What is the proper procedure for performing an episiotomy?

How to Perform an Episiotomy

Episiotomy should only be performed by indication, not routinely, and when necessary, a mediolateral technique at a 60° angle from the midline is recommended to minimize the risk of obstetric anal sphincter injuries. 1, 2

Indications for Episiotomy

Episiotomy is indicated only in specific clinical situations, not as a routine procedure:

• Suspected fetal hypoxia requiring shortened second stage of labor 2
• Prevention of obstetric anal sphincter injury during operative vaginal deliveries (forceps or vacuum) 2
• History of previous obstetric sphincter injury in prior deliveries 2
• Restrictive use is superior to routine use, with non-episiotomy approaches showing the lowest complication rates when clinically feasible 3

Pre-Procedure Preparation

Anesthesia Requirements

• Test the perineal skin for pain sensation before performing episiotomy, even when epidural analgesia is in place, as epidural may provide insufficient perineal anesthesia 2
• Administer local anesthetic infiltration or pudendal block if epidural is inadequate or not present 1, 2
• Ensure adequate lighting and patient positioning for optimal visualization 1

Antiseptic Preparation

• Prepare the perineal area with povidone-iodine or chlorhexidine gluconate (if iodine allergy) 1

Episiotomy Technique

Choice of Incision Type

A mediolateral or lateral episiotomy should be used rather than midline episiotomy to reduce the risk of obstetric anal sphincter injuries (OASIS). 1, 2, 4

• Midline episiotomy increases the risk of third- and fourth-degree tears compared to mediolateral technique 4
• OASIS rates are similar between mediolateral and lateral episiotomies 4

Mediolateral Episiotomy Procedure

The incision should be made at a 60° angle from the midline to achieve a final scar angle of at least 45° after suturing, which is associated with lower OASIS risk. 1, 4

Specific technique:

• Start the incision within 3 mm of the midline at the posterior fourchette 1
• Direct the incision laterally at a 60° angle from the midline toward the ischial tuberosity 1, 4
• The incision extends through perineal skin, vaginal epithelium, and perineal muscles 1
• Use scissors to make a single, deliberate cut during a contraction when the perineum is thinned 5

Midline Episiotomy (When Used)

• Starts within 3 mm of the midline at the posterior fourchette 1
• Extends 0° to 25° downward in the sagittal plane 1
• Carries higher risk of extension to anal sphincter and should generally be avoided 5, 4

Immediate Post-Episiotomy Assessment

After delivery, perform a systematic evaluation including visual inspection, thorough perineal examination, and digital rectal examination to identify the full extent of injury. 1, 6

• Digital rectal examination improves detection of OASIS and should be performed after all vaginal deliveries 1, 6
• Palpate the anal sphincter to identify possible injury 2
• If uncertainty exists regarding degree of injury, a second experienced examiner should evaluate the tear 1

Repair Technique

Timing and Environment

• Primary suturing should be offered immediately after childbirth 2
• If the primary surgeon is inexperienced, the wound can be safely packed and repair delayed 8-12 hours until an experienced provider is available 1
• Ensure adequate lighting, anesthesia, and surgical instruments 1

Suturing Technique

Use continuous non-locking suturing technique for all layers, which is associated with less pain, reduced analgesic use, and decreased need for suture removal. 1, 2

Layer-by-layer repair:

1. Anchor suture above the apex of the incision in the vaginal epithelium 1
2. Close vaginal epithelium, underlying muscularis, and rectovaginal fascia using continuous non-locking suture to the level of the hymenal ring 1
3. Reapproximate the bulbocavernosus and transverse perineal muscles in the perineal body using continuous non-locking technique 1
4. Close perineal skin with continuous non-locking subcuticular suture to avoid damage to nerve endings on the skin surface 1

Suture Material

• Use rapidly-absorbing or standard synthetic sutures (polyglactin or polydioxanone) 1, 4
• Rapidly-absorbing sutures reduce need for postpartum suture removal despite higher cost 1
• Monofilament sutures cause less bacterial seeding 7

Post-Repair Verification

Perform digital rectal examination after completing the repair to check for sutures penetrating the rectal mucosa, which can lead to rectovaginal fistula formation. 6

• Count all surgical instruments, sponges, and sutures pre- and post-operatively 1, 6
• Document the repair technique and confirmation of no rectal sutures 6

Postoperative Care

• Prescribe stool softeners (polyethylene glycol or mineral oil twice daily) for six weeks to achieve toothpaste consistency stools 1
• Pain control with acetaminophen, ibuprofen, and ice packs 1, 7
• Sitz baths twice daily until first wound check 1, 8
• Arrange early follow-up within two weeks, ideally in a specialized postpartum perineal clinic 1, 7

Common Pitfalls to Avoid

• Performing routine episiotomy without indication increases maternal morbidity without benefit 1, 2, 3
• Using midline technique instead of mediolateral increases OASIS risk 4
• Cutting at less than 60° angle results in inadequate final scar angle and higher OASIS rates 4
• Using interrupted sutures instead of continuous technique causes more pain 1, 2
• Failing to perform rectal examination after repair misses sutures through rectal mucosa 6
• Using locking sutures causes excessive tension leading to tissue edema and necrosis 1