Episiotomy Types, Procedure and Complication

What is an Episiotomy?

Episiotomy is a surgical incision or a tear made on the perineum during labour that is usually performed at a point when the perineum is stretched and distended, just prior to crowning of the fetal head. The purpose of Episiotomy is to increase the diameter of the soft tissue pelvic outlet, thereby preventing perineal tear while facilitating delivery and reducing the time it takes for child birth. This is a very controversial procedure and whether it is best for a woman about to deliver is entirely up to the medical professional attending to the birth process.

Episiotomy is one of the common procedures performed on pregnant women who are in labour but the prevalence is reducing. The prevalence of episiotomy is highest in Latin America and lower in Europe.

Advantages or Benefits of Episiotomy

1. Ensures quicker, easier and safer delivery of the fetus
2. It saves unnecessary wear and tears upon the fetal skull
3. Avoids irregular lacerations of the perineum
4. Avoids injury to the maternal soft tissues with subsequent Uterovaginal (UV) prolapse

Indications and Contraindications for Episiotomy

There are reasons why an Episiotomy is necessary (indications) and there are also reasons why a Medical doctor should not (contraindications) carry out episiotomy.

The only reason why episiotomy is done in which the reason cannot be categorically dismissed is for fetal concerns that arise urgently during advanced labor. When the baby is in distress (fetal distress); other indications for episiotomy are not evidence-based and are proven to do more harm than good and at such may not be necessary.

Episiotomy Indications (Reasons for Episiotomy)

1. The delayed second stage of labor
2. Fetal distress in the second stage
3. Women with rigid perineum
4. Primigravidae (woman with first pregnancy) with breech presentation
5. In cases of prematurity to protect the fetal head
6. Nulliparity (those who have never given birth)
7. Imminent perineal tear
8. Previous pelvic floor repair
9. Shoulder dystocia
10. When there is a need for vacuum or forceps delivery

Contraindications for Episiotomy (Reasons why Episiotomy should not be done)

1. Women with bleeding abnormalities
2. Women with HIV infection (this is a relative contraindication and not absolute, hence may be done in some cases)
3. Rhesus negative mother with a rhesus positive child (this is also relative contraindication as Rhogam anti D immunoglobulin may be given after delivery)

Episiotomy Procedure: How to give anesthesia before episiotomy

Episiotomy Procedure

Episiotomy is performed using the episiotomy scissors. It is timed.

Episiotomy Technique

1. In the conscious patient, the best method is to inject 10 ml of lignocaine 1% along the track of the proposed incision. Time should be allowed for this to take effect
2. Two fingers are placed as shown in the image below to protect the fetal head, and a long clean cut is made with scissors. It is important to start from the fourchette (lower part of the vulva when the woman is lying down it is the posterior meet point of the labia minora), otherwise anatomical apposition will be difficult when the repair is undertaken.
3. The timing of an episiotomy must be learned by experience. If done too soon, blood loss will increase, if delayed too long or deep perineal muscles will occur.

How to cut during episiotomy

Timing of episiotomy

Episiotomy should be done during crowning i.e. when the head is visible at the introitus and before the application of forceps in forceps application. This is because, when performed unnecessarily early, bleeding from the episiotomy may be considered during the interim between incision and delivery; and when it is performed too late, lacerations will not be prevented.

Episiotomy Layers of Tissues or Structures that are cut through during the Procedure

1. Skin
2. Vaginal wall
3. Bulbospongiosus muscle
4. Superficial transverse perineal muscle
5. Deep transverse perineal muscle

Different types of Episiotomy incisions

Episiotomy Types

1. Midline Episiotomy or Median Episiotomy
2. Mediolateral Episiotomy
3. J-shaped Episiotomy

Midline or Median Episiotomy

In this, the incision starts at the fourchette at extends towards the anus. This type of Episiotomy is easier to repair; it is the standard type commonly done in the United States of America and Canada; with the mediolateral type being done in some selected cases as recommended by the American College of Obstetricians and Gynecologists (ACOG)

Advantages of midline Episiotomy

1. Less blood loss
2. It is easier to repair
3. The wound heals faster
4. There is less pain the postpartum period
5. The incidence of dyspareunia is reduced

The disadvantage of median episiotomy

1. High risk of third or fourth-degree perineal tear

Mediolateral Episiotomy

In this type, the incision starts at the fourchette and is directed diagonally inferiolaterally to avoid the anal sphincter. This is the recommended case in the UK and other parts of Europe as the Royal College of Obstetricians and Gynecologists recommend mediolateral episiotomy rather than median episiotomy when an episiotomy is clinically indicated.

The disadvantage of the mediolateral episiotomy is that it may damage the Bartholin’s gland which causes dyspareunia after the episiotomy procedure; it however has the advantage of avoiding the damage of the anal sphincter.

J-Shaped Episiotomy

This type of Episiotomy starts on the median plane before taking a lateral course or before deviating.

Ways on How to Avoid Episiotomy during Delivery or Labour

As early as possible in pregnancy:

1. Encourage the pregnant women to learn about episiotomy as part of learning about pregnancy, labor, and delivery
2. Encourage patients to create a birth plan that takes into account their values and preferences
3. Encourage Kegel exercises this helps strengthen the pelvic floor muscles
4. Perineal massage: start practicing daily perineal massage for about 5 to 6 weeks prior to the expected date of delivery (EDD) this makes it less likely for an episiotomy to be done by stretching and relaxing the tissues around the vaginal opening
5. Use of warm Compresses during delivery
6. Slowed and spontaneous pushing during the second stage of labor may allow the tissues to stretch rather than tear
7. Upright birthing position

Episiotomy Complications

Episiotomy problems may arise years later following the procedure these are referred to as long term complications or chronic complications while others occur within a short period of time (acute complications)

Acute complications of Episiotomy

1. Severe vaginal or perineal trauma
2. Need for suturing
3. Posterior and anterior perineal tear
4. Perineal pain
5. Perineal infection
6. Bleeding (hemorrhage)
7. Extension to third-degree tear
8. Breakdown of sutures (Episiotomy wound reopens)

Chronic complications of Episiotomy

1. Dyspareunia (painful sexual intercourse)
2. Urinary incontinence (leakage of urine following procedure)
3. Healing complications
4. Painful episiotomy scar
5. Perineal infection (foul-smelling discharge after episiotomy)
6. Injury to Bartholins Gland duct