Definition: An episiotomy is a surgically planned incision on the perineum and posterior vaginal wall during the second stage of labor to enlarge the vaginal opening and facilitate delivery, while minimizing perineal tearing.
Objectives
Enlarge the vaginal introitus.
Facilitate easy and safe delivery of the fetus (either spontaneous or manipulative).
Minimize overstretching and rupture of perineal muscles and fascia.
Reduce stress and strain on the fetal head.
Indications
Rigid (inelastic) perineum.
Anticipating perineal tear.
Operative deliveries (forceps, breech, occipitoposterior or face delivery).
Previous perineal surgery.
Common indications include threatened perineal injury in primigravidae and rigid perineum.
Timing
Performed during contraction, just prior to crowning (when 3–4 cm of the fetal head is visible).
During forceps delivery, it is done after the application of blades.
Early episiotomy may result in more blood loss, while late episiotomy may not prevent invisible lacerations.
Advantages
Maternal:
A clear and controlled incision that is easy to repair and heals better.
Shortens the duration of the second stage of labor.
Reduces trauma to muscles.
Fetal:
Minimizes intracranial injuries.
Types of Episiotomy Incisions
Mediolateral: Incision is made downwards and outwards from the midpoint of the fourchette to the right or left, directed diagonally about 2.5 cm from the anus.
Median: Incision starts from the center of the fourchette and extends posteriorly along the midline for about 2.5 cm.
Lateral: Starts about 1 cm from the center of the fourchette and extends laterally. Drawbacks include a risk of injury to the Bartholin’s duct.
J Shaped: Begins at the center of the fourchette and extends posteriorly along the midline, then directed downwards and outwards. Rarely used due to imperfect apposition and puckering.
Steps of Mediolateral Episiotomy
Preparation: Perineum swabbed with antiseptic and draped properly.
Anesthesia: Local infiltration with 1% lignocaine.
Incision: Made with scissors at the height of a contraction.
Structures Cut:
Posterior vaginal wall.
Superficial and deep transverse perineal muscles, bulbospongiosus, and part of levator ani.
Fascia covering these muscles.
Transverse perineal branches of pudendal vessels and nerves.
Subcutaneous tissue and skin.
Timing and Steps for Repair
Repair is done soon after the expulsion of the placenta.
Early repair prevents sepsis and reduces the patient's apprehension of stitches.
Repair involves:
Lithotomy position, good light source, antiseptic cleansing.
Performed in three layers: vaginal mucosa, perineal muscles, skin, and subcutaneous tissue.
Emphasizes perfect hemostasis, obliteration of dead space, and suturing without tension.
Postoperative Care
Includes dressing, pain management with ibuprofen, and removal of non-absorbable stitches on the sixth day.
Complications
Immediate:
Extension of incision to rectum, vulval hematoma, infection, wound dehiscence, anal sphincter injury.
Treatment includes drainage of pus, local antiseptic dressing, and systemic antibiotics.
Remote:
Dyspareunia, perineal lacerations in subsequent labor, rare scar endometriosis.