Episiotomy is a surgical incision made in the perineum during labor to prevent severe tearing and complications. There are various types of episiotomies, including medio-lateral and median, each with its own advantages and disadvantages concerning healing, blood loss, and postoperative comfort. Proper technique and care during and after the procedure are crucial to minimize complications such as infection, extension of the incision, and dyspareunia.

1. EPISIOTOMY
An episiotomy also known as perineotomy, is a
surgically planned incision on the perineum
and the posterior vaginal wall during second
stage of labor.

2. • Indications
• There is a serious risk to the mother of second or third degree
tearing
• In cases where a natural delivery is adversely affected, but a
Caesarean section is not indicated
• 'Natural' tearing will cause an increased risk of maternal disease
being vertically transmitted
• The baby is very large
• When perineal muscles are excessively rigid
• When instrumental delivery is indicated
• When a woman has undergone FGM (female genital mutilation),
indicating the need for an anterior and or mediolateral episiotomy
• Prolonged late decelerations or fetal bradecardia during active
pushing
• The baby's shoulders are stuck (shoulder dystocia), or a bony
association.

3. Types:
• Medio-lateral: The incision is made downward and outward from
midpoint of fourchette either to right or left. It is directed diagonally in
straight line which runs about 2.5cm away from the anus (midpoint
between anus and ischial tuberosity).
• Median: The incision commences from centre of the fourchette and
extends on posterior side along midline for 2.5cm.
• Lateral: The incision starts from about 1 cm away from the
centre of fourchette and extends laterally. Drawback include chance of
injury to Bartholin's duct. It is totally condemned it.
• 'J' shaped: The incision begins in the centre of the fourchette and is
directed posteriorly along midline for about 1.5cm and then directed
downwards and outwards along 5 or 7 o'clock position to avoid the
anal sphincter. This is also not done widely.

7. Relative merits and demerits of median and medio-lateral episiotomy
Merits
Demerits
Median Medio-lateral
The muscles are not cut
Blood loss is least
Repair is easy
Post operative comfort is
maximum
Healing is superior
Wound disruption is rare
Dyspareunia is rare
relative safety from rectal
involvement from extension.
If necessary, the incision can be
extended.
Extension, if occurs, may
involve the rectum.
Not suitable for manipulative
delivery or in abnormal
presentation or position. As such,
its use is selective.
Apposition of the tissues is not
so good.
Blood loss is little more,
Post operative discomfort is
more
Relative increased incidence of
wound disruption
Dyspareunia is comparatively
more

8. • Steps of medio- lateral episiotomy.
• Median incisions are believed to be less painful than mediolateral, but
when properly repaired there is little difference. Mediolateral incisions
are only rarely extended into the rectum and anal sphincter and are
often used when more room is required for the delivery process.
• A right-handed obstetrician usually incises from the posterior
fourchette at the midline toward the patient's left ischial tuberosity.
The same structures are separated as with the median incision, and the
ischiorectal fossa is exposed. a mediolateral incision has the advantage
that it can be extended through the levator ani muscles, expanding the
outlet.
• A. Incision from midline toward ischial tuberosity. B. Repair of vaginal
wall. C. Approximation of leavatores. D. Approximation of
bulbocavernosus muscle. E. Reconstruction of urogenital diaphragm. F.
Skin closure.

9. • the mediolateral episiotomy be performed as a two-step procedure. The
first incision is made in the soft tissues of the fourchette and the vagina,
followed by incision of the perineum, extending in the mediolateral
direction.
• Repair is similar to the midline repair. Blood loss can be greater, however,
and for this reason repair often is begun before the placenta has been
expressed. Before beginning the repair, the rectal mucosa should be
palpated for any defects. The vaginal mucosa and underlying supportive
tissues are repaired with a running locked suture. The vaginal closure
allows reapproximation of the hymenal ring and subsequent anatomical
accuracy.
• The deep tissues of the perineal body are closed with interrupted fine
absorbable suture . Attention made to close the dead space as well as to
obtain hemostasis is important, as it is for the median closure. The skin is
closed as with the median closure. The Vaginal and rectal examination at
the conclusion of the procedure is again important to ensure that no suture
has been placed in the rectal mucosa and that the closure is adequate.

11. • Post operative care
Dressing : the wound is to be dressed each time following
urination and defaecation to keep the area clean and dry.
Dressing is done by using antiseptic soaked swabs.
The attendant should wear a mask while doing dressing.
Comfort : to relieve pain in the area, magnesium sulphate
compress to be given
Analgesic drugs may be given according to instruction.
Ambulance: the is allowed to move out of the bed after 24
hours.
Removal of stitches : the stitches are to be cut on 6th
day.

12. Complications
Immediate Remote
I. Extension of the incision to
involve the rectum.
II. Vulval haematoma.
III. Infection.
IV. Wound dehiscence.
I. Dyspareunia .
II. Chance of perineal
lacerations.
III. Scar endometriosis (rare).