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Approach to episiotomy

Authors
Lori R Berkowitz, MD
Caroline E Foust-Wright, MD, MBA
Section Editor
Charles J Lockwood, MD, MHCM
Deputy Editor
Kristen Eckler, MD, FACOG

INTRODUCTION

Episiotomy is performed to enlarge the birth outlet and facilitate delivery of the fetus. Routine use of episiotomy has fallen out of favor based on evidence of increased complications with use. Episiotomy is now performed on an individualized basis. Episiotomy is considered when the clinical circumstances place the patient at high risk of a third or fourth degree laceration or when the fetal heart tracing is of concern and hastening vaginal delivery is warranted. Mediolateral episiotomy is associated with a lower risk of third and fourth degree laceration than a median episiotomy.

This topic will review the indications, risks, benefits, and procedure for episiotomy. The repair of episiotomy and obstetric anal sphincter laceration are presented separately.

(See "Repair of episiotomy and perineal lacerations associated with childbirth".)

(See "Effect of pregnancy and childbirth on anal sphincter function and fecal incontinence".)

DEFINITION

Episiotomy is the surgical enlargement of the posterior aspect of the vagina by an incision to the perineum during the last part of the second stage of labor [1]. The incision is performed with scissors or scalpel and is typically midline (median) or mediolateral in location. (See 'Procedures and selection' below.)

                    

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Literature review current through: Nov 2016. | This topic last updated: Thu Oct 13 00:00:00 GMT+00:00 2016.
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References
Top
  1. Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst Rev 2009; :CD000081.
  2. World Health Organization Division of Family Health Maternal Health and Safe Motherhood. Care in normal birth: a practical guide. Report of a technical working group. World Health Organization; Geneva, 1996.
  3. Friedman AM, Ananth CV, Prendergast E, et al. Variation in and factors associated with use of episiotomy. JAMA 2015; 313:197.
  4. Howden NL, Weber AM, Meyn LA. Episiotomy use among residents and faculty compared with private practitioners. Obstet Gynecol 2004; 103:114.
  5. Robinson JN, Norwitz ER, Cohen AP, Lieberman E. Predictors of episiotomy use at first spontaneous vaginal delivery. Obstet Gynecol 2000; 96:214.
  6. Practice Bulletin No. 165: Prevention and Management of Obstetric Lacerations at Vaginal Delivery. Obstet Gynecol 2016; 128:e1.
  7. National Institute for Health and Care Excellence. Intrapartum care for healthy women and babies. NICE Guidelines [CG190], National Institute for Health and Care Excellence, 2014.
  8. Hale RW, Ling FW. Episiotomy: Procedure and repair techniques. American College of Obstetricians and Gynecologists; Washington, DC, 2007.
  9. Bottoms S. Delivery of the premature infant. Clin Obstet Gynecol 1995; 38:780.
  10. Sartore A, De Seta F, Maso G, et al. The effects of mediolateral episiotomy on pelvic floor function after vaginal delivery. Obstet Gynecol 2004; 103:669.
  11. Klein MC, Gauthier RJ, Robbins JM, et al. Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation. Am J Obstet Gynecol 1994; 171:591.
  12. Röckner G, Jonasson A, Olund A. The effect of mediolateral episiotomy at delivery on pelvic floor muscle strength evaluated with vaginal cones. Acta Obstet Gynecol Scand 1991; 70:51.
  13. Woolley RJ. Benefits and risks of episiotomy: a review of the English-language literature since 1980. Part I. Obstet Gynecol Surv 1995; 50:806.
  14. Woolley RJ. Benefits and risks of episiotomy: a review of the English-language literature since 1980. Part II. Obstet Gynecol Surv 1995; 50:821.
  15. Klein MC, Gauthier RJ, Jorgensen SH, et al. Does episiotomy prevent perineal trauma and pelvic floor relaxation? Online J Curr Clin Trials 1992; Doc No 10:[6019 words; 65 paragraphs].
  16. Pergialiotis V, Vlachos D, Protopapas A, et al. Risk factors for severe perineal lacerations during childbirth. Int J Gynaecol Obstet 2014; 125:6.
  17. Sagi-Dain L, Sagi S. The role of episiotomy in prevention and management of shoulder dystocia: a systematic review. Obstet Gynecol Surv 2015; 70:354.
  18. Macleod M, Strachan B, Bahl R, et al. A prospective cohort study of maternal and neonatal morbidity in relation to use of episiotomy at operative vaginal delivery. BJOG 2008; 115:1688.
  19. Alperin M, Krohn MA, Parviainen K. Episiotomy and increase in the risk of obstetric laceration in a subsequent vaginal delivery. Obstet Gynecol 2008; 111:1274.
  20. Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin No. 154: Operative Vaginal Delivery. Obstet Gynecol 2015; 126:e56.
  21. Cargill YM, MacKinnon CJ, Arsenault MY, et al. Guidelines for operative vaginal birth. J Obstet Gynaecol Can 2004; 26:747.
  22. Royal College of Obstetricians and Gynaecologists. Green-top guideline No. 26: Operative vaginal delivery, 2011. https://www.rcog.org.uk/globalassets/documents/guidelines/gtg26.pdf (Accessed on August 03, 2016).
  23. Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Instrumental vaginal birth, 2002. https://www.ranzcog.edu.au/doc/instrumental-vaginal-delivery.htm (Accessed on August 03, 2016).
  24. College National des Gynecologues & Obstetriciens Francaise (CNGOF). 2008 French national guidelines on instrumental delivery. http://www.cngof.asso.fr/D_TELE/091204RPC_extractions_en.pdf (Accessed on August 03, 2016).
  25. Fitzgerald MP, Weber AM, Howden N, et al. Risk factors for anal sphincter tear during vaginal delivery. Obstet Gynecol 2007; 109:29.
  26. Kudish B, Blackwell S, Mcneeley SG, et al. Operative vaginal delivery and midline episiotomy: a bad combination for the perineum. Am J Obstet Gynecol 2006; 195:749.
  27. Verghese TS, Champaneria R, Kapoor DS, Latthe PM. Obstetric anal sphincter injuries after episiotomy: systematic review and meta-analysis. Int Urogynecol J 2016; 27:1459.
  28. Intrapartum and postpartum care of the mother. In: Guidelines for Perinatal Care, 7th ed, Riley L, Stark A (Eds), American Academy of Pediatrics and American College of Obstetricians and Gynecologists, 2012. p.188.
  29. Stones RW, Paterson CM, Saunders NJ. Risk factors for major obstetric haemorrhage. Eur J Obstet Gynecol Reprod Biol 1993; 48:15.
  30. Combs CA, Murphy EL, Laros RK Jr. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 1991; 77:69.
  31. Royal College of Obstetricians and Gynaecologists. Green-top guideline No. 29: The management of third- and fourth-degree perineal tears, 2007. https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg29/ (Accessed on September 26, 2016).
  32. Coats PM, Chan KK, Wilkins M, Beard RJ. A comparison between midline and mediolateral episiotomies. Br J Obstet Gynaecol 1980; 87:408.
  33. Fodstad K, Staff AC, Laine K. Effect of different episiotomy techniques on perineal pain and sexual activity 3 months after delivery. Int Urogynecol J 2014; 25:1629.
  34. Necesalova P, Karbanova J, Rusavy Z, et al. Mediolateral versus lateral episiotomy and their effect on postpartum coital activity and dyspareunia rate 3 and 6 months postpartum. Sex Reprod Healthc 2016; 8:25.
  35. El-Din AS, Kamal MM, Amin MA. Comparison between two incision angles of mediolateral episiotomy in primiparous women: a randomized controlled trial. J Obstet Gynaecol Res 2014; 40:1877.
  36. Fodstad K, Staff AC, Laine K. Sexual activity and dyspareunia the first year postpartum in relation to degree of perineal trauma. Int Urogynecol J 2016; 27:1513.
  37. May JL. Modified median episiotomy minimizes the risk of third-degree tears. Obstet Gynecol 1994; 83:156.
  38. Rusavy Z, Karbanova J, Kalis V. Timing of episiotomy and outcome of a non-instrumental vaginal delivery. Acta Obstet Gynecol Scand 2016; 95:190.
  39. Eogan M, Daly L, O'Connell PR, O'Herlihy C. Does the angle of episiotomy affect the incidence of anal sphincter injury? BJOG 2006; 113:190.
  40. Stedenfeldt M, Pirhonen J, Blix E, et al. Episiotomy characteristics and risks for obstetric anal sphincter injuries: a case-control study. BJOG 2012; 119:724.
  41. Cheung TH, Chang A. Puerperal haematomas. Asia Oceania J Obstet Gynaecol 1991; 17:119.
  42. Nager CW, Helliwell JP. Episiotomy increases perineal laceration length in primiparous women. Am J Obstet Gynecol 2001; 185:444.
  43. Jallad K, Steele SE, Barber MD. Breakdown of Perineal Laceration Repair After Vaginal Delivery: A Case-Control Study. Female Pelvic Med Reconstr Surg 2016; 22:276.