Episiotomy procedure explanation
Episiotomy is a surgical incision made in the posterior vaginal wall and perineum to enlarge the vaginal
opening for easier childbirth. This procedure is commonly performed worldwide, especially during the
second stage of labor. It is often recommended for first-time mothers (primiparous women) whose birth
canal has not yet been stretched by previous deliveries.
Episiotomy is performed to prevent perineal tears or excessive stretching of the muscles during
childbirth. Severe tears may extend to the anal sphincter and rectum, potentially leading to fecal
incontinence. Additionally, natural tears are often irregular, harder to control, and more challenging to
repair. Overstretching of the muscles and ligaments can also increase the risk of utero-vaginal prolapse
in the future.
Uses of Episiotomy:
Reduces the risk of severe perineal tears
Facilitates smoother and controlled delivery
Helps protect the pelvic floor muscles from excessive strain
Reduces the risk of complications like fecal incontinence and prolapse
Episiotomy may be performed to protect the fetus, especially in cases where it is premature or
experiencing repeated pressure against a rigid perineum that is obstructing delivery. It also helps
prevent trauma in situations involving abnormal fetal positions, such as occipitoposterior positions, face
presentations, and after-coming heads in breech deliveries. Additionally, it is often necessary during
shoulder dystocia and all instrumental deliveries. In such cases, the procedure may be done before the
perineum becomes fully stretched.
Uses of Episiotomy:
Protects a premature or distressed fetus
Facilitates delivery in cases of abnormal fetal positions
Prevents trauma during breech deliveries and shoulder dystocia
Aids in safer instrumental deliveries
Types of Episiotomy
1. Median Episiotomy:
In this type, the incision starts at the center of the fourchette and extends along the midline towards the
posterior for about 2.5 cm (1 inch). It is the easiest to perform and repair. However, if the incision
extends unintentionally, it offers no protection to the anal sphincter, increasing the risk of injury.
2. Medio-Lateral Episiotomy:
In this type, the incision is made downward and outward from the center of the fourchette, extending
diagonally to either the right or left. It follows a straight line, approximately 2.5 cm away from the anus,
positioned midway between the anus and the ischial tuberosity. This approach reduces the risk of anal
sphincter injury compared to a median episiotomy.
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However, a medio-lateral episiotomy is more challenging to repair due to uneven retraction of the
edges, making precise anatomical alignment more difficult. Despite this, it provides the best protection
against anal sphincter injury and effectively serves the purpose of the procedure. As a result, it is the
most commonly performed type of episiotomy.
3. J-Shaped Episiotomy:
In this technique, the incision starts at the center of the fourchette and extends posteriorly along the
midline for about 1.5 cm. It then curves downward and outward towards the 5 or 7 o’clock position to
avoid injury to the internal and external anal sphincter. However, this method is not commonly used in
clinical practice.
4. Lateral Episiotomy:
In this technique, the incision begins about 1 cm away from the center of the fourchette and extends
laterally. However, it carries a risk of injuring the Bartholin’s gland, making it less favorable. Due to its
drawbacks, most practitioners strongly discourage its use.
Technique of Episiotomy
To perform an episiotomy, two fingers are inserted into the vagina to protect the fetal head, and a
precise incision is made using sterile scissors. It is crucial to start the incision from the fourchette to
ensure proper anatomical alignment during repair.
The timing of the procedure is a skill acquired through experience. Ideally, the incision should be made
when the presenting part is stretching the vulva. Performing it too early can lead to excessive blood loss,
while delaying it may result in vaginal or deep perineal muscle tears.
Repair of Episiotomy
The repair is performed in three layers using absorbable sutures:
1. Vaginal Mucosa: Suturing begins at the apex of the episiotomy to ensure proper closure.
2. Muscle Layer: The underlying muscles are carefully sutured for structural support.
3. Perineal Skin: Sutures can be continuous or interrupted, with knots buried beneath the surface for
better healing. A subcuticular technique is preferred for a smoother finish and reduced discomfort.
Complications of Episiotomy
1. Bleeding: This can occur if suturing does not begin at the apex of the incision, leading to
continued blood loss.
2. Pain: Significant discomfort is common during the puerperium, and even after healing, some
women may experience pain during intercourse.
3. Infection: Poor healing or infection can cause the episiotomy wound to break down, delaying
recovery.
4. Extension of the Incision: If the presenting part causes the incision to extend, it may result in anal
sphincter damage, potentially leading to fecal incontinence.
Episiotomy Care
Take a daily sitz bath with warm water to promote healing.
Maintain good perineal hygiene, especially after urination or bowel movements.
Use pain relief methods such as ibuprofen or lignocaine gel for comfort.
Applying ice packs can help reduce swelling and discomfort.
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Change sanitary pads every 2–4 hours to keep the area clean and dry.
Controversy Surrounding Episiotomy
Research suggests that episiotomies may contribute to many of the complications they are intended to
prevent, with significant morbidity associated with the procedure. As a result, the routine use of
episiotomy, even in first-time mothers, is being reconsidered. A more restrictive approach is now
recommended, where the decision to perform an episiotomy is individualized based on the specific
needs of each delivery.
Perineal Tears (Lacerations)
Perineal tears, or vaginal lacerations, occur during childbirth, often when the baby's head is too large for
the vaginal opening or when the vaginal tissues do not stretch easily. These tears are more common in
first-time mothers (primigravidae) due to the increased rigidity of the perineal tissues.
The width of the pubic arch and the size and position of the fetal head are key factors influencing
perineal tears. Malpresentations increase perineal stretching, raising the risk of injury.
Perineal tears are the most common obstetric injury and vary in severity. While most are superficial
and may not require treatment, severe tears can lead to significant bleeding, long-term pain, and
functional complications.
Classification of Perineal Tears
1. First-Degree Tear: Involves only the vaginal and perineal skin, with the perineal muscles
remaining intact.
2. Second-Degree Tear: Extends beyond the vaginal and perineal skin to involve the perineal muscles
and fascia, but the anal sphincter remains unaffected.
Classification of Perineal Tears
3. Third-Degree Tear: Involves the perineal skin, vaginal mucosa, perineal muscles, and anal
sphincter.
4. Fourth-Degree Tear: The most severe type, affecting the perineal skin, vaginal mucosa, perineal
muscles, anal sphincter, and rectal mucosa.
Management of Perineal Tears
The approach to treatment depends on the severity of the tear:
First-Degree Tears: These are minor injuries. Suturing is optional and left to the clinician’s
discretion.
Second-Degree Tears: Although still considered minor, suturing is recommended to ensure proper
wound healing and tissue alignment.
Management of Severe Perineal Tears
Third- and Fourth-Degree Tears should be repaired promptly in an operating theatre under
regional or general anesthesia.
Immediate repair leads to better healing outcomes compared to delayed intervention, which may
result in complications if left untreated for months or years.
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Postoperative Management
Antibiotics: Broad-spectrum antibiotics are prescribed to prevent infection.
Pain Management: Analgesics such as paracetamol, NSAIDs, and limited opioid use help control
pain.
Laxatives & Stool Softeners: To prevent strain and reduce the risk of wound dehiscence, stool
softeners should be given for up to 10 days postoperatively.
Postoperative Care Recommendations
Limit prolonged sitting for the first 48 hours to reduce pressure on the wound. Instead, rest on a
flat bed and adopt a side-lying position while breastfeeding.
Start pelvic floor exercises 2–3 days postpartum or when comfortable to promote healing and
strengthen muscles.
Maintain good hygiene by washing the wound after toileting and gently patting it dry to prevent
infection.
Recovery and Long-Term Impact
First- and Second-Degree Tears are minor, and most patients recover without complications.
Third- and Fourth-Degree Tears are more severe and may lead to residual defects, potentially
causing long-term symptoms that can significantly affect a woman's quality of life.
Long-Term Complications
The most common long-term issues include:
Dyspareunia (pain during intercourse)
Persistent perineal pain
Flatal and fecal incontinence
However, 60%–80% of women remain asymptomatic 12 months after delivery following proper
healing and external anal sphincter repair.
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