Episiotomy and Repair

Indications & Basics - The Kindest Cut?

• Surgical incision of perineum & posterior vaginal wall to enlarge vaginal outlet during late 2nd stage of labor.
• Goal: Prevent uncontrolled perineal tears, facilitate delivery.
• Current View: Selective use, not routine. "Kindest cut" is debatable; benefits weighed against risks.
• Indications (Maternal/Fetal):
  • Fetal distress requiring expedited delivery.
  • Shoulder dystocia (e.g., McRoberts maneuver insufficient).
  • Operative vaginal delivery (forceps, ventouse).
  • Rigid perineum impeding delivery.
  • To prevent severe spontaneous tear in high-risk cases.

⭐ Routine episiotomy is associated with an increased risk of third and fourth-degree perineal tears compared to restrictive use (Cochrane Review).

Types & Procedure - Precision Cuts

• Purpose: Enlarge vaginal outlet to facilitate delivery, prevent uncontrolled tears.
• Timing: During contraction, at crowning (3-4 cm head visible).
• Anesthesia: Pudendal block or local infiltration (1% Lignocaine).
• Technique: Sterile episiotomy scissors (e.g., Braun-Stadler); single, deliberate cut (3-5 cm).

⭐ The incision for a mediolateral episiotomy is ideally made at an angle of 60° from the midline as the perineum is stretched during crowning; this becomes approximately 45° after delivery.

Repair Techniques - Suture Science

• Goal: Precise anatomical restoration, ensure hemostasis, minimize pain and infection risk.
• Suture Choice: Absorbable sutures are standard.
  • Synthetic braided: Polyglactin 910 (Vicryl), Polyglycolic acid (Dexon). Good handling, strength. Size 2-0 or 3-0.
  • Synthetic monofilament: Poliglecaprone 25 (Monocryl) for skin/subcuticular. Rapid absorption.
  • Chromic catgut: Infrequent use due to higher tissue reactivity.
• Layered Closure Technique:
  • Vaginal Mucosa: Continuous non-locking stitch (e.g., Vicryl 2-0). Initiate 1 cm above the apex.

    ⭐ Continuous non-locking technique for vaginal mucosa repair is associated with less early postpartum pain.

  • Perineal Muscles: Interrupted or continuous figure-of-eight stitches (e.g., Vicryl 2-0).
  • Perineal Skin/Subcuticular: Continuous subcuticular stitch (e.g., Monocryl 3-0 or 4-0) for optimal cosmesis and reduced pain.

Complications & Care - Healing Hurdles

• Immediate Complications:
  • Pain (most common)
  • Bleeding, hematoma formation
  • Infection: cellulitis, abscess; assess with REEDA scale (Redness, Edema, Ecchymosis, Discharge, Approximation)
  • Wound dehiscence
  • Extension to 3rd/4th degree tears
• Late Complications:
  • Dyspareunia, apareunia
  • Chronic perineal pain, neuroma
  • Scar endometriosis
  • Fistula (rectovaginal)
  • Anal incontinence (fecal/flatal)
• Post-operative Care:
  • Analgesia: NSAIDs, paracetamol
  • Local: Ice packs (first 24-48h), warm sitz baths (after 24h), perineal hygiene (front to back)
  • Diet: High fiber, stool softeners (e.g., lactulose)
  • Pelvic floor muscle training (PFMT)
  • Follow-up: Wound check, address concerns.

⭐ Breakdown of episiotomy repair (dehiscence) occurs in 0.1-5% of cases; risk factors include infection, hematoma, and poor surgical technique.

High‑Yield Points - ⚡ Biggest Takeaways

• Mediolateral episiotomy is preferred, angled 45-60° to avoid sphincter injury.
• Indications: fetal distress, shoulder dystocia, instrumental delivery, rigid perineum.
• Muscles cut (mediolateral): Bulbospongiosus, Superficial transverse perineal, part of Levator ani.
• Repair in three layers (vaginal mucosa, muscles, skin) with absorbable sutures.
• Median episiotomy: easier repair, less pain, but ↑ risk of sphincter tears.
• Performed at crowning (3-4 cm head visible) to prevent uncontrolled tears.
• Complications: pain, infection, bleeding, dyspareunia, fistula (rare).