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Episiotomy/perineotomy

Definition

Episiotomy is the surgical enlargement of the


posterior aspect of the vagina by an incision
to the perineum during the last part of the
second stage of labor.

The incision is performed with scissors or


scalpel and is typically midline (median) or
mediolateral in location.
Prevalence

WHO (1996) – recommends for an


episiotomy rate of 10%

US episiotomy rate – dropped from 17.3 to 11.6


from 2006 to 20012
In the past, routine use of episiotomy was believed to
have several benefits:

• Reduction of trauma to the fetal head


(Intraventricullar hemorrhage)
• Ease of repair and improved wound healing
• Preservation of the muscular and fascial support of
the pelvic floor
• Prevention of anal sphincter laceration
• Prevention of shoulder dystocia

THE BODY OF EVIDENCE DOES NOT SUPPORT THESE


BENEFITS
Adverse outcomes

• Extension of the incision, leading to third and fourth


degree tears, particularly for median episiotomy
• Risk of unsatisfactory anatomic results (eg, skin tags,
asymmetry, fistula, narrowing of introitus).
• Increased blood loss
• Higher rates of infection and dehiscence
• Increased risk of severe perineal laceration in
subsequent deliveries
WHEN to consider EPISIOTOMY

• Expedite delivery of the fetus (i.e. - cat III FHR)

• Operative vaginal delivery (forceps, vacuum)

• Shoulder dystocia - not to prevent dystocia but to


increase space for operator maneuvers
Classification of perineal lacerations
I. First degree lacerations involve injury to the skin and
subcutaneous tissue of the perineum and vaginal epithelium
only. The perineal muscles remain intact.
II. Second degree lacerations extend into the fascia and
musculature of the perineal body, which includes the deep
and superficial transverse perineal muscles and fibers of the
pubococcygeus and bulbocavernosus muscles. The anal
sphincter muscles remain intact.
III. Third degree lacerations extend through the fascia and
musculature of the perineal body and involve some or all of
the fibers of the EAS and/or the IAS.
Third degree lacerations are subclassified as follows:
– 3a: <50 percent of EAS thickness is torn
– 3b: >50 percent of EAS thickness is torn
– 3c: IAS is torn (in addition to complete rupture of the EAS)
IV. Fourth degree lacerations involve the perineal structures,
EAS, IAS, and the rectal mucosa.
Classification of perineal lacerations
Performing the episiotomy

• Verbal consent

• Anesthesia – spinal/epidural; pudental block; local


anestaetic (5 to 20 mL of 1% lidocaine)

• Perform the procedure (performed at crowning)

• Complete delivery
Pudental nerve block
Mediolateral episiotomy
• Except for the important issue of third - and fourth - degree
extensions, midline episiotomy is superior??
• Fourfold decrease in severe perineal lacerations following
mediolateral episiotomy compared with rates after midline
incision.
• Proper selection of cases can minimize this one disadvantage.
• Kudish and co-workers (2006) advised against midline
episiotomy with operative vaginal delivery because of an
increased incidence of anal sphincter tears.
Midline episiotomy
Episiorraphy

https://www.youtube.com/watch?v=_a8c2qskuzA
Complications

• Infection • Altered sexual


• Hematoma function
• Third and fourth • Perineal pain
degree extension • Incontinence:
• Cellulitis urinary, fecal, flatus
• Dehiscence • Rectovaginal fistula
• Abscess • Impaired pudendal
• Dyspareunia nerve conduction
• Necrotizing fasciitis
To Remember
• For women undergoing vaginal delivery, we recommend against routine
episiotomy

• The decision to perform episiotomy is heavily dependent on the opinion of the


delivering clinician and is based on the clinical scenario at the time of
delivery
– no specific situations in which episiotomy is essential

• When an episiotomy is to be performed, we suggest a mediolateral


episiotomy (reduces the risk of anal sphincter laceration)

• Once the decision is made to perform an episiotomy, patient consent is


obtained, adequate anesthesia is provided, and the fetal scalp is protected
by the clinician prior to incision

• Common complications of episiotomy include extension of the incision into


the perineum or anal sphincter complex, infection, postpartum pain, and
dyspareunia.

• Episiotomy use at the time of the first vaginal delivery appears to increase the
risk of a severe obstetric laceration in a subsequent vaginal delivery