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Chapter 2

Repair of Episiotomy

Anne Horak

Degrees of Vaginal Tears

There are four degrees of tear that can occur during vaginal delivery:

1. First-degree tear: Involves the vaginal mucosa and connective tissue
2. Second-degree tear and Episiotomy: Involves the vaginal mucosa, connective tissue, and
the underlying muscles
3. Third-degree tear: Involves the vaginal mucosa, connective tissue, underlying muscles, and
the anal sphincter
4. Fourth-degree tear: Involves the anal sphincter as well as the rectal mucosa

Materials for Repair

1. Absorbable sutures should always be used for repair
2. Polyglycolic/polyglactin sutures are preferred over chromic catgut as they have superior
tensile strength, non-allergenic properties, and are associated with a lower probability of
infectious complications
3. A tapering/round-bodied needle should be used, as a cutting needle is more traumatic and
causes more bleeding
4. A curved needle is preferred over a straight needle

General Principles

1. It is always best to repair vaginal tears within the first few hours after delivery, as further
delay is associated with infective complications and poor healing
2. First degree tears that are not bleeding do not need to be sutured, as most of them will
heal spontaneously
3. It is important to perform an initial detailed examination of the vagina, perineum, and
cervix to make sure that the full extent of any tear is correctly assessed and that any
damage to the anal sphincter is identified
4. Haemorrhage from the lower genital tract should always be suspected when there is
ongoing bleeding in the presence of a well-contracted uterus. This may require more
detailed examination in theatre under anaesthetic


Technique of Repair

1. Good light is paramount, and in the presence of more extensive tears, assistance may be
necessary to provide adequate exposure
2. Position the women in lithotomy, or at least with her buttocks towards the lower end of
the bed
3. Clean the perineum with antiseptic solution
4. Anaesthetize the perineum early to provide sufficient time for effect:
- Use +/- 10ml of 0.5% lignocaine solution to infiltrate beneath the skin of the perineum,
beneath the vaginal mucosa, and deeply into the perineal muscle
- Insert the needle along each side of the vaginal tear/incision and slowly inject the
lignocaine solution while withdrawing the needle
- The vaginal tissues should swell as you inject the lignocaine
5. Insert a tampon into the upper vagina to absorb any blood from the uterus, thereby
ensuring a clear suturing field. Do not forget to remove this at the end of the procedure

Repair of the Perineal Muscle Layer

1. Repair the perineal muscles using an interrupted 2-0 suture
2. Attempt to identify and ligate any bleeding blood vessel
3. If the tear is deep, a second layer may required
4. It is important that any potential dead space is obliterated, as this can later lead to
haematoma formation

Repair of the Vaginal Mucosa

1. Repair the vaginal mucosa using a continuous 2-0 suture
2. Ensure that the first suture is placed above the apex of the tear or episiotomy incision
3. Continue the continuous suture to the level of the vaginal opening, obliterating any dead
spaces, yet ensuring that the sutures are not inserted too tightly
4. At the level of the vaginal opening, bring the needle out through the perineal tear and tie

Repair of the Skin

1. Repair the perineal skin using either an interrupted or subcuticular 2-0 suture
2. Start at the level of the vaginal opening
3. Ensure that the sutures are not inserted too tightly

End of Procedure

A rectal examination should be performed in the case of deep vaginal tears to ensure that no
sutures have been place in the rectum. If suture material is felt in the rectum, the sutures must
be removed, and the repair repeated.