Episiotomy Acog 3b3o5z

EPISIOTOMY Procedure and Repair Techniques

The American College of Obstetricians and Gynecologists W O M E N ’ S H E A LT H C A R E P H Y S I C I A N S

EPISIOTOMY Procedure and Repair Techniques RALPH W. HALE, MD FRANK W. LING, MD

The American College of Obstetricians and Gynecologists W O M E N ’ S H E A LT H C A R E P H Y S I C I A N S

Episiotomy: Procedure and Repair Techniques represents the knowledge and experience of experts in the field and does not necessarily reflect College policy. Methods and techniques of clinical practice that are currently acceptable and used by recognized authorities are described in this publication. These recommendations do not dictate an exclusive course of treatment or of practice. Variations taking into the needs of the individual patient, resources, and limitations unique to the institution or type of practice may be appropriate.

Library of Congress Catag-in-Publication Data Hale, Ralph W., 1935– Episiotomy : procedure and repair techniques / Ralph W. Hale, Frank W. Ling. p. ; cm. Includes bibliographical references. ISBN 978-1-932328-29-5 (alk. paper) 1. Episiotomy. I. Ling, Frank W. II. American College of Obstetricians and Gynecologists. III. Title. [DNLM: 1. Episiotomy. WQ 415 H163e 2007] RG971.H35 2007 618.8’5--dc22 2006036891

Copyright © 2007 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. ISBN 978-1-932328-29-5

12345/10987

CONTENTS Preface

v

Introduction

1

Indications 3 Types of Episiotomy ACOG Position 5

4

Basic Anatomy of the Perineum External

3

Internal

6

Midline Episiotomy

3

8

Procedure 8 Repair 11

Mediolateral Episiotomy Procedure Repair

16

16

Complications Bleeding

19

Infection

19

19

Pain and Dyspareunia Extension

20

21

Other Complications

21

Perineal Laceration Periurethral Tears

21

21

Vaginal Tears

23

Perineal Tears

23

References

16

24 iii

Preface Episiotomy is the most common operative procedure that most obstetricians will perform in their lifetime. Because it is so common and considered minor surgery, teaching students or interns the principles and techniques usually is left to the most junior of residents. As a result, the Residency Review Committee for Obstetrics and Gynecology (RRC) asked the American College of Obstetricians and Gynecologists (ACOG) to prepare a teaching aid for all residents, but especially those with the least experience. The result is this monograph. As with most surgical procedures, there are many approaches and modifications to episiotomy. However, the principle is the same. It does not matter if your preference is 4-0 chromic catgut suture or 3-0 polyglycolic suture. What matters is how, where, and when you suture. It is hoped that this monograph will be a guide to your approach to episiotomy. Many Fellows of ACOG participated in the development of this monograph, and it would be impossible to name them all. However, special thanks go to Frank Ling, MD, Howard Blanchette, MD, John Hauth, MD, and Gary Hankins, MD. A very special thank you goes to Tamara Tin-May Ho Chao, MD, resident member of the RRC, for her insightful comments. Finally, this document would not have been possible without the of the ACOG Development Committee. Countless of ACOG donate to the Development Fund annually to allow ACOG to expand its activities and further our educational endeavors. This monograph is just one example of how those donations can have a major impact.

Ralph W. Hale, MD ACOG Executive Vice President

v

Introduction The first use of an episiotomy to facilitate the delivery of an infant is lost in the past. Whether ancient midwives or birth attendants used primitive knives has been questioned for years. Perhaps they did or perhaps they did not. What is known, however, is that intentional incision of the perineum was not practiced as a routine procedure until the 20th century. Treatises on management of the perineum as the fetal head emerges at the time of delivery focused on protecting against tears and lacerations. In the 1700s, the usual description of a delivery of the infant’s head concentrated on preserving the intact perineum by allowing a slow, controlled dilation and delivery by exerting pressure on the perineum (1). In 1828, Ferdinand von Ritgen described a similar maneuver for easing the head over an intact perineum (2). His procedure, which he modified to use extension rather than flexion of the head, also was designed to prevent trauma to the perineum while facilitating the delivery (3). This was accomplished by placing the examiner’s fingers on the perineal body and gently pushing the head from flexion to extension. This maneuver is still performed in deliveries today and is known as the Ritgen maneuver. Although procedures for increasing the size of the vaginal outlet may have been used in the United States by Native Americans, immigrant midwives, or others, the first reported use was in Virginia in 1852 (4). However, there is little evidence that it gained any regional or widespread acceptance as part of a vaginal delivery. In 1893, Karl August Schuchardt, preparing to perform a vaginal approach to excision of a large cervical cancer, performed a mediolateral incision of the perineum to obtain additional exposure (5). He reported on this procedure to increase exposure in the same year. In his report, he described incision in the mediolateral tissue and muscles with much the same anatomical detail we would use today. Although

1

2

Episiotomy

he never used the word “episiotomy,” the procedure would be called gynecologic episiotomy today. J. B. Delee usually is credited with popularizing the use of the episiotomy when he became the champion for the use of forceps to protect the fetal head during delivery (6). He felt strongly that use of the forceps always should be accompanied by an episiotomy to prevent damage to the pelvic floor. Because of Delee’s stature in the field of obstetrics, his premise rapidly became accepted by U.S. obstetricians. As more and more women gave birth in hospitals rather than homes, episiotomy became the rule rather than the exception. The lithotomy position, especially if extreme, actually accentuated the tightening of the perineal opening and further contributed to the perceived need for a surgical approach to increase the vaginal opening. This procedure, which began as a mediolateral approach, slowly evolved in the United States during the 1950s and 1960s to predominantly a midline procedure. The purpose of the procedure, which was explained to residents year after year, was to facilitate the second stage of labor. It also was reported to reduce perianal trauma, pelvic floor dysfunction and prolapse, urinary and fecal incontinence, and sexual dysfunction. Benefits to the fetus were a shortened second stage and less potential trauma to the fetal head. In the 1970s and 1980s, however, obstetricians began to question the validity of the concept of protecting the perineum and the benefits related to “routine episiotomy.” In 1981, the National Childbirth Trust in London published a study that questioned the use of episiotomy as a routine procedure (7). This led to further review and questioning of routine use of episiotomy for vaginal delivery given that there was little evidence to the reported benefits. Today, episiotomy is still the most common surgical procedure performed by most obstetricians; however, it is much less common than in the 20th century. In 2003, 716,000 episiotomies were performed in the United States, whereas 11 years earlier, more than 1.6 million episiotomies were performed (8, 9) (see table). It most often is used in women who are having their first child and less frequently used with later children.

Episiotomy

Episiotomies Performed in the United States Year

No.

Rate per 10,000 Population/Female

2003

716,000

24.7

2002

780,000

53.2

2001

843,000

58.2

2000

944,000

66.4

1999

1,048,000

74.4

1998

1,220,000

87.3

1997

1,183,000

85.7

1996

1,294,000

956.6

1995

1,410,000

1,050.3

1994

1,512,000

1,136.1

1993

1,562,000

1,184.4

1992

1,611,000

1,235.1

Data from Des CJ, Hall MJ, Podgornik MN. Advance data from Vital and Health Statistics. Hyattsville (MD): U.S. Dept of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 2005. No. 359. Advance Data available at: http://www.cdc.gov/nchs/products/pubs/pubd/ad/ad.htm. Retrieved June 8, 2004.

Indications Today, the indications for episiotomy are based primarily on the clinical situation at the time of delivery and, therefore, vary greatly depending on the opinion of the obstetrician. In general, an episiotomy is indicated when shortening of the second stage of labor and expediting the delivery of the infant is indicated. Situations that may fall in this category are clinical circumstances such as a nonreassuring fetal heart rate pattern, shoulder dystocia, or operative vaginal delivery. Another indication is the potential for a significant spontaneous laceration at the time of delivery, which may occur with a short perineal body, a previous laceration, or a very large infant. However, two recent studies have not shown that episiotomy provided perineal protection,

3

4

Episiotomy

facilitated operative delivery, or improved neonatal outcome (10, 11). Current review and opinion suggest that evidence-based criteria are insufficient for establishing recommendations; therefore, clinical judgment remains the best guide (12).

Types of Episiotomy The two basic types of episiotomy in use in the United States today are the median and the mediolateral (Fig. 1). The median is also commonly referred to as the midline and is the most frequently used episiotomy in the United States. However, it is also associated with a greater risk of extension. This extension may include the anal sphincter (third degree) or the rectum (fourth degree) (13) (see box). A mediolateral episiotomy, which is an incision at least 45 degrees from the midline, is less frequently performed in the United States, but is more commonly found in other countries. This episiotomy is favored in those countries because it reduces the risk of third- and

Extension of Episiotomy First-degree tear:

A superficial laceration of the mucosa of the vagina, which may extend into the skin at the introitus. It does not involve deeper tissues and may not require repair.

Second-degree tear:

A first-degree laceration that involves the vaginal mucosa and perineal body. It may extend to the transverse perineal muscles and requires a suture repair.

Third-degree tear:

A second-degree laceration that extends into the muscle of the perineum and may involve both the transverse perineal muscles as well as the anal sphincter. It does not involve the rectal mucosa.

Fourth-degree tear:

A laceration involving the rectal mucosa.

Note: Some definitions are limited to the three levels of tear and will combine the first- and second-degree tears as only one level.

Episiotomy

Head of baby

5

Fig. 1. Midline and mediolateral episiotomy. (Pilliteri A. Maternal and child nursing. 4th ed. Philadelphia [PA]: Lippincott, Williams & Wilkins; 2003.)

Mediolateral Midline

fourth-degree extensions (14). Disadvantages of the mediolateral episiotomy are reported to be a more difficult repair, increased blood loss, and increased postpartum discomfort (15).

ACOG Position The American College of Obstetricians and Gynecologists has concluded: “The best available data do not liberal or routine use of episiotomy. Nonetheless, there is a place for episiotomy for maternal or fetal indications, such as avoiding severe maternal lacerations or facilitating or expediting difficult deliveries” (16). Further information is available in Practice Bulletin Number 71, Episiotomy (16).

Basic Anatomy of the Perineum Before performing and repairing an episiotomy, it is essential that the obstetrician have a thorough knowledge of the anatomy of the perineum and adjacent structures. A lack of knowledge of this area can lead to failure to adequately perform and repair the incision.

External The external genitalia are seen in Figure 2. The most critical area of the perineum is the distance from the vestibular fossa to the anus. This area is frequently referred to as the pudenda or perineal body, and it averages 3–4 cm in length in nonpregnant women. It will vary significantly from woman to woman, and it will expand as the head begins to emerge. The midline episiotomy is made in this anatomical area and this is where the mediolateral episiotomy begins.

6

Episiotomy

Mons pubis Anterior commissure of labia majora Prepuce of clitoris Pudendal cleft (groove or space between the labia majora) Glans of clitoris Frenulum of clitoris External urethral orifice Labium minus Labium majus Openings of paraurethral (Skene’s) ducts Vestibule of vagina (cleft or space surrounded by labia minora) Vaginal orifice Opening of greater vestibular (Bartholin’s) gland Hymenal caruncle Vestibular fossa Frenulum of labia minora Posterior commissure of labia majora Perineal raphe (over perineal body) Anus

Fig. 2. External genitalia. (Netter RH. Atlas of human anatomy. 4th ed. Philadelphia [PA]: Saunders Elsevier; 2006. Netter illustrations used with permission of Elsevier Inc. All rights reserved.)

Internal Underlying the skin are the muscle and fascial s of the perineum (Fig. 3). A midline episiotomy will extend from the vaginal orifice caudad toward the anus. The incision will be in the central point of the perineum and usually extends to the transverse perineal muscles, of which there are two: superficial and deep. The two muscles are in such close approximation that they usually are not identifiable as two separate entities. Because they also intertwine with the anal

Episiotomy

Bulbospongiosus muscle with deep perineal (investing or Gallaudet’s) fascia partially removed

7

Suspensory ligament of clitoris

Clitoris

Ischiocavernosus muscle Bulb of vestibule

Superficial perineal space (pouch or compartment)

Perineal membrane

Ischiopubic ramus with cut edge of superficial perineal (Colles’) fascia

Greater vestibular (Bartholin’s) gland Bulbospongiosus muscle (cut away)

Perineal membrane

Superficial transverse perineal muscle

Ischial tuberosity Sacrotuberous ligament

Perineal body

Gluteus maximus muscle

Ischioanal fossa

Coccyx Urethra

Crus of clitoris

Sphincter urethrae muscle

Ischiopubic ramus

Perineal membrane (cut and reflected) Compressor urethrae muscle

Bulb of vestibule

Sphincter urethrovaginalis muscle Vagina Greater vestibular (Bartholin’s) gland

Deep transverse perineal muscle

Perineal membrane

Fig. 3. Muscle and fascial s of the perineum. (Netter RH. Atlas of human anatomy. 4th ed. Philadelphia [PA]: Saunders Elsevier; 2006. Netter illustrations used with permission of Elsevier Inc. All rights reserved.)

Obturator fascia Tendinous arch of levator ani muscle Inferior fascia of pelvic diaphragm (cut) Levator ani muscle External anal sphincter muscle Anococcygeal (ligament) body

8

Episiotomy

sphincter, they often are mistaken for the sphincter itself. They extend laterally from the midline to the ischial tuberosity, and near the lateral vaginal edge their fascial covering is also next to the bulbospongiosus muscle. The bulbospongiosus is the main muscle that is incised when making a mediolateral episiotomy. This muscle extends from the pubic rami, circumscribes the vaginal opening, and then spreads slightly as it terminates just above the transverse perineal muscles. Lateral to the bulbospongiosus muscle is the superficial perineal compartment, which is usually filled with fatty tissue. The Bartholin’s gland, vestibular bulb, and multiple veins are also in this compartment. The blood supply to this area is seen in Figure 4. The internal pudendal artery, a branch of the anterior trunk of the internal iliac artery, is the main supplier of the perineum. Its branches are the perineal, labial, and hemorrhoidal arteries. The venous drainage follows essentially the same patterns as the arteries. However, in the paravaginal area, varicosities are not uncommon during pregnancy. The area is innervated by the pudendal nerve and its branches as seen in Figure 5. The pudendal nerve is a branch of sacral 2, 3, and 4. Occasionally, a cutaneous branch of the inferior anal nerve can innervate the area around the anus. When this occurs, the traditional pudendal block anesthesia will not be adequate for performance of an episiotomy, and local infiltration will be needed.

Midline Episiotomy Procedure Before performance of the episiotomy, adequate pain relief is needed. This can be obtained by use of local infiltration, pudendal nerve block, or conduction analgesia, such as an epidural or saddle block. Once pain relief is ensured, the procedure can commence. It is important to make certain that the fetal head is protected during the episiotomy. For that reason, a scalpel or other blade should be used only if scissors are not available. Initially, the index and middle finger should be inserted into the vagina between the perineum and the fetal head. The perineum is then

Episiotomy

9

Dorsal artery of clitoris

Posterior labial artery

Deep artery of clitoris

Ischiocavernosus muscle

Bulb of vestibule Compressor urethrae muscle

Bulbospongiosus muscle

Artery to bulb of vestibule Greater vestibular (Bartholin’s) gland

Superficial perineal space

Deep transverse perineal muscle

Perineal membrane

Internal pudendal (clitoral) artery Perineal membrane (cut)

Perineal artery

Perineal artery (cut)

Superficial transverse perineal muscle

Superficial perineal (Colles’) fascia (cut and reflected) to open superficial perineal space Internal pudendal artery in pudendal canal (Alcock’s)

Perineal artery

Inferior rectal artery

Internal pudendal artery in pudendal canal (Alcock’s)

Round ligament Tubal Ovarian

Inferior rectal artery External anal sphincter muscle Note: Deep perineal (investing or Gallaudet’s) fascia removed from muscles of superficial perineal space

Ovarian vessels Tubal branches of ovarian vessels Uterine vessels Ureter Vaginal branches of uterine artery Vaginal artery Levator ani muscle Perineal membrane Internal pudendal artery Perineal artery Superficial perineal space Superficial perineal (Colles’) fascia

Fig. 4. Blood supply of the perineum. (Netter RH. Atlas of human anatomy. 4th ed. Philadelphia [PA]: Saunders Elsevier; 2006. Netter illustrations used with permission of Elsevier Inc. All rights reserved.)

Branches of uterine artery

10

Episiotomy

Anterior labial nerve (from ilioinguinal nerve) Dorsal nerve of clitoris Posterior labial nerves Superficial Deep

Branches of perineal nerve

Perineal branch of posterior femoral cutaneous nerve Dorsal nerve of clitoris ing superior to perineal membrane Perineal nerve Pudendal nerve in pudendal canal (Alcock’s) (dissected) Inferior clunial nerves Gluteus maximus muscle (cut away) Sacrotuberous ligament Perforating cutaneous nerve Inferior anal (rectal) nerves Anococcygeal nerves

Fig. 5. Innervation of the perineum. (Netter RH. Atlas of human anatomy. 4th ed. Philadelphia [PA]: Saunders Elsevier; 2006. Netter illustrations used with permission of Elsevier Inc. All rights reserved.)

Episiotomy

incised vertically extending toward, but not into, the transverse perineal muscles (Fig. 6). Although in some women a raphe or dimpling can be seen, the incision should be made as close to the midline as possible. A question often arises as to when to perform the episiotomy. Some recommend before the head is fully crowning; others suggest only just before expulsion when the perineum is thinned and stretched. Both approaches have advantages and disadvantages and rely on the clinical judgment of the obstetrician. In general, it is better to perform the episiotomy later to avoid excessive blood loss and complete the delivery shortly thereafter. After completion of the delivery, it is critical to inspect the incision site carefully to determine the extent of the episiotomy and any possible tears or extensions. In primiparous women, the reported odds ratio is +22.08 that midline episiotomies will extend beyond the initial incision into and through the transverse perineal muscles and the anal sphincter (third degree) or into the rectal mucosa (fourth degree) (17). In another study, 14.9% of midline episiotomies resulted in an extension (18).

Repair Surgical repair of an episiotomy is a reapproximation of separated vaginal mucosa, soft tissue, and muscle so that each part is paired with its counterpart (Fig. 7, A–F). A complete knowledge of perineal anatomy is necessary if this is to occur (see “Basic Anatomy of the Perineum”).

Fig. 6. Midline episiotomy. (Beckman CRB, Ling FW, Laube DW, Smith RP, Barzansky BM, Herbert WN. Obstetrics and Gynecology. 4th ed. Baltimore [MD]: Lippincott, Williams & Wilkins; 2002.)

11

12

Episiotomy

The choice of suture is based on the extent of the repair. If the rectal mucosa is to be repaired, the suture should be no larger than 4-0. The standard suture material is chromic catgut, but synthetic material also is used by many obstetricians. The needle should be small and tapered for the mucosa, and a larger suture may be preferable for the soft tissue and muscle. Use of two different suture sizes and needles certainly is acceptable. For the sake of inclusion, this description will begin with a rectal extension and proceed upward. Obviously, if no extension occurred, the repair will begin at the appropriate lowest point of episiotomy. If the rectal mucosa is involved, the apex should be identified. A suture is then placed approximately 1 cm above the apex. This suture should extend through the submucosa, but usually not the mucosa itself. It is placed 1 cm above the apex to ensure that any retracted vessels are ligated. The mucosa is then closed in a running or locking fashion with 4-0 suture to the two mucosal edges (Fig. 7A). The suture should not penetrate the mucosal layer but bring the submucosa together. Sutures should be placed no more than 0.5 cm apart, and the running nonlocking suture should continue to the anal sphincter and perineal body. Next, the anal sphincter should be identified. The two edges usually will be retracted laterally, and an Allis clamp may be necessary to identify the cut edges and bring them together in the midline (Fig. 7B). When repairing the anal sphincter, it is important to suture the fascial sheath and not just the muscle. This repair is best accomplished with several interrupted sutures around the muscle rather than one large figure eight. The repair is strengthened by the sheath, not the muscle. Some obstetricians recommend that it is best to first apply the bottommost suture at the 6 o’clock position, then the most internal suture at the 9 o’clock position, then at the top or most superior part of the muscle, followed by a 3 o’clock placement, which is the most superficial and easiest. Because the transverse perineal muscles also are separated, they can be repaired in a similar fashion. The 12 o’clock anal sphincter suture usually will include a portion of the lower capsule of

Episiotomy

the transverse muscular tissue. Some obstetricians advocate use of 2-0 suture for these capsule repairs because it will give for a longer time and thus increase the healing capability. This is a personal choice, and there is no evidence to suggest which size suture is best. Now the underlying rectal fascial layer should be closed (Fig. 7C). This gives a second layer over the rectal mucosa and helps to further the extension. In addition, it also closes some of the potential “dead space” between the vaginal mucosa and the rectum. Some do this layer before sphincter repair and incorporate the 6 o’clock sphincter suture at the inferior end of this second-layer rectal repair. Throughout these procedures, the obstetrician should be checking carefully for any bleeding vessels and appropriately ligate them to prevent future hematomas. At this point, the procedure has reached the level of repair that is needed for a midline episiotomy without extension or a secondary laceration repair. A suture is placed approximately 1 cm above the apex of the vagina (Fig. 7D). The suture is then continued in a running or running locking fashion to the hymenal ring. Care should be taken to avoid deep suturing that could extend through the submucosal tissue into the rectum. Careful attention should be directed to ensuring the submucosal tissue is incorporated in the running suture (Fig. 7E). The size of suture for this portion of the repair usually is 3-0, although, for the novice surgeon, 2-0 is easier to use. The needle should be noncutting. At the hymen, careful approximation of the two edges can be obtained by bringing the outer portion together. The running suture is then continued to the squamomucosal junction. When this area is reached, it is important to assess the perineal body and submucosal areas. If there is a deep defect, interrupted sutures may be needed to approximate the sides to prevent dead space. Finally, the skin is ready for closure (Fig. 7F). This can be done by a continuous subcuticular extension of the suture that has been brought to the squamomucosal area; it also can be closed with a separate 3-0 or 4-0 subcuticular repair.

13

14

Episiotomy

Fig. 7. Repair of midline episiotomy. A. Closure of the rectal mucosa. B. Closure of the anal sphincter. C. Second layered closure of the rectal mucosa using the rectovaginal fascia. D. Anchor stitch placed 1 cm beyond the most superior extent of the episiotomy. E. Use of one suture for closure. F. Completion of repair using a subcuticular suture. (Hankins GDV, Clark SL, Cunningham FG, Gilstrap LC. Operative obstetrics. New York [NY]: McGraw-Hill; 1995. Reproduced with permission of The McGraw-Hill Companies.)

A

B

Episiotomy

C

D

E

F

15

16

Episiotomy

Mediolateral Episiotomy Procedure A mediolateral episiotomy requires the same pain prevention as noted for a midline repair. The debate about when to perform the episiotomy is also the same. Most surgeons recommend these procedures be done just before delivery because mediolateral episiotomies tend to bleed more than midline procedures. Once the decision is made, the fingers are inserted into the vagina between the head and the perineum. An incision is then made at approximately a 45-degree angle from the midline to the perineal body (Fig. 8). The apex should be in the exact midline of the perineum, not lateral to the midline. This incision can be on the left or right side depending on the preference of the obstetrician. Some authorities suggest that repair of an incision on the patient’s left side is mechanically easier for a right-handed surgeon. It is important to use large, straight sharp scissors to allow the incision to be made in a single cut. The incision will extend approximately 4 cm into the perineum and may reach the ischioanal fossa. If the incision is not deep enough, there will be little relaxation, and a second incision to extend the first will be necessary. Although not prohibited, a second incision increases the risk of a zigzag line upon healing. Optimal timing of the episiotomy usually is when the vertex is crowning. Before crowning, there is the risk of excessive bleeding because the vessels are not compressed.

Repair Immediately after the delivery, the obstetrician should examine the extent of the episiotomy. Upward extension of the vaginal incision should be evaluated carefully, especially if a forceps delivery occurred. Once this evaluation is completed, the repair should begin (Fig. 9, A–D). Any arterial bleeding should be managed to prevent subsequent hematoma formation. Two fingers are placed in the vagina for traction and to spread the incisional edges. A suture of 2-0 or 3-0 material is then placed approximately 1 cm above the apex. This will prevent retracted vessels from bleeding and disrupting the repair. A running suture using a noncutting needle is then used to close the vaginal mucosal and submucosal areas (Fig. 9A). It may be necessary to place additional interrupted sutures in the submucosal space if inadequate tissue is obtained with the mucosal

Episiotomy

Fig. 8. Mediolateral episiotomy. (Hankins GDV, Clark SL, Cunningham FG, Gilstrap LC. Operative obstetrics. New York [NY]: McGraw-Hill; 1995. Reproduced with the permission of The McGraw-Hill Companies.)

stitch. Once the introitus is reached, it will be necessary to close the ing tissue (Fig. 9B). There is usually no attempt to reapproximate the hymen in this approach. Several more interrupted sutures will be necessary to close the remainder of the tissue. Because the incision is in a lateral direction, the medial tissue will be lower than the distal edge, and careful approximation is necessary to avoid subsequent distortion of the vaginal opening. Placing sutures diagonally rather than horizontally will help maintain appropriate anatomical approximation (Fig. 9C). It is usually not necessary to use more than six interrupted sutures, and less is better than more. Before closing the skin and underlying tissue, the bulbospongiosus muscle usually will need to be repaired because it extends into the incision site (see “Basic Anatomy of the Perineum”). The upper end of the muscle, if transected, will have retracted and will need to be identified and reapproximated. Sutures should be placed in the fascial sheath and not the muscle. Once this repair is complete, the underlying tissue and skin can be reapproximated. Diagonal, not horizontal, sutures should be used. The skin itself is best approximated with a subcuticular stitch (Fig. 9D).

17

18

Episiotomy

Fig. 9. Repair of mediolateral episiotomy. A. Placement of the first suture at the vaginal apex. B. Approximation of the vaginal mucosa. C. The vaginal wound is sutured to the approximate level of the posterior commissure. D. Approximation of the perineal skin edges. (Hankins GDV, Clark SL, Cunningham FG, Gilstrap LC. Operative obstetrics. New York [NY]: McGraw-Hill; 1995. Reproduced with the permission of The McGraw-Hill Companies.)

A

C

B

D

Episiotomy

Complications Bleeding One of the most frequent complications of episiotomy is bleeding. The area surrounding the perineum has extensive vasculature, which has been accentuated secondary to the effects of pregnancy. During the second stage of labor, pressure of the fetal head has compressed many of these vessels, so they are not readily visible until after the episiotomy is performed and the infant is delivered. The episiotomy site should be inspected immediately after delivery and before placental expulsion. At that time, compression with a sterile gauze sponge should control most bleeding. However, if a small artery is bleeding, it may require clamping and ligation. Once the repair begins, incorporation of the tissue in the suture usually will be sufficient. However, careful attention must be paid to episiotomy sites that continue to bleed to avoid the formation of a hematoma. If a hematoma does form, it increases the risk of infection and causes increased pain. Small hematomas can be treated with ice packs and analgesics. Larger ones may need to be drained or evacuated. A mediolateral episiotomy will bleed more than a midline episiotomy. Because this incision is more likely to involve muscle, the risk of heavy bleeding is increased. Arterial bleeding from muscle usually comes from a vessel that is retracted deep into the muscle so ligation is often difficult. Because the ischioanal fossa area is adjacent to the mediolateral site, careful hemostasis is essential to prevent formation of deep hematomas, which can dissect upward into the upper vagina and broad ligament. In rare instances, a hematoma can spread into the anterior abdominal wall through a defect in Colles’ fascia connection to the pubic rami.

Infection The area of the episiotomy is heavily colonized by bacteria naturally and frequently is contaminated by fecal matter during the delivery process. Therefore, the risk of infection is very high. However, the woman’s own defenses will help prevent most episiotomies from being

19

20

Episiotomy

infected. The obstetrician also can help by gently irrigating the area using sterile saline or water, with or without the use of an antiseptic. If infection does occur, rapid treatment is essential to avoid necrosis, breakdown of the site, and sepsis. Necrotizing fasciitis can occur, and its presence can be life threatening. Some physicians recommend irrigating with an antibacterial solution for fourth-degree extension. If an examining finger is placed in the rectum during the repair, the surgeon’s gloves should be changed once the closure is complete to reduce contamination during the remaining repair. Antibiotic therapy is not indicated in the absence of infection. The use of sitz baths and stool softeners may be helpful and reduce the need for pain medication.

Pain and Dyspareunia Pain in the site of the episiotomy is not uncommon. Although women without episiotomies have perineal pain, those with episiotomies will often have pain that is more localized and lasts longer. If the patient experiences severe pain, it is important to examine the site to rule out hematoma or infection. These two complications can greatly increase the pain level. Most pain related to a midline episiotomy will respond to mild analgesics and resolve in 3–5 days. Pain from a mediolateral episiotomy may last longer. The pain will be most noticeable during ambulation. A concern for many women is the first episode of intercourse after giving birth. For some women, the episiotomy site will be tender. Almost 40% of women have dyspareunia following an episiotomy (19, 20). The association of dyspareunia appears to be stronger with mediolateral incisions than with midline incisions, but there are no good comparisons. There is some evidence that third- and fourth-degree extensions will result in greater pain with intercourse (17). The type of suture material used in the repair also may be a factor, and the use of certain synthetic polyglycolic sutures has been shown to be associated with earlier resumption of intercourse (21). Dyspareunia also is related to the couple’s relationship both before and after the delivery. When a woman experiences dyspareunia, it should be evaluated and not automatically assumed to result from the episiotomy.

Episiotomy

Extension A common complication of a midline episiotomy is extension into the rectum. Careful exploration of the incision is necessary to ascertain if this occurred. Once the transverse perineal muscles and the anal sphincter tear, the rectal mucosa must be inspected carefully for involvement. At the time of the episiotomy, the perineum is stretched and thinned, which may result in iatrogenic extensions. Failure to recognize the extension can lead to infection, fistula formation, and even breakdown of the episiotomy.

Other Complications Rare, but more serious complications are dehiscence, fistula formation, and anal incontinence. These conditions are beyond the scope of this monograph but should be kept in mind as potentially serious complications.

Perineal Lacerations Although not related to the episiotomy, during the process of childbirth, tears may occur in multiple areas of the vaginal and paravaginal area (Fig. 10). In most instances, they are minor and require no specific therapy. However, it is important to examine the vagina and periurethral areas carefully to determine if tears have occurred.

Periurethral Tears Small tears and abrasions are seen frequently in the periurethral and clitoral area after delivery. This is especially true when delivery occurs without an episiotomy. These tears are usually 1–1.5 cm in length and do not bleed. However, if the tears are bleeding, they should be sutured. Very small, usually 4-0 suture is preferable. Secondary swelling can occur, causing difficult voiding, and should be evaluated as part of the immediate postpartum examination. Some women will report dysuria, but careful questioning will reveal that urine touching the site of the laceration is the cause of the discomfort and not true dysuria.

21

22

Episiotomy

1st degree perineal laceration

2nd degree perineal laceration plus tear of clitoris

A B

3rd degree perineal laceration and labial tear

C

High vaginal laceration

D

Fig. 10. Obstetric lacerations. A. First-degree perineal laceration. B. Seconddegree perineal laceration plus tear of clitoris. C. Third-degree perineal laceration and labial tear. D. High vaginal laceration. (Netter RH. Atlas of human anatomy. 4th ed. Philadelphia [PA]: Saunders Elsevier; 2006. Netter illustrations used with permission of Elsevier Inc. All rights reserved.)

Episiotomy

Vaginal Tears As the fetal head descends through the vagina, age over the ischial spines and through the outlet can compress the vaginal mucosa and cause abrasions and tears. These tears can be extensive, especially in the presence of a small pelvis with prominent spines and a large baby. They are also more common with forceps deliveries. After delivery of the infant, with or without an episiotomy, the vaginal vault should be examined. Specific areas to be examined include the paracervical areas, over the spines, and near the outlet. Minor abrasions that are not bleeding do not require suturing, even if they are extensive. The most difficult to repair and the most serious are those tears in the deep vaginal areas. They should be sutured even if they are not bleeding at the time of exploration. A running, locking suture of 2-0 or 3-0 is best because the tissue often is edematous and friable. The suture should begin at least 1 cm above the apex of the tear because vessels may have retracted, and continued bleeding can result in a hematoma extending up into the broad ligament. It is important to inspect the cervix to ascertain that the vaginal tear is not in reality an extension of a cervical tear. If it is a cervical tear, usually at 3- or 9o’clock positions, it should be repaired if it is actively bleeding, extends into the vagina, or is longer than 1–2 cm in length.

Perineal Tears Tears in the perineum may occur when an episiotomy is not performed or is performed late in delivery. These tears may appear jagged and irregular in appearance (see Fig. 10). However, they should be repaired by the same method that is used when repairing a similar episiotomy. Smaller tears in the perineal skin may occur during a delivery. These tears usually do not need to be repaired unless they are bleeding. Once the legs are removed from the lithotomy position, the tears will come together and no further therapy is needed. If active bleeding is observed, one or two small sutures may be needed.

23

24

Episiotomy

References 1.

Harvie J. Practical directions showing a method of preserving the perineum in birth and delivering the placenta without violence. London: D Wilson and G Nicol; 1767.

2.

von Ritgen FVA. Geburtshülfliche Erfahrungen und Bemerkungen. Gem Deutschve. Ztschr F Geburtsk 1828;3viv, 147–69.

3.

von Ritgen FVA. Ueber sein Dammschutzverfahren. Monatschr f. Geburtisk LI, Frauenkrankeiten, 1855;6:321.47.

4.

Taliaferro RM. Rigidity of soft parts: delivery effected by incision in the perineum. Stethoscope Va Med G 1852;2:383–5.

5.

Schuchardt K. Eine neue Methode der Gebärmutterexstirpation. Centralbl F Chir 1893;20:1121–6.

6.

DeLee JB. The prophylactic forceps operation. Trans Am Gynecol Soc 1920;45: 66–77; discussion 77–83.

7.

Kitzinger S. Episiotomy: physical and emotional aspects. London: The National Childbirth Trust; 1981.

8.

Des CJ, Podgornik MN. 2004 National Hospital Discharge Survey. Adv Data 2006;(371):1–19.

9.

Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson ML. Births: final data for 2003. Natl Vital Stat Rep 2005;544(2):1–116.

10.

Myles TD, Santolaya J. Maternal and neonatal outcomes in patients with prolonged second stage of labor. Obstet Gynecol 2003;102:52–8.

11.

Bodner-Adler B, Bodner K, Kimberger O, Wagenbichler P, Mayerhofer K. Management of the perineum, during forceps delivery. Association of episiotomy with the frequency and severity of perineal trauma in women undergoing forceps delivery. J Reprod Med 2003;48:239–42.

12.

Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J Jr, Lohr KN. Outcomes of routine episiotomy: a systematic review. JAMA 2005;293:2141–8.

13.

Coats PM, Chan KK, Wilkins M, Beard RJ. A comparison between midline and mediolateral episiotomies. Br J Obstet Gynaecol 1980;87:408–12.

14.

Shiono P, Klebanoff MA, Carey JC. Midline episiotomies: more harm than good? Obstet Gynecol 1990;75:765–70.

15.

Thacker SB, Banta HD. Benefits and risks of episiotomy: an interpretive review of the English language literature, 1860-1980. Obstet Gynecol Surv 1983;38:322–38.

16.

Episiotomy. ACOG Practice Bulletin No. 71. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;107:957–62.

17.

Klein MC, Gauthier RJ, Robbins JM, Kaczorowski J, Jorgensen SH, Franco ED, et al. Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation. Am J Obstet Gynecol 1994;171:591–8.

18.

Bodner-Adler B, Bodner K, Kaider A, Wagenbichler P, Leodolter S, Husslein P, et al: Risk factors for third-degree perineal tears in vaginal delivery, with an analysis of episiotomy types. J Reprod Med 2001;46(8):752–6.

19.

Bex PJ, Hofmeyr GJ. Perineal management during childbirth and subsequent dyspareunia. Clin Exp Obstet Gynecol 1987;14:97–100.

20.

Signorello LB, Harlow BL, Chekos AK, Repke JT. Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primiparous women. Am J Obstet Gynecol 2001;184:881–8; discussion 888–90.

21.

Leroux N, Bujold E. Impact of chromic catgut versus polyglactin 910 versus fastabsorbing polyglactin 910 sutures for perineal repair: a randomized, controlled trial. Am J Obstet Gynecol 2006;194:1589–90; discussion 1590.