Episiotomy

To prevent severe spontaneous third- and fourth-degree perineal lacerations

To increase the diameter of the soft-tissue pelvic outlet to relieve shoulder dystocia

To facilitate delivery of fetus having nonreassuring fetal heart-rate tracings

To facilitate delivery in malpresentations, including breech and occiput posterior presentations

CONTRAINDICATIONS

Not recommended for routine delivery, especially in the primiparous patient

LANDMARKS (FIGURE 43.1)

General Basic Steps

Organize supplies

Local anesthesia

Incision

Closure

TECHNIQUE

Supplies

A 3-0 or 2-0 absorbable suture (polyglactin preferred or chromic catgut) on atraumatic needle

Needle holder

Tissue scissors or scalpel

Suture scissors

Gauze

Local anesthesia and injection materials

FIGURE 43.1 Episiotomy landmarks.

Initiation of Procedure

For vertex presentations, episiotomy is started when the fetal head begins to stretch the perineum and when 3 to 4 cm diameter of the caput is visible during a contraction (prior to crowning)

For breech presentations, episiotomy is started just before extraction of the fetus

Inject 1% or 2% lidocaine locally in the perineum where episiotomy is planned (may also perform pudendal nerve block) (FIGURE 43.2)

Median or Midline Technique

Most commonly performed

Just prior to crowning, two fingers are placed inside the vaginal introitus to expose the mucosa, posterior fourchette, and the perineal body

Tissue scissors are used to make a vertical incision beginning at the fourchette and extending caudally in the midline. The goal is to release the constriction caused by the perineal body.

Incision should be directed internally to minimize the amount of perineal skin incised

Incision includes the vaginal mucosa, perineal body, and the junction of the perineal body with the bulbocavernosus muscle in the perineum

Mediolateral Technique

As the head crowns, two fingers are placed inside the vaginal introitus to expose the mucosa, posterior fourchette, and the perineal body

Tissue scissors are used to make a 3- to 5-cm incision directed downward and outward toward the lateral margin of the anal sphincter in a 45-degree angle. This incision may be either to the left or the right.

Incision includes the vaginal mucosa, transverse perineal and bulbocavernosus muscles, and the perineal skin

Repair: Layer Closure

A 2-0 or 3-0 absorbable suture is used

Close the vaginal mucosa using a continuous suture from just above the apex of the incision to the mucocutaneous junction

Burying the closing knot minimizes the amount of scar tissue and prevents pain and dyspareunia

Large actively bleeding vessels may require ligation with separate absorbable sutures

The perineal musculature is reapproximated using three to four interrupted sutures

Closure of the superficial layers is done with several interrupted sutures through the skin and subcutaneous fascia that are loosely tied. The skin can also be closed using a running subcuticular suture.

Finally, examine the rectum and anal sphincters with the index finger in the rectum and the thumb on the sphincter, using a pill-rolling motion to assess integrity (FIGURE 43.3)

FIGURE 43.2 Midline episiotomy. As the fetal head distends, with the perineum under adequate anesthesia, a cut is made through the perineal body and the tissues of the vagina and the rectovaginal septum for the episiotomy. (From Rouse DJ, St John E. Normal labor, delivery, newborn care, and puerperium. In: Scott JR, Gibbs RS, Karlan BY, et al. eds. Danforth’s Obstetrics and Gynecology. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:44, with permission.)

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