It is a fully extended episiotomy, which carries deep into one vaginal sulcus and is curved downward and laterally part way around the rectum.
The anterior episiotomy or deinfibulation the procedure of opening the scar associated with some degrees of female genital mutilation is usually performed during delivery on women who have had female infibulation performed previously. To free the scar, fused labia minora are incised in the midline until the external urethral meatus can be seen and the anterior flap is completely open.
Another type of episiotomy preferably mediolateral may be required during delivery. Even in the recent Cochrane review of episiotomy, an exact classification or definition of episiotomies is lacking, 1 and the individual studies included in the Cochrane Review are variable and lacking in specific details see Supplementary material, Table S1.
Furthermore, the descriptions of mediolateral episiotomy in standard obstetric textbooks differ widely see Supplementary material, Table S2. There is emerging evidence that the angle of the episiotomy does indeed affect the risk of obstetric anal sphincter injury OASIS , 28 , 29 together with the finding of a wide variation in the actual angle of incision made by accoucheurs 28 , 30 - 32 or institutions 31 - 33 when they report using mediolateral episiotomy, measured during and after delivery.
Lateral episiotomy is a method generally used in Finland 34 - 36 and is used as much as mediolateral episiotomy in Greece. There is a need to standardise the practice of mediolateral episiotomy, both to inform practice in those specific situations where it is clearly clinically indicated, but also particularly in the context of future research into the risks and benefits of episiotomy with respect to major perineal trauma. We now propose a standardised classification system in terms of the origin of the incision, the direction e.
If adopted, this definition system could be adopted in a manner similar to the CONSORT statement for randomised trials, 40 where explicit reference to the type of incision would be an essential requirement for reporting any primary or secondary research relating to episiotomy. Standard textbooks contain different and imprecise definitions of what a mediolateral episiotomy is. Moreover, they rarely make reference to alternative types of episiotomy. Most published research has concentrated on mediolateral episiotomy, albeit with a lack of consistency and methodological rigour in the description of the incision actually used.
Recent research has established that the angle of episiotomy is an important determinant of the risk of OASIS, and more importantly, there are differences between the angle at which the incision is made during crowning of the head when the perineum is stretched , and the angle of the surgical wound once the infant has been delivered.
Evidence suggests that correct execution of the episiotomy incision can have significant implications on the degree of perineal trauma. The results of studies evaluating whether mediolateral episiotomy increases or reduces the risk of OASIS have conflicting results, 41 , 42 which we suggest could be because of variation in the actual position of a suboptimal incision.
Standardisation of the description of episiotomy in intervention studies will facilitate the next phase of research into the benefits and risks of this frequently performed, yet still poorly understood, obstetric procedure. Achieving consensus among clinicians with regard to the classification of the different types of episiotomy is crucial if a proper evaluation of this surgical procedure is to be made, along with its alleged benefits, possible side effects and impact on pelvic floor function.
VK conceived the manuscript, wrote the first draft and performed the literature search. Table S1. Description of mediolateral episiotomy in studies and trials include d in the Cochrane database. Table S2. Description of mediolateral episiotomy presented in textbooks, reviews and clinical guidelines. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors.
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Share full text access. Please review our Terms and Conditions of Use and check box below to share full-text version of article. Introduction Episiotomy is a surgical enlargement of the vaginal orifice by an incision to the perineum during the last part of the second stage of labour or delivery.
Search strategy and selection criteria Papers and text books included in this review were identified by searches of PubMed, the Cochrane Collaboration and internet searches with the Google search engine particularly to identify text books. Figure 1 Open in figure viewer PowerPoint. Median midline, medial episiotomy Median episiotomy begins at the posterior fourchette and runs along the midline through the central tendon of the perineal body.
Modified median episiotomy A modification of median episiotomy is performed by adding two transverse incisions in opposite directions just above the expected location of the anal sphincter. Mediolateral episiotomy This is the most frequently used type of episiotomy in Europe.
Lateral episiotomy This type of episiotomy was first described in Anterior episiotomy The anterior episiotomy or deinfibulation the procedure of opening the scar associated with some degrees of female genital mutilation is usually performed during delivery on women who have had female infibulation performed previously.
Evidence Even in the recent Cochrane review of episiotomy, an exact classification or definition of episiotomies is lacking, 1 and the individual studies included in the Cochrane Review are variable and lacking in specific details see Supplementary material, Table S1.
Recommendations There is a need to standardise the practice of mediolateral episiotomy, both to inform practice in those specific situations where it is clearly clinically indicated, but also particularly in the context of future research into the risks and benefits of episiotomy with respect to major perineal trauma. Conclusion Standard textbooks contain different and imprecise definitions of what a mediolateral episiotomy is. Disclosure of interest None to declare.
Contributions to authorship VK conceived the manuscript, wrote the first draft and performed the literature search. Traditionally, an end-to-end technique is used to bring the ends of the sphincter together at each quadrant 12, 3, 6, and 9 o'clock using interrupted sutures placed through the capsule and muscle Figure Allis clamps are placed on each end of the external anal sphincter. We use polydioxanone sulfate PDS , a delayed absorbable monofilament suture, to allow the sphincter ends adequate time to scar together.
Recent evidence suggests that end-to-end repairs have poorer anatomic and functional outcomes than was previously believed. An alternative technique is overlapping repair of the external anal sphincter. Colorectal surgeons prefer to use this method when they repair the sphincter remote from delivery. Dissection of the external anal sphincter from the surrounding tissue with Metzenbaum scissors may be required to achieve adequate length for the overlapping of the muscles. The suture is passed from top to bottom through the superior and inferior flaps, then from bottom to top through the inferior and superior flaps.
The proximal end of the superior flap overlies the distal portion of the inferior flap.
Two more sutures are placed in the same manner. After all three sutures are placed, they are each tied snugly, but without strangulation. When tied, the knots are on the top of the overlapped sphincter ends. Care must be taken to incorporate the muscle capsule in the closure. The literature contains little information on patient care after the repair of perineal lacerations. We recommend the use of sitz baths and an analgesic such as ibuprofen.
If a woman has excessive pain in the days after a repair, she should be examined immediately because pain is a frequent sign of infection in the perineal area. After repair of a third- or fourth-degree laceration, we include several weeks of therapy with a stool softener, such as docusate sodium Colace , to minimize the potential for repair breakdown from straining during defecation. The perineal muscles, vaginal mucosa, and skin are repaired using the same techniques described for the repair of second-degree lacerations.
The incidence of severe perineal trauma can be decreased by minimizing the use of episiotomy and operative vaginal delivery. A Cochrane review demonstrated that liberal use of episiotomy does not reduce the incidence of anal sphincter lacerations and is associated with increased perineal trauma. Already a member or subscriber? Log in. He is also director of family practice maternity and infant care and comedical director of the mother-baby unit at the University of New Mexico Hospital, Albuquerque.
Leeman completed a family practice residency at the University of New Mexico School of Medicine and a fellowship in obstetrics at the University of Rochester N. School of Medicine and Dentistry. In addition, he earned a master of public health degree at the University of California, Berkeley. Rogers graduated from Harvard Medical School, Boston, and completed a residency in obstetrics and gynecology and a fellowship in urogynecology at the University of New Mexico.
Address correspondence to Lawrence Leeman, M. The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported. Figure 2 supplied by Janet Yagoda Shagam, Ph. Distribution of genital tract trauma in childbirth and related postnatal pain. Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primiparous women. Am J Obstet Gynecol. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. A prospective cohort study of women after primary repair of obstetric anal sphincter laceration.
Viktrup L, Lose G. The risk of stress incontinence 5 years after first delivery. Internal and external anal sphincter anatomy as it relates to midline obstetric lacerations.
Obstet Gynecol. Benedetti TJ. Obstetric hemorrhage. Obstetrics: normal and problem pregnancies. New York: Churchill Livingstone, — Cunningham FG, et al. Williams Obstetrics. New York: McGraw-Hill, The Southmead perineal suture study. A randomized comparison of suture materials and suturing techniques for repair of perineal trauma. Br J Obstet Gynaecol.
The Ipswich Childbirth Study: 2. A randomised comparison of polyglactin with chromic catgut for postpartum perineal repair. Grant A. The choice of suture materials and techniques for repair of perineal trauma: an overview of the evidence from controlled trials. Kettle C, Johanson RB. Absorbable synthetic versus catgut suture material for perineal repair. Cochrane Database Syst Rev.
Continuous versus interrupted perineal repair with standard or rapidly absorbed sutures after spontaneous vaginal birth: a randomised controlled trial. A randomized clinical trial comparing primary overlap with approximation repair of third-degree obstetric tears. The Ipswich Childbirth Study: 1. A randomised evaluation of two stage postpartum perineal repair leaving the skin unsutured. Continuous versus interrupted sutures for perineal repair.
Primary repair of obstetric anal sphincter rupture using the overlap technique. Carroli G, Belizan J. Episiotomy for vaginal birth. Preventing perineal trauma during childbirth: a systematic review. This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference.
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Identify the extent of the injury — irrigation and rectal exam facilitates visualization of the injury. Best Value. However, we prefer the interrupted approach because it facilitates a more anatomic repair, allowing reapproximation of the bulbocavernosus muscle and reattachment of the vaginal septum with minimal use of sutures. About Search. Conclusion No difference was detected in perineal pain perception 3 months after delivery between different episiotomy techniques.
Want to use this article elsewhere? Get Permissions. Read the Issue. Sign Up Now. Next: Ezetimibe for Hypercholesterolemia. Oct 15, Issue. Repair of Obstetric Perineal Lacerations. Muscles of perineal body. Anal sphincter complex cadaver dissection. Second-degree perineal laceration. Vaginal mucosa and underlying rectovaginal fascia. Second-degree perineal laceration with underlying muscles exposed.