Episiotomy 11

incised vertically extending toward, but not into, the transverse perineal
muscles ( Fig. 6) . Although in some women a raphe or dimpling can be
seen, the incision should be made as close to the midline as possible. A
question often arises as to when to perform the episiotomy. Some rec-
ommend before the head is fully crowning; others suggest only just
before expulsion when the perineum is thinned and stretched. Both
approaches have advantages and disadvantages and rely on the clinical
judgment of the obstetrician. In general, it is better to perform the epi-
siotomy later to avoid excessive blood loss and complete the delivery
shortly thereafter.
After completion of the delivery, it is critical to inspect the incision
site carefully to determine the extent of the episiotomy and any possi-
ble tears or extensions. In primiparous women, the reported odds ratio
is +22.08 that midline episiotomies will extend beyond the initial inci-
sion into and through the transverse perineal muscles and the anal
sphincter ( third degree) or into the rectal mucosa ( fourth degree) ( 17) .
In another study, 14.9% of midline episiotomies resulted in an exten-
sion ( 18) .
Repair
Surgical repair of an episiotomy is a reapproximation of separated vagi-
nal mucosa, soft tissue, and muscle so that each part is paired with its
counterpart ( Fig. 7, AF) . A complete knowledge of perineal anatomy is
necessary if this is to occur ( see Basic Anatomy of the Perineum) .
Fig. 6. Midline episiotomy. (Beckman
CRB, Ling FW, Laube DW, Smith
RP, Barzansky BM, Herbert WN.
Obstetrics and Gynecology. 4th ed.
Baltimore [MD]: Lippincott,
Williams & Wilkins; 2002.)
12 Episiotomy
The choice of suture is based on the extent of the repair. If the rectal
mucosa is to be repaired, the suture should be no larger than 4-0. The
standard suture material is chromic catgut, but synthetic material also
is used by many obstetricians. The needle should be small and tapered
for the mucosa, and a larger suture may be preferable for the soft tissue
and muscle. Use of two different suture sizes and needles certainly is
acceptable.
For the sake of inclusion, this description will begin with a rectal
extension and proceed upward. Obviously, if no extension occurred, the
repair will begin at the appropriate lowest point of episiotomy.
If the rectal mucosa is involved, the apex should be identified. A
suture is then placed approximately 1 cm above the apex. This suture
should extend through the submucosa, but usually not the mucosa
itself. It is placed 1 cm above the apex to ensure that any retracted ves-
sels are ligated. The mucosa is then closed in a running or locking fash-
ion with 4-0 suture to join the two mucosal edges ( Fig. 7A) . The suture
should not penetrate the mucosal layer but bring the submucosa
together. Sutures should be placed no more than 0.5 cm apart, and the
running nonlocking suture should continue to the anal sphincter and
perineal body.
Next, the anal sphincter should be identified. The two edges usually
will be retracted laterally, and an Allis clamp may be necessary to iden-
tify the cut edges and bring them together in the midline ( Fig. 7B) .
When repairing the anal sphincter, it is important to suture the fascial
sheath and not just the muscle. This repair is best accomplished with
several interrupted sutures around the muscle rather than one large fig-
ure eight. The repair is strengthened by the sheath, not the muscle.
Some obstetricians recommend that it is best to first apply the bottom-
most suture at the 6 oclock position, then the most internal suture at
the 9 oclock position, then at the top or most superior part of the
muscle, followed by a 3 oclock placement, which is the most superfi-
cial and easiest. Because the transverse perineal muscles also are sepa-
rated, they can be repaired in a similar fashion. The 12 oclock anal
sphincter suture usually will include a portion of the lower capsule of
Episiotomy 13
the transverse muscular tissue. Some obstetricians advocate use of 2-0
suture for these capsule repairs because it will give support for a longer
time and thus increase the healing capability. This is a personal choice,
and there is no evidence to suggest which size suture is best.
Now the underlying rectal fascial layer should be closed ( Fig. 7C) .
This gives a second layer over the rectal mucosa and helps to further
support the extension. In addition, it also closes some of the potential
dead space between the vaginal mucosa and the rectum. Some do
this layer before sphincter repair and incorporate the 6 oclock sphinc-
ter suture at the inferior end of this second-layer rectal repair. Through-
out these procedures, the obstetrician should be checking carefully for
any bleeding vessels and appropriately ligate them to prevent future
hematomas.
At this point, the procedure has reached the level of repair that is
needed for a midline episiotomy without extension or a secondary lacer-
ation repair. A suture is placed approximately 1 cm above the apex of
the vagina ( Fig. 7D) . The suture is then continued in a running or run-
ning locking fashion to the hymenal ring. Care should be taken to avoid
deep suturing that could extend through the submucosal tissue into the
rectum. Careful attention should be directed to ensuring the submucos-
al tissue is incorporated in the running suture ( Fig. 7E) . The size of
suture for this portion of the repair usually is 3-0, although, for the
novice surgeon, 2-0 is easier to use. The needle should be noncutting.
At the hymen, careful approximation of the two edges can be
obtained by bringing the outer portion together. The running suture is
then continued to the squamomucosal junction.
When this area is reached, it is important to assess the perineal
body and submucosal areas. If there is a deep defect, interrupted
sutures may be needed to approximate the sides to prevent dead space.
Finally, the skin is ready for closure ( Fig. 7F) . This can be done by a
continuous subcuticular extension of the suture that has been brought
to the squamomucosal area; it also can be closed with a separate 3-0 or
4-0 subcuticular repair.