous, non-locking fashion 1
4. Close perineal skin using continuous, non-locking, subcuticular, deep dermal suturing 1
5. Alternative for skin closure: Consider leaving skin unsutured or using skin adhesive, which results in less pain and dyspareunia with similar functional outcomes 1

Suture Material Considerations

• Continuous suturing distributes tension more evenly across the entire suture length 1
• Non-locking technique prevents excessive tension that causes tissue edema and necrosis 1
• Subcutaneous suturing avoids damage to nerve endings on the skin surface, reducing pain 1

Evidence Supporting Selective Over Routine Episiotomy

Maternal Outcomes

Selective episiotomy results in:

• 30% reduction in severe perineal/vaginal trauma (RR 0.70,95% CI 0.52-0.94) 2
• No increase in perineal infection rates (RR 0.90,95% CI 0.45-1.82) 2
• No difference in long-term dyspareunia at 6+ months (RR 1.14,95% CI 0.84-1.53) 2
• No difference in long-term urinary incontinence (RR 0.98,95% CI 0.67-1.44) 2

Neonatal Outcomes

• No difference in Apgar scores less than 7 at five minutes between selective and routine episiotomy 2

Common Pitfalls to Avoid

1. Do not perform routine episiotomy based on outdated beliefs that it prevents severe trauma—current evidence refutes this 1, 4, 2

2. Do not assume epidural provides adequate perineal anesthesia—always test sensation before incision 3

3. Avoid locking sutures during repair, as they create excessive tension and increase pain 1

4. Do not use transcutaneous interrupted sutures for perineal skin—subcuticular continuous sutures cause less pain 1

5. Do not skip rectal examination post-delivery, as it significantly improves OASIS detection 1

Postoperative Care

• Provide clear documentation of laceration type and repair technique 1
• Arrange early follow-up within two weeks, ideally in specialized postpartum perineal clinic 1
• Prescribe stool softeners (polyethylene glycol or mineral oil twice daily) for six weeks to achieve toothpaste consistency stools 1
• Pain control: acetaminophen and ibuprofen as first-line; ice packs; sitz baths twice daily until first wound check 1
• Reserve opioids only for breakthrough pain 1