Episiotomy

Episiotomy is a surgical incision made in the perineum during the second stage of labor to facilitate childbirth and prevent severe perineal tears. It has been widely used in obstetric practice, although its routine use has declined with evolving evidence. Understanding its anatomy, indications, and technique is essential for safe maternal and neonatal outcomes.

Anatomy Relevant to Episiotomy

Perineal Anatomy

The perineum is the area between the vaginal introitus and the anus, containing muscles, connective tissue, and neurovascular structures that support the pelvic floor.

• Muscles: Includes the bulbospongiosus, superficial and deep transverse perineal muscles, and components of the levator ani.
• Blood Vessels: Branches of the internal pudendal artery supply the perineal region, providing rich vascularization.
• Nerves: Pudendal nerve branches provide sensory innervation to the perineum and vulvar structures.

Vaginal and Pelvic Floor Anatomy

The vaginal introitus, perineal body, and anal sphincter complex are key structures involved in episiotomy, influencing both the incision site and healing.

• Vaginal Introitus: The opening of the vagina, surrounded by the labia minora and majora, which is stretched during delivery.
• Perineal Body: Fibromuscular mass between the vagina and anus that provides attachment for perineal muscles and contributes to pelvic floor integrity.
• Anal Sphincter Complex: Includes the internal and external sphincters, which must be preserved to prevent incontinence and functional impairment.

Indications

Episiotomy is performed selectively based on maternal, fetal, and obstetric considerations. It is intended to reduce severe perineal trauma and facilitate safe delivery.

• Maternal Indications: Rigid or non-elastic perineum, primigravida with high risk of tearing, or need for instrumental delivery such as forceps or vacuum.
• Fetal Indications: Fetal distress requiring rapid delivery, shoulder dystocia, or macrosomic infants where prolonged labor may compromise neonatal outcome.
• Obstetric Considerations: Prolonged second stage of labor, malposition, or anticipated perineal trauma that may not be managed by controlled delivery techniques alone.

Types of Episiotomy

Episiotomies can be classified based on the direction and location of the incision. Each type has specific advantages and potential risks, influencing the choice in clinical practice.

• Median (Midline) Episiotomy: The incision extends straight from the posterior vaginal wall toward the perineal body. It is easier to repair and generally less painful but has a higher risk of extending into the anal sphincter.
• Mediolateral Episiotomy: The incision starts at the vaginal opening and extends laterally at an angle, usually toward the right or left. It reduces the risk of anal sphincter injury but may involve more blood loss and postoperative pain.
• Lateral Episiotomy: Less commonly used, this incision begins lateral to the vaginal opening and avoids the perineal body. It is rarely performed due to increased technical difficulty and potential for neurovascular injury.

Procedure

Preparation

Proper preparation is essential to ensure maternal comfort and reduce complications during episiotomy.

• Maternal Positioning: Typically in lithotomy or semi-recumbent position to allow optimal access and visualization.
• Anesthesia and Analgesia: Local infiltration, pudendal block, or regional anesthesia can be used to provide adequate pain relief.

Technique

The surgical technique involves precise incision and careful repair to minimize trauma and promote healing.

• Incision Site and Direction: Chosen based on the type of episiotomy and perineal anatomy. The incision should avoid the anal sphincter and major blood vessels.
• Instrumentation and Suturing: Scissors are commonly used for the incision, followed by layered closure of the vaginal mucosa, perineal muscles, and skin using absorbable sutures.
• Hemostasis: Achieved by careful suturing and pressure to control bleeding and prevent hematoma formation.

Complications

Immediate Complications

Episiotomy, like any surgical procedure, carries potential risks during or shortly after the incision.

• Bleeding: Excessive blood loss may occur if major perineal vessels are injured.
• Extension to Third or Fourth Degree Tears: The incision may unintentionally extend into the anal sphincter complex.
• Infection: Bacterial contamination can lead to perineal or wound infections.

Delayed Complications

Some complications may arise during the healing period or long after delivery.

• Pain and Dyspareunia: Persistent perineal pain or discomfort during sexual activity is common in some women.
• Scarring and Perineal Dysfunction: Scar tissue may affect elasticity and normal function of the perineum.
• Pelvic Floor Disorders: Weakness or dysfunction of pelvic floor muscles can result in urinary or fecal incontinence.

Healing and Recovery

Proper wound healing and postpartum care are critical to restore perineal integrity and prevent long-term complications.

• Tissue Repair and Healing Timeline: Vaginal and perineal tissues typically heal within 4 to 6 weeks, while deeper muscular layers may take longer.
• Postpartum Care: Includes hygiene measures, sitz baths, and perineal support to promote healing and prevent infection.
• Pain Management: Analgesics, cold compresses, and topical treatments help reduce discomfort and facilitate mobility.
• Follow-up: Regular postpartum evaluation ensures proper wound healing and identifies any complications early.

Prevention and Alternatives

Strategies to prevent unnecessary episiotomy and reduce perineal trauma have gained prominence in obstetric practice. Selective approaches are preferred over routine incisions.

• Perineal Massage: Regular antenatal perineal massage can increase tissue elasticity and reduce the likelihood of tears.
• Controlled Delivery Techniques: Techniques such as slow crowning and hands-on support can minimize perineal trauma.
• Selective Episiotomy Policy: Performing episiotomy only when medically indicated rather than routinely helps reduce complications and improve maternal outcomes.

Evidence and Guidelines

International guidelines and clinical studies provide recommendations on the appropriate use of episiotomy, emphasizing safety and evidence-based practice.

• WHO Recommendations: Episiotomy should not be performed routinely and should be reserved for specific maternal or fetal indications.
• ACOG Guidelines: Advocate for selective use of episiotomy to prevent severe perineal trauma while ensuring safe delivery.
• Comparative Studies: Research comparing midline and mediolateral episiotomies highlights differences in rates of extension, pain, and long-term outcomes, guiding clinical decision-making.

Clinical Significance and Outcomes

Episiotomy has significant implications for both maternal and neonatal outcomes. Its judicious use can facilitate delivery, reduce severe perineal trauma, and influence postpartum recovery.

• Maternal Outcomes: Properly performed episiotomy can decrease the risk of extensive perineal tears, reduce labor complications, and improve postpartum recovery. However, inappropriate use may increase pain, scarring, and perineal dysfunction.
• Neonatal Outcomes: Episiotomy can shorten the second stage of labor and facilitate delivery in cases of fetal distress, potentially improving neonatal Apgar scores and reducing birth trauma.
• Long-term Implications on Pelvic Health: Selective use reduces the risk of pelvic floor disorders, urinary and fecal incontinence, and chronic dyspareunia, contributing to better quality of life for the mother.

References

1. World Health Organization. Care in Normal Birth: A Practical Guide. Geneva: WHO; 1996.
2. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 207: Episiotomy. Obstet Gynecol. 2019;133(2):e104-e118.
3. Thacker SB, Stroup DF. Routine Episiotomy for Vaginal Birth. Cochrane Database Syst Rev. 2005;(2):CD000081.
4. MacLennan AH, et al. Outcomes of Routine vs Selective Episiotomy: Maternal and Neonatal Effects. Lancet. 2000;355:2014-2020.
5. Kettle C, et al. Perineal Massage in Labour to Reduce Perineal Trauma. Cochrane Database Syst Rev. 2012;(8):CD005123.
6. Edwards N, et al. Episiotomy: Indications, Technique, and Postpartum Care. BMJ. 2014;349:g4511.
7. Fenner DE, et al. Pelvic Floor Disorders Following Episiotomy. Obstet Gynecol. 2003;102(3):601-606.
8. RCOG Green-top Guideline No. 29: Episiotomy. London: Royal College of Obstetricians and Gynaecologists; 2016.