What is the proper management and technique for an episiotomy (perineal incision during childbirth)?

The Art of Episiotomy: Proper Management and Technique

Types of Episiotomy

Two main episiotomy techniques exist: midline (median) and mediolateral, with mediolateral or lateral episiotomy being the strongly recommended approach to minimize risk of obstetric anal sphincter injuries (OASIS). 1

• Midline episiotomy starts within 3 mm of the midline at the posterior fourchette and extends 0-25° downward in the sagittal plane 1
• Mediolateral episiotomy starts within 3 mm of the midline at the posterior fourchette and is directed laterally at an angle of at least 60° from the midline toward the ischial tuberosity 1
• Mediolateral technique should be used preferentially as it reduces the risk of extension to third- or fourth-degree tears involving the anal sphincter 2
• Midline incisions, while not bisecting major neuromuscular structures, increase the risk of direct and indirect injury to the external anal sphincter 3
• Mediolateral incisions pose greater risk of iatrogenic injury to ipsilateral nerve, muscle, erectile, and gland tissues, but this is outweighed by the reduced risk of severe sphincter trauma 3

Indications for Episiotomy

Episiotomy should be performed by indication only, not routinely, as restrictive policies result in 30% fewer women experiencing severe perineal/vaginal trauma. 2, 4

• Accepted indications include:
  • Suspected fetal hypoxia requiring shortened second stage of labor 2
  • Prevention of obstetric anal sphincter injury during operative vaginal deliveries 2
  • History of obstetric sphincter injury in previous deliveries 2
• Routine episiotomy is associated with more posterior perineal trauma, more suturing, and more healing complications compared to selective use 5, 4
• In restrictive episiotomy policies, only 27.6% of women require episiotomy compared to 72.7% with routine policies 5

Pre-Procedure Preparation

Adequate pain relief must be ensured before performing episiotomy, as epidural analgesia may be insufficient for perineal sensation. 2

• Test the perineal skin for pain sensation before performing episiotomy, even when epidural is in place 2
• Consider local anesthetics or pudendal block as isolated or additional pain relief methods 2
• Ensure adequate lighting and proper patient positioning for optimal visualization 1
• Prepare the surgical site with povidone-iodine or chlorhexidine gluconate (if iodine allergy) 1
• Labor ward staff should receive regular training in correct episiotomy techniques 2

Repair Technique

Use continuous non-locking intracutaneous sutures for episiotomy repair, as this technique results in less short-term pain, less dyspareunia, and uses less suture material. 1

Step-by-Step Repair Approach:

1. Anchor the suture above the apex of the laceration in the vaginal epithelium 1

2. Close the vaginal epithelium using a continuous, non-locking suture in a running fashion, including the underlying muscularis and rectovaginal fascia to the level of the hymenal ring 1

3. Transition into the axial plane parallel to the perineal muscles 1

4. Reapproximate the perineal muscles (bulbocavernosus and transverse perineal muscles) in a running, continuous, non-locking fashion 1

5. Close the perineal skin using a running, continuous, non-locking, subcuticular, and deep dermal fashion back toward the hymenal ring 1

   • Alternative approach: Consider leaving the skin unsutured or close with skin adhesive to reduce pain and dyspareunia 1
   • Skin adhesive is associated with shorter procedure time (2.29 vs 7.88 minutes; P<.001), less pain, and greater satisfaction 1

6. Anchor the final suture by transitioning back into the coronal plane and knotting behind the hymen 1

Critical Technical Points:

• Use continuous non-locking technique because it distributes tension more evenly across the entire suture length 1
• Avoid locking sutures as they cause excessive tension leading to tissue edema and necrosis 1
• Use subcutaneous suturing for perineal skin rather than transcutaneous interrupted suturing, as it avoids damage to nerve endings on the skin surface 1
• Ensure complete reapproximation of all layers: vaginal epithelium, muscularis, perineal body musculature, rectovaginal fascia, and perineal skin 1
• Primary suturing should be performed immediately after childbirth 2

Postoperative Management

Arrange early follow-up within two weeks, ideally in a specialized postpartum perineal clinic, with clear documentation of repair technique. 1

Immediate Postoperative Care:

• Prophylactic antibiotics: First-generation cephalosporin (cefazolin 2g) or second-generation cephalosporin (cefoxitin 2g); for penicillin allergy use gentamicin 5 mg/kg plus clindamycin 900 mg or metronidazole 500 mg 1
• Stool softeners: Polyethylene glycol 4450 or mineral oil twice daily for six weeks postpartum to achieve toothpaste consistency stools 1
• Pain control: Acetaminophen and ibuprofen as primary analgesics; ice packs for additional relief; reserve opiates only if needed 1
• Sitz baths: Twice daily until first wound check 1, 6
• Infrared lamp therapy may be considered as an effective modality for episiotomy pain relief and wound healing 6

Documentation and Follow-up:

• Document the laceration type and repair technique clearly 1
• Provide patient education on degree of injury 1
• If concern for anal sphincter compromise exists, perform endoanal ultrasound to assess full extent of damage 1
• Count all surgical instruments, sponges, and sutures pre- and postoperatively 1

Systematic Post-Delivery Evaluation

After all vaginal deliveries, perform systematic evaluation including visual inspection, thorough perineal exam, and mandatory digital rectal examination. 1

• Digital rectal examination improves detection rate of OASIS and is essential after all vaginal deliveries 1
• Up to 35% of anal sphincter injuries are missed without rectal examination 1
• Clinical examination by a knowledgeable birth attendant has no significantly different OASIS detection rate compared to endoanal ultrasound, so routine imaging is not needed immediately after delivery 1
• If uncertainty exists regarding OASIS diagnosis, a second experienced examiner should aid in determining the degree of perineal injury 1

Common Pitfalls to Avoid

• Never perform routine episiotomy as it increases trauma without benefit 2, 5, 4
• Never skip the rectal examination as this leads to missed anal sphincter injuries in up to 35% of cases 1
• Never use locking sutures as they cause excessive tension, tissue edema, and necrosis 1
• Never use transcutaneous interrupted sutures for perineal skin as they damage nerve endings and increase pain 1
• Never assume epidural provides adequate perineal anesthesia without testing sensation first 2
• Never choose midline episiotomy when mediolateral is an option, as it increases risk of anal sphincter extension 2, 3