Episiotomy • Definition. A surgical incision made in the perineum to facilitate delivery. • Incidence.

It used to be performed in >30% of vaginal deliveries, most often in nulliparous women, but there
was a steep decline to <10% by 2006. It remains highly dependent on practice style and provider
preference. • Indications. It may be performed in isolation or in preparation for surgical vaginal
delivery. It may also be used to facilitate delivery complicated by shoulder dystocia (see Chapter 63).
• Goal. Episiotomy was introduced to reduce complications of pelvic floor trauma at delivery,
including bleeding, infection, genital pro- lapse, and incontinence. However, there does not appear
to be any benefit to the mother of elective episiotomy. • Types/extensions (Figure 66.1): 1
Midline episiotomy refers to a vertical midline incision from the posterior forchette toward
the rectum. It is effective in hastening delivery, but is associated with increased severe perineal
trauma involving the external anal sphincter (third and fourth degree exten- sions). Used more
commonly in the USA. 2 Mediolateral episiotomy is cut at 45° to the posterior forchette on one side.
Such incisions appear to protect against severe perineal trauma, but have been associated with
increased blood loss, wound infection, and worsened postpartum pain (none of which has been
definitively demonstrated). Used more commonly in the UK. • Episiotomy repair. Primary
approximation affords the best oppor- tunity for functional repair, especially if there is rectal
involvement. The external anal sphincter should be repaired by securing the cut ends using
interrupted sutures.