Perineal lacerations and

episiotomy repair
Paweena Phangsuwan, M.D.
Department of obstetric and gynecology
Phrae Hospital
Birth canal lacerations

Cervix Vaginal wall Perineum

High vaginal wall and cervical laceration
Perineal protection
Perineal massage
Perineal muscles
Degree of lacerations
Degree of perineal lacerations
First-degree Second-degree
laceration laceration

BC

STP
 Third-degree laceration

3a 3b 3c
Fourth-degree laceration
 OASIS
(Obstetric Anal Sphincter Injuries)
OASIS (Obstetric anal sphincter injuries)
• Third and fourth degree perineal tear
• Incidence 0.5-5%
• Risk factors
• Nulliparity
• Midline episiotomy
• Persistent OP position
• Operative vaginal delivery
• Asian
• Short perineal length
• Increasing fetal birthweight
OASIS (Obstetric anal sphincter injuries)
• Associated morbidity
• Short-term
• Excessive blood loss
• Puerperal pain
• Wound disruption and infection
• Long-term
• Fecal incontinence
• Dyspareunia
• Recurrence rate
• Psychological trauma
Episiotomy
Episiotomy
• Surgical incision to perineum and posterior vagina during second
stage of labor

• Objectives
• To enlarge birth outlet and facilitate delivery
• To minimize overstretching and rupture of perineal muscles
 Type of episiotomy
• Midline
• Mediolateral
• Lateral
 Median vs. Mediolateral episiotomy

Complications Median Mediolateral

Anal sphincter tear ✓

Blood loss ✓

Perineal pain Conflicted data

Dyspareunia Conflicted data

Complications
• Extension of incision
• Third and fourth degree tears
• Risk of unsatisfactory anatomic results
• Skin tags, asymmetry, fistula, narrowing of introitus
• Increased blood loss
• Vulvar hematoma
• Higher rate of infection and dehiscence
• Risk of severe perineal laceration in subsequent deliveries
• Dyspareunia
Current evidence-based
• Compare restricted and routine episiotomy
• Lower rates of severe perineal/vaginal trauma in restricted group
• No differences in postpartum perineal pain, dyspareunia, urinary
incontinence, or genital prolapse

ACOG2016 : restricted use of episiotomy is

preferred to routine use
Indications Considered
episiotomy

• Shoulder dystocia
• Breech delivery
• Fetal macrosomia High risk of 3rd or 4th
• Operative vaginal delivery degree lacerations

• Persistent OP positions
• Markedly short perineal length
Timing of episiotomy

Burst perineal laceration

Thick tissue
Incisional bleeding
Timing of episiotomy

4 cm • Crowning of fetal head

• Thinned perineum
• Less bleeding
Optimal angle of the mediolateral episiotomy

Ginath S, et al. Int Urogynecol J, 2017

Before episiotomy
• Decision making
• Restricted episiotomy
• Mediolateral vs. Medial episiotomy
• Sterile technique
• Equipment preparation
• Adequate analgesia
• Timing
Set ทำคลอด Standard precaution
 Episiotomy Scissors

1% Lidocaine
Suture set Suture materials

Absorbable suture

Synthetic
- Polyglactin 910 :
- Vicryl©
- Novosyn ©
- Polyglycolic acid
- Dexon ©
Natural
- Chromic catgut
 Right mediolateral
Adequate analgesia
episiotomy

Local infiltration of 1% lidocaine Angle 60 degrees off the midline

Perineal laceration care
• Rectal examination after episiotomy repair
• Locally applied ice packs
• Reduce swelling and discomfort
• Adequate pain control
• Early detection of hematoma
• Evaluation for urinary retention
• Stool softeners and oral laxatives
• Warm sitz baths
• Comfort and hygiene
• Antibiotics for 3rd and 4th degree tear
Episiotomy repair
Before episiotomy repair
• Evaluate and assess degree of laceration
• Adequate analgesia
• Sterile technique
• Equipment preparation
• Empty bladder
Continuous non-locking technique Continuous locking technique

Subcuticular technique
Episiotomy repair : first-degree
• Not always require repair
• Sutures are placed to control bleeding or restore anatomy
Episiotomy repair : second-degree

Posterior vaginal wall

Skin
Episiotomy repair : second-degree
Vaginal epithelium
• Continuous locking or nonlocking suture
• Absorbable suture material
• 2-0 polyglactin 910 (Vicryl or Vicryl Rapide)
• 2-0 chromic catgut
Perineal muscles
• Continuous nonlocking suture
• Similar suture material
Perineal skin
• Subcuticular suture
• Similar suture material
Episiotomy repair : second-degree
Vaginal epithelium
• Continuous locking or nonlocking suture
• Absorbable suture material
• 2-0 polyglactin 910 (Vicryl or Vicryl Rapide)
• 2-0 chromic catgut
Perineal muscles
• Continuous nonlocking suture
• Similar suture material
Perineal skin
• Subcuticular suture
• Similar suture material
Episiotomy repair : second-degree
Vaginal epithelium
• Continuous locking or nonlocking suture
• Absorbable suture material
• 2-0 polyglactin 910 (Vicryl or Vicryl Rapide)
• 2-0 chromic catgut
Perineal muscles
• Continuous nonlocking suture
• Similar suture material
Perineal skin
• Subcuticular suture
• Similar suture material
Median episiotomy repair

Vaginal epithelium
 Median episiotomy repair

Perineal muscles
Perineal skin
 Clip video ตัวอย่าง
• Episiotomy
• https://www.youtube.com/watch?v=PR88v5CS07g
• 1st-2nd degree perineal repair
• MedNav : https://www.youtube.com/watch?v=m5Vm8ZT24HM&t=7s
• Merck Manuals : https://www.youtube.com/watch?v=39frZ9lQ4f0
• International Islamic University Malaysia 2008 : https://www.youtube.com/watch?v=FtwuMIs5ct0
• 3rd degree perineal repair
• https://www.youtube.com/watch?v=oZW2KSuD800
• 4th degree perineal repair
• https://www.youtube.com/watch?v=qXzZUqXFPDE