September 6, 2011

Episiotomy is a procedure designed to enlarge the vaginal opening at the time of delivery of the fetal head. It is performed when the baby’s head is crowning (visible 3-4 cm). Options for pain relief during the procedure include local injection of an anesthetic such as lidocaine, epidural anesthesia, intravenous narcotics, or local nerve block. The procedure is performed by making a vertical incision at the midline directly below the vagina between the vagina and the anus (“midline” episiotomy) or creating an incision at a 30° angle from the vertical (“mediolateral” episiotomy). In the United States, the midline technique is most common.

Episiotomy was a routine obstetrical practice for many years. It was thought that routine episiotomy decreased the length of the second stage of labor (“pushing”) and protected the baby’s head, as well as protected the mother from damage to the anal sphincter and long-term problems with bowel and bladder incontinence. However, based on recent studies, it is clear that avoidance of episiotomy results in fewer and smaller tears, particularly in women undergoing their first vaginal delivery. Indeed, massaging or stretching the vaginal tissue daily for several weeks prior to delivery has been shown to decrease the rate of episiotomy and tears.

Current indications for episiotomy include shoulder dystocia (impaction of the baby’s shoulder against the maternal symphysis pubis), breech delivery, and instrumented vaginal delivery (forceps or vacuumassisted vaginal delivery). These are all circumstances in which additional room may be required for certain maneuvers in order to deliver the baby safely.

Episiotomy and perineal lacerations are classified based on the layers of tissue that are disrupted during the procedure. Firstand second-degree episiotomy or tear both disrupt the vaginal wall but spare the anal sphincter (ring of muscles around the anus). A thirddegree episiotomy or extension severs the anal sphincter (ring of muscles surrounding the anus). If the episiotomy extends from the vagina into the rectum, it is referred to as a fourth-degree extension, or if cut deliberately, a proctoepisiotomy.

Episiotomy and laceration (cut or tear) repair are generally performed using a continuous length of absorbable synthetic suture. This technique reduces pain in the postpartum period. The suture does not need to be removed at a later date.

Care of the perineum after episiotomy or perineal laceration includes the use of ice packs, nonsteroidal
anti-inflammatory medication (i.e., ibuprofen), and topical sprays, all of which reduce swelling and pain. Infection and bleeding or the formation of a hematoma (collection of blood beneath the sutures) are possible complications. Infection is generally treated by removing the sutures and prescription of oral antibiotics. A hematoma may be evacuated by removing the sutures and allowing the tissues to heal openly. Occasionally, fecal (stool) incontinence can develop if the anal sphincter or its nerve are damaged. This may require surgery at a later date.

SEE ALSO: Labor and delivery, Urinary incontinence and voiding dysfunction

Suggested Reading

  • Baxley, E. G., & Gobbo, R. (2001). Episiotomy and repair of lacerations. In S. D. Ratcliffe (Ed.), Family practice obstetrics (2nd ed.). Philadelphia: Hanley & Belfus.
  • Carroli, G., & Belizan, J. (2003). Episiotomy for vaginal birth (Cochrane review). In: The Cochrane Library, Issue 1. Oxford: Update Software.
  • Eason, E., Labrecque, M., Wells, G., & Feldman, P. (2000). Preventing perineal trauma during childbirth: A systematic review. Obstetrics and Gynecology, 95, 464—471.


  • proctoepisiotomy
  • definition of proctoepisiotomy

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