Episiotomy, also known as perineotomy, is a surgical incision of the perineum and the posterior vaginal wall generally done by a midwife or obstetrician. Episiotomy is usually performed during second stage of labor to quickly enlarge the opening for the baby to pass through.

1. EPISIOTOMY
MUKESH SAH, MD
PGI
GOOSAM MEDICAL CENTER

2. EPISIOTOMY
Definition:
 A surgically planned incision on the perineum and the
posterior vaginal wall during the second stage of labor is
called episiotomy (Perineotomy).
Objectives:
 To enlarge the vaginal introitus so as to facilitate easy and
safe delivery of the fetus-spontaneous or manipulative.
 To minimize overstretching and rupture of the perineal
muscles.

3. INDICATIONS (1/2)
 Episiotomy is recommended in selective cases rather than
as a routine. A constant care during the second stage
reduces the incidence of episiotomy and perineal trauma.
 In elastic (rigid) perineum: causing arrest or delay in
descent of the presenting part as in elderly primigravida.
 Anticipating perineal tear: Big baby, face to pubis
delivery, breech delivery, Shoulder dystocia.
 Operative delivery: forceps delivery, ventouse delivery.

4. INDICATIONS (1/2)
 Previous perineal : pelvic floor repair, perineal
reconstructive surgery.
Common indications are:
 Threatened perineal injury in primigravida, rigid
perineum, forceps, breech , occipitoposterior or face
delivery.

5. TIMING OF THE EPISIOTOMY
 The timing of performing the episiotomy requires
judgment ,
 If done early, the blood loss will be more. If done late, it
fails to prevent the invisible lacerations of the perineal
body and thereby fails to protect the pelvic floor.
 Bulging thinned perineum during contraction just prior
to crowning (when 3-4 cm of the head is visible) is the
ideal time. During forceps delivery, it is made after
application of blades.

6. ADVANTAGES
 Maternal:
 A clear and controlled incision is easy to repair and
heals better than a lacerated wound that might occur.
 Reduction in the duration of the second stage
 Reduction of trauma to the pelvic floor muscles-that
reduces the incidence of prolapse and perhaps urinary
incontinence.
 Fetal: it minimizes intracranial injuries specially in
premature babies or after-coming head of breech.

7. TYPES (1/3)
 The following are the various types of episiotomy:
 Mediolateral
 Median
 Lateral
 ‘J’ shaped
Mediolateral- The incision is made downwards and outwards
from the midpoint of the fourchette either to the right or left. It is
directed diagonally in a straight line which runs about 2.5 cm
away from the anus (midpoint between anus and ischial
tuberosity).

8. FOURCHETTE

9. MEDIOLATERAL EPISIOTOMY

10. MEDIOLATERAL EPISIOTOMY

11. TYPES (2/3)
Median:
The incision commences from the center of the fourchette
and extends posteriorly along the midline for about 2.5cm.
Lateral:
The incision starts from about 1cm away from the center of
the fourchette and extend laterally. It has got many
drawbacks including chance of injury to the bartholin’s duct.

12. MEDIAN EPISIOTOMY

13. LATERAL EPISIOTOMY

14. TYPES (3/3)
‘J’ shaped:
the incision begins in the center of the fourchette and is
directed posteriorly along the midline for about 1.5cm and
then directed downwards and outwards along 5 or 7 O’clock
position to avoid the anal sphincture. The repaired wound
tends to be puckered. This is also not done widely.
 Thus, only mediolateral or median episiotomy is done
commonly.

15. J-SHAPED EPISIOTOMY

16. STEPS OF MEDIOLATERAL EPISIOTOMY (1/7)STEP-I: Preliminaries-
 The perineum is thoroughly swabbed with antiseptic
(povidine-iodine) lotion and draped properly. Local
anesthesia-the perinuem, in the line of proposed incisions
is infiltrated with 10ml of 1% solution lignocaine.
STEP-II: Incision-
 Two fingers are places in the vagina between the
presenting part and the posterior vaginal wall. The
incision is made by a curved or straight blunt pointed sharp
scissors (scapel may also be used).

17. STEPS OF MEDIOLATERAL EPISIOTOMY
(2/7)
 one blade of which is placed inside, in between the fingers
and the posterior vaginal wall and the other on the skin.The
incision should be ,made at the height of an uterine
contraction when an accurate idea of the extend of incision
can be better judged from the stage perineum.
 Deliberate cut should be made starting from the center of
fourchette extending laterally either to the right or to the left.
It is directed diagonally in a straight line which runs about
2.5cm away from the anus.

18. STEPS OF MEDIOLATERAL EPISIOTOMY

19. STEPS OF MEDIOLATERAL EPISIOTOMY
(3/7)
STRUCTURES CUT ARE:
 Posterior vaginal wall
 Superficial and deep transverse perineal muscles,
bulbospongious and part of levatorani.
 Fascia covering those mucsles.
 Transverse perineal branches of peudendal vessels and
nerves.
 Subcutaneous tissue and skin

20. STEPS OF MEDIOLATERAL EPISIOTOMY
(4/7)
STEP-iii- Repair
 Timing of repair:
 The repair is done soon after expulsion of placenta. If repair
is done prior to that, disruption of the wound is inevitable, if
subsequent manual removal or exploration of the genital tract is
needed.
 Oozing during this period should be controlled by the pressure
with a sterile gauze swab and bleeding by the artery forceps.
 Early repair prevents sepsis and eliminates the patient prolonged
apprehension of stitches.

21. STEPS OF MEDIOLATERAL EPISIOTOMY
(5/7)
 Preliminaries:
 The patient is placed in lithotomy position. A good light
source from behind is needed. The perineum including
the wound area is cleansed with antiseptic solution. Blood
clots are removed from vagina and wound area.
 The patient is draped properly and repair should be done
under strict antiseptic precaution. If the repair field is
obscured by oozing of the blood from above, a vaginal pack
may be inserted and is placed high up. Don’t forget to
remove the pack after the repair is completed.

22. STEPS OF MEDIOLATERAL EPISIOTOMY
(6/7)
 Repair:
 The repair is done in three later . The principles to be followed are-
- Perfect hemostasis
- To obliterate the dead space
- Suture without tension
 The repair is to be done in the following order-
 Vaginal mucosa and sub-mucosal tissues.
 Perineal muscles.
 Skin and sub-cutaneous tissues.

23. STEPS OF MEDIOLATERAL EPISIOTOMY
(7/7)
 The vaginal mucosa sutured first. The first suture is
placed at or just above the apex of the tear . There after,
the vaginal walls are apposed by interrupted sutures with
polygycolic acid suture (Dexon) or No. ‘0’ chromic catgut,
from above downward till the fourchette is reached.
 The suture should included the deep tissue to obliterate the
dead space. A continuous suture may be cause
puckering and shortening of the posterior vaginal wall.
 The repair of perineal muscle is done by interrupted suture
using No. ‘0’ PDS, or Dexon or polyglytin (vicryl)

24. STEPS OF REPAIR EPISIOTOMY

25. POSTOPERATIVE CARE (1/2)
 Dressing: The wound is to be dress each time
following urination and defecation to keep the area
clean and dry. The dressing is done swabbing with cotton
swabs soaked in antiseptic solution followed by
application of antiseptic powder or ointment (Furacin or
Neosporin).
 Comfort: to relief pain in the area, magnesium sulfate
compress or application of the infrared heat may be
used. Ice packs reduce swelling and pain also.
Analgesic drugs (ibuprofen) may be given when
required.

26. POSTOPERATIVE CARE (2/2)
 Ambulance: the patient is allowed to move out of the
bed after 24 hours. Prior to that, she is allowed to roll over
on to her side or even to sit but only with thighs apposed .
 Removal of stitches: when the wound is suture by catgut
or Dexon which will be absorbed, the suture need not be
removed . But if non-absorbable material like silk or nylon
is used, the stiches are to be cut on 6th days. The number
of stiches removed should be checked with the record of
the stiches given.

27. COMPLICATION OF EPISIOTOMY
Immediate:
 Extension of incision
 Vulval hematoma
 Infection
 Wound dehiscence
 Injury to anal sphincter causing incontinence of flatus or
feces.
Remote:
 Dyspareunia
 Change of perineal laceration

28. VULVAL HEMATOMA

29. WOUND DEHISCENCE

30. REFERENCES
 Dc Dutta’s , 7th edition, Textbooks of obstetrics . Page
no:568-571
 Arun Kumar Majhi, 2nd edition Bedsides clinics in
Obstetrics, Academic publishers.Page no: 583-592
 Myles, 5th edition, Textbook for Midwives Page no:523-
525