Beruflich Dokumente
Kultur Dokumente
Procedure and
Repair Techniques
EPISIOTOMY
Procedure and
Repair Techniques
RALPH W. HALE, MD
FRANK W. LING, MD
12345/10987
CONTENTS
Preface
Introduction
Indications 3
Types of Episiotomy
ACOG Position 5
Internal
Midline Episiotomy
Procedure 8
Repair 11
Mediolateral Episiotomy
Procedure
Repair
16
16
Complications
Bleeding
19
Infection
19
19
20
21
Other Complications
21
Perineal Laceration
Periurethral Tears
21
21
Vaginal Tears
23
Perineal Tears
23
References
16
24
iii
Preface
Episiotomy is the most common operative procedure that most obstetricians will perform in their lifetime. Because it is so common and
considered minor surgery, teaching students or interns the principles
and techniques usually is left to the most junior of residents. As a
result, the Residency Review Committee for Obstetrics and Gynecology
(RRC) asked the American College of Obstetricians and Gynecologists
(ACOG) to prepare a teaching aid for all residents, but especially those
with the least experience. The result is this monograph.
As with most surgical procedures, there are many approaches and
modifications to episiotomy. However, the principle is the same. It
does not matter if your preference is 4-0 chromic catgut suture or 3-0
polyglycolic suture. What matters is how, where, and when you suture.
It is hoped that this monograph will be a guide to your approach to
episiotomy.
Many Fellows of ACOG participated in the development of this
monograph, and it would be impossible to name them all. However,
special thanks go to Frank Ling, MD, Howard Blanchette, MD, John
Hauth, MD, and Gary Hankins, MD. A very special thank you goes to
Tamara Tin-May Ho Chao, MD, resident member of the RRC, for her
insightful comments.
Finally, this document would not have been possible without the
support of the ACOG Development Committee. Countless members of
ACOG donate to the Development Fund annually to allow ACOG to
expand its activities and further our educational endeavors. This
monograph is just one example of how those donations can have a
major impact.
Ralph W. Hale, MD
ACOG Executive Vice President
Introduction
The first use of an episiotomy to facilitate the delivery of an infant is
lost in the past. Whether ancient midwives or birth attendants used
primitive knives has been questioned for years. Perhaps they did or perhaps they did not. What is known, however, is that intentional incision
of the perineum was not practiced as a routine procedure until the 20th
century.
Treatises on management of the perineum as the fetal head
emerges at the time of delivery focused on protecting against tears
and lacerations. In the 1700s, the usual description of a delivery of
the infants head concentrated on preserving the intact perineum by
allowing a slow, controlled dilation and delivery by exerting pressure
on the perineum (1).
In 1828, Ferdinand von Ritgen described a similar maneuver for
easing the head over an intact perineum (2). His procedure, which he
modified to use extension rather than flexion of the head, also was
designed to prevent trauma to the perineum while facilitating the delivery (3). This was accomplished by placing the examiners fingers on the
perineal body and gently pushing the head from flexion to extension.
This maneuver is still performed in deliveries today and is known as the
Ritgen maneuver.
Although procedures for increasing the size of the vaginal outlet
may have been used in the United States by Native Americans, immigrant midwives, or others, the first reported use was in Virginia in 1852
(4). However, there is little evidence that it gained any regional or widespread acceptance as part of a vaginal delivery.
In 1893, Karl August Schuchardt, preparing to perform a vaginal
approach to excision of a large cervical cancer, performed a mediolateral incision of the perineum to obtain additional exposure (5). He
reported on this procedure to increase exposure in the same year. In his
report, he described incision in the mediolateral tissue and muscles
with much the same anatomical detail we would use today. Although
Episiotomy
Episiotomy
No.
2003
716,000
24.7
2002
780,000
53.2
2001
843,000
58.2
2000
944,000
66.4
1999
1,048,000
74.4
1998
1,220,000
87.3
1997
1,183,000
85.7
1996
1,294,000
956.6
1995
1,410,000
1,050.3
1994
1,512,000
1,136.1
1993
1,562,000
1,184.4
1992
1,611,000
1,235.1
Data from DeFrances CJ, Hall MJ, Podgornik MN. Advance data from Vital and Health Statistics.
Hyattsville (MD): U.S. Dept of Health and Human Services, Centers for Disease Control and
Prevention, National Center for Health Statistics; 2005. No. 359. Advance Data available at:
http://www.cdc.gov/nchs/products/pubs/pubd/ad/ad.htm. Retrieved June 8, 2004.
Indications
Today, the indications for episiotomy are based primarily on the clinical situation at the time of delivery and, therefore, vary greatly
depending on the opinion of the obstetrician. In general, an episiotomy is indicated when shortening of the second stage of labor and
expediting the delivery of the infant is indicated. Situations that may
fall in this category are clinical circumstances such as a nonreassuring
fetal heart rate pattern, shoulder dystocia, or operative vaginal delivery.
Another indication is the potential for a significant spontaneous laceration at the time of delivery, which may occur with a short perineal
body, a previous laceration, or a very large infant. However, two recent
studies have not shown that episiotomy provided perineal protection,
Episiotomy
Types of Episiotomy
The two basic types of episiotomy in use in the United States today are
the median and the mediolateral (Fig. 1). The median is also commonly referred to as the midline and is the most frequently used episiotomy in the United States. However, it is also associated with a
greater risk of extension. This extension may include the anal sphincter
(third degree) or the rectum (fourth degree) (13) (see box).
A mediolateral episiotomy, which is an incision at least 45 degrees
from the midline, is less frequently performed in the United States, but
is more commonly found in other countries. This episiotomy is
favored in those countries because it reduces the risk of third- and
Extension of Episiotomy
First-degree tear:
Second-degree tear:
Third-degree tear:
Fourth-degree tear:
Note: Some definitions are limited to the three levels of tear and will combine
the first- and second-degree tears as only one level.
Episiotomy
Head of baby
Mediolateral
Midline
fourth-degree extensions (14). Disadvantages of the mediolateral episiotomy are reported to be a more difficult repair, increased blood loss,
and increased postpartum discomfort (15).
ACOG Position
The American College of Obstetricians and Gynecologists has concluded: The best available data do not support liberal or routine use of
episiotomy. Nonetheless, there is a place for episiotomy for maternal
or fetal indications, such as avoiding severe maternal lacerations or
facilitating or expediting difficult deliveries (16). Further information
is available in Practice Bulletin Number 71, Episiotomy (16).
External
The external genitalia are seen in Figure 2. The most critical area of the
perineum is the distance from the vestibular fossa to the anus. This
area is frequently referred to as the pudenda or perineal body, and it
averages 34 cm in length in nonpregnant women. It will vary significantly from woman to woman, and it will expand as the head begins
to emerge. The midline episiotomy is made in this anatomical area and
this is where the mediolateral episiotomy begins.
Episiotomy
Mons pubis
Anterior commissure of
labia majora
Prepuce of clitoris
Pudendal cleft (groove or
space between the
labia majora)
Glans of clitoris
Frenulum of clitoris
External urethral orifice
Labium minus
Labium majus
Openings of paraurethral
(Skenes) ducts
Vestibule of vagina
(cleft or space surrounded
by labia minora)
Vaginal orifice
Opening of greater
vestibular (Bartholins) gland
Hymenal caruncle
Vestibular fossa
Frenulum of labia minora
Posterior commissure of
labia majora
Perineal raphe
(over perineal body)
Anus
Internal
Underlying the skin are the muscle and fascial supports of the perineum (Fig. 3). A midline episiotomy will extend from the vaginal orifice caudad toward the anus. The incision will be in the central point
of the perineum and usually extends to the transverse perineal muscles, of which there are two: superficial and deep. The two muscles are
in such close approximation that they usually are not identifiable as
two separate entities. Because they also intertwine with the anal
Episiotomy
Bulbospongiosus muscle
with deep perineal (investing
or Gallaudets) fascia
partially removed
Clitoris
Ischiocavernosus muscle
Bulb of vestibule
Perineal membrane
Ischiopubic ramus
with cut edge of
superficial
perineal (Colles)
fascia
Greater vestibular
(Bartholins) gland
Bulbospongiosus
muscle
(cut away)
Perineal
membrane
Superficial
transverse
perineal
muscle
Ischial
tuberosity
Sacrotuberous
ligament
Perineal
body
Gluteus
maximus
muscle
Ischioanal fossa
Coccyx
Urethra
Crus of
clitoris
Sphincter urethrae
muscle
Ischiopubic
ramus
Perineal membrane
(cut and reflected)
Compressor urethrae
muscle
Bulb of
vestibule
Sphincter urethrovaginalis
muscle
Vagina
Greater vestibular
(Bartholins) gland
Deep transverse
perineal muscle
Perineal membrane
Obturator
fascia
Tendinous arch of
levator ani muscle
Inferior fascia of
pelvic diaphragm (cut)
Levator ani muscle
External anal sphincter muscle
Anococcygeal (ligament) body
Episiotomy
sphincter, they often are mistaken for the sphincter itself. They extend
laterally from the midline to the ischial tuberosity, and near the lateral
vaginal edge their fascial covering is also next to the bulbospongiosus
muscle.
The bulbospongiosus is the main muscle that is incised when making a mediolateral episiotomy. This muscle extends from the pubic
rami, circumscribes the vaginal opening, and then spreads slightly as it
terminates just above the transverse perineal muscles. Lateral to the
bulbospongiosus muscle is the superficial perineal compartment,
which is usually filled with fatty tissue. The Bartholins gland, vestibular bulb, and multiple veins are also in this compartment.
The blood supply to this area is seen in Figure 4. The internal
pudendal artery, a branch of the anterior trunk of the internal iliac
artery, is the main supplier of the perineum. Its branches are the perineal, labial, and hemorrhoidal arteries. The venous drainage follows
essentially the same patterns as the arteries. However, in the paravaginal area, varicosities are not uncommon during pregnancy.
The area is innervated by the pudendal nerve and its branches as
seen in Figure 5. The pudendal nerve is a branch of sacral 2, 3, and 4.
Occasionally, a cutaneous branch of the inferior anal nerve can innervate the area around the anus. When this occurs, the traditional pudendal block anesthesia will not be adequate for performance of an
episiotomy, and local infiltration will be needed.
Midline Episiotomy
Procedure
Before performance of the episiotomy, adequate pain relief is needed.
This can be obtained by use of local infiltration, pudendal nerve block,
or conduction analgesia, such as an epidural or saddle block. Once
pain relief is ensured, the procedure can commence. It is important to
make certain that the fetal head is protected during the episiotomy. For
that reason, a scalpel or other blade should be used only if scissors are
not available.
Initially, the index and middle finger should be inserted into the
vagina between the perineum and the fetal head. The perineum is then
Episiotomy
Posterior
labial artery
Ischiocavernosus
muscle
Bulb of vestibule
Compressor urethrae muscle
Bulbospongiosus
muscle
Superficial
perineal space
Perineal
membrane
Perineal
artery
Superficial
transverse
perineal
muscle
Perineal
artery
Internal
pudendal
artery in
pudendal
canal
(Alcocks)
Round ligament
Tubal
Ovarian
Inferior
rectal artery
External anal sphincter muscle
Note: Deep perineal (investing or
Gallaudets) fascia removed from
muscles of superficial perineal space
Ovarian vessels
Tubal branches of ovarian vessels
Uterine vessels
Ureter
Vaginal branches of uterine artery
Vaginal artery
Levator ani muscle
Perineal membrane
Internal pudendal artery
Perineal artery
Superficial perineal space
Superficial perineal (Colles) fascia
Branches
of
uterine
artery
10
Episiotomy
Branches
of perineal
nerve
Perineal branch of
posterior femoral
cutaneous nerve
Dorsal nerve of
clitoris passing
superior to
perineal membrane
Perineal nerve
Pudendal nerve in
pudendal canal
(Alcocks) (dissected)
Inferior clunial
nerves
Gluteus maximus
muscle (cut away)
Sacrotuberous ligament
Perforating cutaneous nerve
Inferior anal (rectal) nerves
Anococcygeal nerves
Episiotomy
incised vertically extending toward, but not into, the transverse perineal
muscles (Fig. 6). Although in some women a raphe or dimpling can be
seen, the incision should be made as close to the midline as possible. A
question often arises as to when to perform the episiotomy. Some recommend before the head is fully crowning; others suggest only just
before expulsion when the perineum is thinned and stretched. Both
approaches have advantages and disadvantages and rely on the clinical
judgment of the obstetrician. In general, it is better to perform the episiotomy later to avoid excessive blood loss and complete the delivery
shortly thereafter.
After completion of the delivery, it is critical to inspect the incision
site carefully to determine the extent of the episiotomy and any possible tears or extensions. In primiparous women, the reported odds ratio
is +22.08 that midline episiotomies will extend beyond the initial incision into and through the transverse perineal muscles and the anal
sphincter (third degree) or into the rectal mucosa (fourth degree) (17).
In another study, 14.9% of midline episiotomies resulted in an extension (18).
Repair
Surgical repair of an episiotomy is a reapproximation of separated vaginal mucosa, soft tissue, and muscle so that each part is paired with its
counterpart (Fig. 7, AF). A complete knowledge of perineal anatomy is
necessary if this is to occur (see Basic Anatomy of the Perineum).
11
12
Episiotomy
The choice of suture is based on the extent of the repair. If the rectal
mucosa is to be repaired, the suture should be no larger than 4-0. The
standard suture material is chromic catgut, but synthetic material also
is used by many obstetricians. The needle should be small and tapered
for the mucosa, and a larger suture may be preferable for the soft tissue
and muscle. Use of two different suture sizes and needles certainly is
acceptable.
For the sake of inclusion, this description will begin with a rectal
extension and proceed upward. Obviously, if no extension occurred, the
repair will begin at the appropriate lowest point of episiotomy.
If the rectal mucosa is involved, the apex should be identified. A
suture is then placed approximately 1 cm above the apex. This suture
should extend through the submucosa, but usually not the mucosa
itself. It is placed 1 cm above the apex to ensure that any retracted vessels are ligated. The mucosa is then closed in a running or locking fashion with 4-0 suture to join the two mucosal edges (Fig. 7A). The suture
should not penetrate the mucosal layer but bring the submucosa
together. Sutures should be placed no more than 0.5 cm apart, and the
running nonlocking suture should continue to the anal sphincter and
perineal body.
Next, the anal sphincter should be identified. The two edges usually
will be retracted laterally, and an Allis clamp may be necessary to identify the cut edges and bring them together in the midline (Fig. 7B).
When repairing the anal sphincter, it is important to suture the fascial
sheath and not just the muscle. This repair is best accomplished with
several interrupted sutures around the muscle rather than one large figure eight. The repair is strengthened by the sheath, not the muscle.
Some obstetricians recommend that it is best to first apply the bottommost suture at the 6 oclock position, then the most internal suture at
the 9 oclock position, then at the top or most superior part of the
muscle, followed by a 3 oclock placement, which is the most superficial and easiest. Because the transverse perineal muscles also are separated, they can be repaired in a similar fashion. The 12 oclock anal
sphincter suture usually will include a portion of the lower capsule of
Episiotomy
13
14
Episiotomy
Episiotomy
15
16
Episiotomy
Mediolateral Episiotomy
Procedure
A mediolateral episiotomy requires the same pain prevention as noted
for a midline repair. The debate about when to perform the episiotomy
is also the same. Most surgeons recommend these procedures be done
just before delivery because mediolateral episiotomies tend to bleed
more than midline procedures.
Once the decision is made, the fingers are inserted into the vagina
between the head and the perineum. An incision is then made at
approximately a 45-degree angle from the midline to the perineal body
(Fig. 8). The apex should be in the exact midline of the perineum, not
lateral to the midline. This incision can be on the left or right side
depending on the preference of the obstetrician. Some authorities suggest that repair of an incision on the patients left side is mechanically
easier for a right-handed surgeon. It is important to use large, straight
sharp scissors to allow the incision to be made in a single cut. The incision will extend approximately 4 cm into the perineum and may reach
the ischioanal fossa. If the incision is not deep enough, there will be
little relaxation, and a second incision to extend the first will be necessary. Although not prohibited, a second incision increases the risk of a
zigzag line upon healing. Optimal timing of the episiotomy usually is
when the vertex is crowning. Before crowning, there is the risk of excessive bleeding because the vessels are not compressed.
Repair
Immediately after the delivery, the obstetrician should examine the
extent of the episiotomy. Upward extension of the vaginal incision
should be evaluated carefully, especially if a forceps delivery occurred.
Once this evaluation is completed, the repair should begin (Fig. 9,
AD). Any arterial bleeding should be managed to prevent subsequent
hematoma formation.
Two fingers are placed in the vagina for traction and to spread the
incisional edges. A suture of 2-0 or 3-0 material is then placed approximately 1 cm above the apex. This will prevent retracted vessels from
bleeding and disrupting the repair. A running suture using a noncutting
needle is then used to close the vaginal mucosal and submucosal areas
(Fig. 9A). It may be necessary to place additional interrupted sutures in
the submucosal space if inadequate tissue is obtained with the mucosal
Episiotomy
17
18
Episiotomy
Episiotomy
Complications
Bleeding
One of the most frequent complications of episiotomy is bleeding. The
area surrounding the perineum has extensive vasculature, which has
been accentuated secondary to the effects of pregnancy. During the second stage of labor, pressure of the fetal head has compressed many of
these vessels, so they are not readily visible until after the episiotomy is
performed and the infant is delivered. The episiotomy site should be
inspected immediately after delivery and before placental expulsion. At
that time, compression with a sterile gauze sponge should control most
bleeding. However, if a small artery is bleeding, it may require clamping and ligation. Once the repair begins, incorporation of the tissue in
the suture usually will be sufficient. However, careful attention must be
paid to episiotomy sites that continue to bleed to avoid the formation
of a hematoma. If a hematoma does form, it increases the risk of infection and causes increased pain. Small hematomas can be treated with ice
packs and analgesics. Larger ones may need to be drained or evacuated.
A mediolateral episiotomy will bleed more than a midline episiotomy. Because this incision is more likely to involve muscle, the risk of
heavy bleeding is increased. Arterial bleeding from muscle usually
comes from a vessel that is retracted deep into the muscle so ligation is
often difficult. Because the ischioanal fossa area is adjacent to the
mediolateral site, careful hemostasis is essential to prevent formation of
deep hematomas, which can dissect upward into the upper vagina and
broad ligament. In rare instances, a hematoma can spread into the
anterior abdominal wall through a defect in Colles fascia connection
to the pubic rami.
Infection
The area of the episiotomy is heavily colonized by bacteria naturally
and frequently is contaminated by fecal matter during the delivery
process. Therefore, the risk of infection is very high. However, the
womans own defenses will help prevent most episiotomies from being
19
20
Episiotomy
infected. The obstetrician also can help by gently irrigating the area
using sterile saline or water, with or without the use of an antiseptic. If
infection does occur, rapid treatment is essential to avoid necrosis,
breakdown of the site, and sepsis. Necrotizing fasciitis can occur, and
its presence can be life threatening. Some physicians recommend irrigating with an antibacterial solution for fourth-degree extension. If an
examining finger is placed in the rectum during the repair, the surgeons gloves should be changed once the closure is complete to reduce
contamination during the remaining repair. Antibiotic therapy is not
indicated in the absence of infection. The use of sitz baths and stool
softeners may be helpful and reduce the need for pain medication.
Episiotomy
Extension
A common complication of a midline episiotomy is extension into the
rectum. Careful exploration of the incision is necessary to ascertain if
this occurred. Once the transverse perineal muscles and the anal
sphincter tear, the rectal mucosa must be inspected carefully for
involvement. At the time of the episiotomy, the perineum is stretched
and thinned, which may result in iatrogenic extensions. Failure to recognize the extension can lead to infection, fistula formation, and even
breakdown of the episiotomy.
Other Complications
Rare, but more serious complications are dehiscence, fistula formation,
and anal incontinence. These conditions are beyond the scope of this
monograph but should be kept in mind as potentially serious complications.
Perineal Lacerations
Although not related to the episiotomy, during the process of childbirth, tears may occur in multiple areas of the vaginal and paravaginal
area (Fig. 10). In most instances, they are minor and require no specific
therapy. However, it is important to examine the vagina and periurethral areas carefully to determine if tears have occurred.
Periurethral Tears
Small tears and abrasions are seen frequently in the periurethral and
clitoral area after delivery. This is especially true when delivery occurs
without an episiotomy. These tears are usually 11.5 cm in length and
do not bleed. However, if the tears are bleeding, they should be
sutured. Very small, usually 4-0 suture is preferable. Secondary swelling
can occur, causing difficult voiding, and should be evaluated as part of
the immediate postpartum examination. Some women will report
dysuria, but careful questioning will reveal that urine touching the site
of the laceration is the cause of the discomfort and not true dysuria.
21
22
Episiotomy
1st degree
perineal
laceration
A
B
3rd degree
perineal
laceration and
labial tear
High vaginal
laceration
Fig. 10. Obstetric lacerations. A. First-degree perineal laceration. B. Seconddegree perineal laceration plus tear of clitoris. C. Third-degree perineal
laceration and labial tear. D. High vaginal laceration. (Netter RH. Atlas of
human anatomy. 4th ed. Philadelphia [PA]: Saunders Elsevier; 2006. Netter
illustrations used with permission of Elsevier Inc. All rights reserved.)
Episiotomy
Vaginal Tears
As the fetal head descends through the vagina, passage over the ischial
spines and through the outlet can compress the vaginal mucosa and
cause abrasions and tears. These tears can be extensive, especially in the
presence of a small pelvis with prominent spines and a large baby. They
are also more common with forceps deliveries.
After delivery of the infant, with or without an episiotomy, the vaginal vault should be examined. Specific areas to be examined include
the paracervical areas, over the spines, and near the outlet. Minor abrasions that are not bleeding do not require suturing, even if they are
extensive. The most difficult to repair and the most serious are those
tears in the deep vaginal areas. They should be sutured even if they are
not bleeding at the time of exploration. A running, locking suture of
2-0 or 3-0 is best because the tissue often is edematous and friable. The
suture should begin at least 1 cm above the apex of the tear because
vessels may have retracted, and continued bleeding can result in a
hematoma extending up into the broad ligament. It is important to
inspect the cervix to ascertain that the vaginal tear is not in reality an
extension of a cervical tear. If it is a cervical tear, usually at 3- or 9oclock positions, it should be repaired if it is actively bleeding, extends
into the vagina, or is longer than 12 cm in length.
Perineal Tears
Tears in the perineum may occur when an episiotomy is not performed
or is performed late in delivery. These tears may appear jagged and
irregular in appearance (see Fig. 10). However, they should be repaired
by the same method that is used when repairing a similar episiotomy.
Smaller tears in the perineal skin may occur during a delivery. These
tears usually do not need to be repaired unless they are bleeding. Once
the legs are removed from the lithotomy position, the tears will come
together and no further therapy is needed. If active bleeding is
observed, one or two small sutures may be needed.
23
24
Episiotomy
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2.
3.
4.
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Klein MC, Gauthier RJ, Robbins JM, Kaczorowski J, Jorgensen SH, Franco ED, et al.
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Bex PJ, Hofmeyr GJ. Perineal management during childbirth and subsequent dyspareunia. Clin Exp Obstet Gynecol 1987;14:97100.
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Signorello LB, Harlow BL, Chekos AK, Repke JT. Postpartum sexual functioning and
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21.
Leroux N, Bujold E. Impact of chromic catgut versus polyglactin 910 versus fastabsorbing polyglactin 910 sutures for perineal repair: a randomized, controlled trial.
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