An episiotomy is a surgical incision in the perineum to enlarge the introitus at delivery. Episiotomy is one of the most common medical procedures performed in the United States. There are two types of episiotomies (Fig. 21-16). The midline or median episiotomy is the most common in the United States. It involves an incision from the posterior aspect of the vagina downward, directly toward the anus, approximately half the length of the perineum. The mediolateral episiotomy is a diagonal incision toward either side of the midline, done to prevent tearing into the rectum. The mediolateral incision may serve to decrease the incidence of third- and fourth-degree extensions but is more difficult to repair and is associated with more blood loss, pain, slow healing, and dyspareunia. It is performed when the fetal head is crowning 3 to 4 cm. An average incision extends 5 to 6 cm into the vagina. Lacerations and extensions of episiotomies are described according to the extent of tissue involvement (Box 21-11).

Historically, episiotomies were performed for a number of indications. These include the substitution of an anticipated ragged spontaneous laceration for a more controlled straight surgical incision, reduction in the second stage of a labor, and reduction in subsequent pelvic relaxation and trauma to pelvic musculature.

The literature since 1980 does not substantiate the alleged benefits of episiotomy (Argentine Episiotomy Trial Collaborative Group, 1993), as supported by more recent review by the Agency for Healthcare Research and Quality (Viswanathan et al., 2005). The reputed long-term and short-term benefits have not been substantiated. Episiotomy is used in approximately one third of vaginal deliveries to hasten birth and prevent tearing of the perineum during delivery, but in fact it fails to accomplish any of the other maternal or fetal benefits traditionally ascribed to it (Klein et al., 1994). Episiotomies fail to prevent perineal damage, pelvic floor relaxation, reduction of the second stage of labor, and protection of the newborn from either intracranial hemorrhage or intrapartum asphyxia. Also, episiotomy does not protect women against urinary or fecal incontinence, pelvic organ prolapse, or difficulties in sexual function in the first 3 months to 5 years after delivery. Furthermore, in primigravid women, episiotomy appears to be causally associated with third-degree and fourth-degree lacerations.

In summary, episiotomy is an unproven, controversial surgical procedure best restricted to specific fetal and maternal indications. Most data do not support its routine application, making its use a decision best left to the individual physician and patient (Sleep et al., 1984).

The repair of an episiotomy should be approached with standard surgical principles. After appropriate positioning of the patient and with adequate lighting, the practitioner should determine the extent of the wound. Efforts should be made to assess the adequacy of the anesthesia. Sites of uncontrolled bleeding should be identified and hemostasis ensured. In the repair the practitioner should aim to use the least amount of suture material possible and achieve wound approximation without dead space. Several techniques of repair are accepted. Typically, an anchoring, hemostatic stitch of an absorbable or delayed-absorbable material such as 2-0 chromic catgut or polyglycolic acid is placed at the apex of the vaginal incision, and the vaginal mucosa is approximated in a continuous interlocking fashion to the hymenal ring (Fig. 21-17, A). Polyglycolic acid sutures may be superior to chromium catgut for episiotomy suturing. Compared with surgical repair using catgut or chromic suture, repair using 3-0 polyglactin 910 (Vicryl) suture results in decreased wound dehiscence and less postpartum perineal pain. This suture can then be tied or brought through to repair the deep layer of the perineum (Fig. 21-17, B). The deep perineal tissues are then approximated with interrupted or continuous stitches in the muscle and fascia. Finally the skin is approximated with a subcuticular stitch, knotted and buried inside the vagina above the hymenal ring (Fig. 21-17, C).

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