Karen D. Bartscht and John O.L. DeLancey
Table Of Contents
Karen D. Bartscht, MD, MPH
John O. L. DeLancey, MD
CARE OF EPISIOTOMY
Among the important duties of attending a vaginal birth is management of the perineum. In current obstetric practice, incision of the perineal body and vagina to enlarge the vaginal opening and facilitate delivery is referred to as an episiotomy. The term episiotomy actually refers to an incision into the external genitals. The more precise name for the obstetric incision is perineotomy, an incision made in the perineum.1 Nevertheless, episiotomy is such a generally accepted term that it is used in this chapter.
Episiotomy is the most common operation in obstetrics, with the exception of cutting and tying the umbilical cord.2 In 1979, episiotomy was performed in 62.5% of vaginal deliveries in the United States, and in nulliparous women, the episiotomy rate rises to 80%. Since that time, the routine use of episiotomy has been increasingly questioned.3 The use of episiotomy has been said to decrease trauma to the fetus, decrease the frequency of extensive perineal tears, and protect the soft maternal tissues, yet disagreement persists about its actual effectiveness.
The origin of episiotomy is difficult to determine, but one of the first to describe it was a midwife, Sir Fielding Ould. In 1742, in his Treatise of Midwifery in Three Parts, he recommended the procedure for those cases in which the external vaginal opening is so tight that labor is dangerously prolonged.4 The first report of the procedure in the United States was 110 years later in a journal entitled The Stethoscope and Virginia Medical Gazette. Taliaferro cut a small mediolateral episiotomy to facilitate delivery in young eclamptic women.5 For these women, episiotomy was used to facilitate an unusually difficult labor. The use of episiotomy was expanded in 1921, when DeLee published a paper entitled “The Prophylactic Forceps Operation.” In this publication, he recommended the use of forceps with a mediolateral episiotomy, which he believed saved the fetal brain from injury, preserved the integrity of the pelvic floor, and restored the parturient canal to “near perfect.”6
DeLee believed labor to be disease producing and therefore to be a “decidedly pathologic process.”6 Historically, physicians have been trained to intervene in disease processes, including protecting the mother from the morbidity of the birthing process. It was on this basis that numerous modalities to support the perineum as well as to incise it have been described. In the 1920s, a shift to hospital deliveries occurred and with it an increase in operative procedures. A 1915 mail survey of prominent obstetricians indicated that few physicians routinely used episiotomy.3,7 By 1938, Diethelm asserted that the indications for episiotomy were well established and needed no defense.8 This opinion supported the increasing trend of the use of episiotomy. The desire to maximize maternal comfort and safety, to improve infant outcomes, and to facilitate the delivery process came together at a time when technological intervention and hospital-based delivery were prevalent.3
Couples have now become more involved in the decision-making process surrounding the birth of their infant and have questioned the routine use of technology during labor and delivery. Along with many other “routine” practices, the use of episiotomy has been examined. The data supporting the use of episiotomy, other than to shorten the second stage of labor and perhaps to allow for a simpler repair, have been observational rather than controlled.
The perineal body is one of the areas of the human body not well understood. In actuality, it is simply a mass of dense connective tissue. When examining the area between the anus and the vagina, the following structures can be found in the midline:
The levator ani, bulbocavernosus, and transverse vaginal muscles all have attachments to or near the perineal body but do not actually cross the midline. If the perineal body is transected and not repaired, the important connections between the two sides of each of these structures are lost. The continuity of structures across the midline in the perineal body can be appreciated by feeling the ridge that is palpable just inside the hymenal ring as the perineum is distended. This probably represents the attachment of structures from both sides through their midline perineal body attachments.
The structural importance of the pelvic floor can be appreciated by looking at its position relative to the abdominal and pelvic contents. If the abdominopelvic cavity is thought of as having a barrel shape, the lid of the barrel is the respiratory diaphragm and the floor is the pelvic diaphragm. Like the respiratory diaphragm, the pelvic diaphragm is a muscle stretched across a relatively circular opening in the pelvis. It is composed of the levator ani and coccygeus muscles. It is in the shape of a fan that has its apex at the coccyx and its opposite edge attached to the pubic bones and the pelvic walls. Its muscle fibers form a series of slings that begin ventrally and loop around the back of the rectum, attaching to its wall and the wall of the vagina. The effect of their activity is to pull the rectum and perineal body toward the pubic bones and to squeeze the lumina of the pelvic viscera closed, occluding any opening in the pelvic floor.
In addition to the levator ani muscles, the perineal membrane (urogenital diaphragm) spans the pelvic outlet. Its broad sheets of connective tissue attach the perineal body to the ischiopubic rami and suspend it. The perineal membrane does not traverse the perineal body as an identifiable structure but is attached to either side of it. The ability of the urogenital diaphragm to suspend the pelvic floor is dependent on a continuity to the two sides, connected through an intact perineal body.
Two changes occur in the pelvic floor during delivery of the fetal head: distention of the vagina and introitus and descent of the perineal body. These are interrelated. Because the fetal head is relatively larger than the introitus, it pushes the pelvic floor in front of it. Once the elastic limit of the tissues is reached in descent, the introitus is dilated by the fetal head. The greater the disproportion between the head and the opening, the greater the downward force exerted on the structures that suspend the dilating introitus.
Several indications have been proposed for the use of an episiotomy. These include prevention of maternal perineal lacerations, fetal intracranial injury, a prolonged second stage of labor, and subsequent symptomatic pelvic relaxation.1
Pomeroy in 1918 advocated episiotomy as a tool to shorten the second stage of labor, and this application has stood the test of time.9,10 Indications for a shortened second stage include significant maternal cardiac disease or any other medical reason to minimize intra-abdominal pressure changes, a prolonged second stage of labor, fetal distress, and breech presentation of a fetus.
Episiotomy has been presumed to be beneficial in preventing fetal anoxia, cerebral hemorrhage, and the possibility of cerebral palsy and mental retardation. Cutting the soft tissues at the vaginal outlet has been thought to reduce direct impact on the fetal head. It has been especially advocated in the delivery of premature infants. Lobb investigated the use of episiotomy in very low birth weight infants and found that when babies of similar weight and age were considered, the routine use of episiotomy appeared to hold no advantage.11 Shortening the second stage of labor rather than opening the birth canal is perhaps the more critical contribution of episiotomy in the delivery of premature infants.
The effect of a prolonged second stage on a fetus has been examined in a number of ways. One study randomly assigned 22 women with uncomplicated pregnancies into slow and fast delivery groups.12 The fast delivery group had a more favorable umbilical artery pH, carbon dioxide tension (pCO2), and oxygen tension (pO2), yet there were no significant differences in Apgar scores or scalp pH. Other studies investigating the length of the second stage and Apgar scoring have not found a difference in the 5-minute score with an extended second stage of labor.13,14 Neurologic deficits have not been found to be less frequent in women with fast labor. However, when an infant is in distress or potentially in distress during the later portion of the second stage of labor, episiotomy could be expected to minimize the length of time it is compromised. This beneficial effect may be lost in studies that investigate large populations of normal individuals, in whom the length of the second stage makes little difference.
Episiotomy is often performed as a prophylactic measure to prevent vaginal and perineal lacerations. Thacker and Banta3 reviewed the literature before the routine use of episiotomy and found that 10% to 90% of primiparas and 5% to 15% of multiparas sustained lacerations of the perineum. In a retrospective study15 of 757 women, patients having an episiotomy were found to have fewer or less-severe lacerations 33% of the time. Episiotomy, as well as lacerations, injures the perineum and causes additional postpartum discomfort. When episiotomy is considered as a laceration, the researchers found that the number of patients benefiting from an episiotomy was reduced to 6%, with the nonepisiotomy patients having fewer lacerations than the episiotomy patients 78% of the time.
Several studies have shown a significant increase in third- and fourth-degree lacerations when a midline episiotomy is made (Table 1 and Table 2). Third-degree lacerations in women who did not receive an episiotomy occurred in 0% to 6.4% of instances, compared with 0.4% to 23.9% of women with a midline episiotomy.3 Borgatta and colleagues16 found a greater than 20-fold increase in deep perineal lacerations in women with an episiotomy compared with women without an episiotomy. Limiting the use of midline episiotomy has been found to decrease significantly the incidence of third- and fourth-degree lacerations and therefore the maternal morbidity.17,18,19 Mediolateral episiotomy has not been shown to increase the incidence of deep perineal lacerations.20
Current opinion suggests that episiotomy be performed if laceration is considered likely.1 This situation tends to be more frequent in primiparous women. Repairing an incision is often simpler than repairing a laceration. Many times, however, lacerations that do occur in the perineum occur in the midline along what would have been the episiotomy site, especially if there is a previous scar.
The use of an episiotomy to prevent permanent damage to the supporting structures of the genital tract is one of the most difficult indications to evaluate for performing an episiotomy. In 1955, Gainey monitored 1000 patients delivered by outlet forceps and mediolateral episiotomy and compared them with his previously studied 1000 patients delivered with an episiotomy done late in the second stage if laceration seemed imminent.21,22 He believed there was significantly less genital support at all levels in those women not routinely receiving an episiotomy. However, he does state that the incidence of descensus was three times greater in the group receiving routine episiotomy. This finding was unexplainable. Nine patients in the group not receiving routine episiotomy clinically had descensus, compared with 26 patients in the routine episiotomy group. Increasing damage to genital supports was also noted with subsequent deliveries.
The present trend to bear fewer children may reveal that the anatomical structures are stressed less and therefore require less protection. Ancillary factors such as exercise and overall fitness may also influence relaxation. It has been shown that pelvic muscle strength may be related more to the extent to which women exercise regularly than to the degree of perineal trauma.23 On the other hand, pelvic relaxation may follow a single traumatic delivery. The merit of an episiotomy in an effort to protect the genital supports rests in its judicious use by experienced clinicians. The protection from subsequent pelvic relaxation with the performance of an episiotomy remains hypothetical and needs further investigation. The damage to the pelvic floor that occurs at the time of parturition may not be manifested until many years later. Perhaps the strength of youthful tissues compensates for some damage that occurs at the time of parturition, and it is not until the tissues lose some of their integrity with age that the damage becomes apparent. A study investigating the effects of the birth process on the genital tract decades later is difficult to design but needed.
Contraindications for an episiotomy are few. Relative contraindications include abnormalities of the perineum. Inflammatory bowel disease, lymphogranuloma venereum, severe perineal scarring, and perineal malformation are some to consider. Coagulation disorders have been suggested as a contraindication, but an episiotomy would be preferable to a cesarean section or a complex laceration if a shortened second stage of labor is all that is needed. Episiotomy is not indicated if there is reasonable doubt that vaginal delivery is possible, as in a trial of forceps.24 The most important contraindication for an episiotomy would be a patient's absolute refusal for the procedure to be performed.1
When in the delivery process an episiotomy should be performed is directed by what benefit is hoped to be gained by its use. For this reason, the timing of an episiotomy has followed the controversy over the benefits of the procedure. DeLee,6 in hope of preventing subsequent pelvic relaxation, recommends perineotomy when the fetal head begins to part the levator ani pillars and just begins to stretch the fascia between them. The area of the fetal scalp visible at the introitus at this time is about 4 cm. To minimize soft-tissue damage, the incision must be made before the supporting structures have been damaged to the extent that they cannot recover.25 Gainey21 believed that the absence of visible tears did not guarantee that the pelvic floor was left undamaged, again emphasizing early episiotomy. Blood loss is increased with this method, but delivery is thought to occur within the next few contractions, if not with maternal effort alone then with outlet forceps.25
When an episiotomy is done to prevent lacerations, it is best performed when the fetus is expected to deliver within the next three or four contractions. An episiotomy performed close to the time of delivery will prevent excessive blood loss. In 1918, Pomeroy9 described the timing to be such that if fissuring of the perineum or bleeding is evident, an episiotomy is done to prevent lacerations. These were signs of inevitable laceration, and to perform an episiotomy any later would result in a laceration as well as an episiotomy.
The median episiotomy incision is made in the perineal body from the midline of the hymenal ring through the connective tissue that unites the bulbocavernous muscle, the superficial transverse perineal muscles, and the perineal membrane (urogenital diaphragm).25 The incision is made down to but not including the anal sphincter (Fig. 1A). The vagina should be incised 3 to 4 cm above the hymenal ring, with the incision entering the rectovaginal space. The risk of vaginal lacerations is thus avoided. Scissors or a scalpal is used with care to avoid injury to the fetus.
The depth of the incision is limited to the distance between the vagina and the anal sphincter and thus poses restrictions on the amount of enlargement of the birth canal. If more room is needed, extension into the rectum either spontaneously or intentionally is inevitable. Intentional extension of the incision to involve the anorectal area is referred to as an episioproctotomy. It is not surprising that a median episiotomy is not elected when the perineal body is short or when the infant is thought to be very large. Opinion varies about whether a mediolateral incision is preferable to episioproctotomy. Episioproctotomy carries the risk of fistula and anal incontinence, whereas a mediolateral episiotomy causes greater blood loss and may be more painful. Mediolateral episiotomy, because it can be extended to incise the levator ani (which episioproctotomy does not), provides more room for delivering impacted shoulders or for managing breech delivery.
Repair of the median incision is often deferred until the placenta has delivered and inspection of the cervix and vaginal canal has been performed. Such delay provides adequate exposure for repair of vaginal and cervical lacerations, if present, and manual removal of the placenta, if necessary. Midline episiotomies may bleed briskly at the time of the incision, but after delivery of the fetus there is remarkably less bleeding. This has been believed to be due to a change in the venous congestion of the perineal tissues at the time of delivery.1
Many methods may be used to repair a midline episiotomy, but all require meticulous surgical technique. Richardson and colleagues26 found less perineal soreness after episiotomy repair using careful surgical technique and fine suture material that excites a minimal tissue reaction. They observed the amount of time elapsed before women resumed sexual activity, which was interpreted as a sign of relative perineal comfort. Richardson and associates found the size of the needle and fineness of the suture to be more important than the type of suture material used. However, a 1987 review of suture material used in episiotomy repair found that polyglycolic acid suture was associated with less perineal pain than chromic suture in several of those studies reviewed. Polyglycolic acid suture causes less tissue reaction and provides greater tensile strength than chromic or plain catgut. However, in only three of the studies do the confidence intervals reflect a real effect rather than one of chance.27
The perineum should be reconstructed in layers after adequate anesthesia has been obtained. Whatever the method of repair, the following principles seem evident. Take care to explore the entire extent of the episiotomy to avoid fistulas that can be created by an incomplete repair. Avoid causing ischemia and trauma to the tissues and restore to the midline all of the tissues that have been separated. The vaginal wall is closed first with a continuous suture that starts 1 cm above the apex of the incision, including any retracted blood vessels, which may otherwise result in hematoma formation. The closure continues to the hymenal ring. Each bite should include the rectovaginal fascia so that posterior vaginal support is maintained.25 In some instances, it is preferable to close the vaginal fascia as a separate layer before closing the vaginal mucosa. The connective tissue of the perineal body is then approximated by first using deep interrupted stitches that include the levator fascia (Fig. 1B). Next, the more superficial tissues in the region of the cut edges of the perineal membrane (urogenital diaphragm) and the transverse perineal muscles are approximated (Fig. 1C). This is done either as a continuation of the vaginal suture or as interrupted sutures. The skin is then closed with a continuous subcuticular stitch (Fig. 1D).
Sutures must not be placed so tight that they interfere with tissue vascularity, and dead space should be obliterated. Avoid placing sutures in the mucocutaneous portion of the fourchette to help prevent postpartum dyspareunia. The number of knots should be reduced as much as possible on the skin surface and in muscle layers. Careful approximation of the incised tissues layer by layer is required to ensure proper healing. Sutures should be placed perpendicular to the incision line to ensure adequate approximation. Occasionally, when the incision or laceration is curved, approximation can still be achieved by placing the sutures at unequal distances on one side.
When the repair is completed, the vaginal and rectal mucosa is palpated to ensure that repair is adequate, that no suture material extends through the rectal mucosa, and no sponge is left in the vagina. The perineum is rinsed, and an ice pack is applied.
The type of episiotomy used depends on the judgment of the physician and often the region of practice. Median incisions are believed to be less painful than mediolateral, but when properly repaired there is little difference. Mediolateral incisions are only rarely extended into the rectum and anal sphincter and are often used when more room is required for the delivery process.
The direction of an episiotomy is dependent on the handedness of the surgeon. A right-handed obstetrician usually incises from the posterior fourchette at the midline toward the patient's left ischial tuberosity (Fig. 2A). The same structures are separated as with the median incision, and the ischiorectal fossa is exposed. In addition, when extra room is needed for a difficult delivery, a mediolateral incision has the advantage that it can be extended through the levator ani muscles, expanding the outlet. This additional room is not available with a median incision, which when extended cannot alleviate resistance from these muscles and their fascia.
It is important to begin the incision at the midline. If the episiotomy is begun in a lateral position on the vaginal outlet, the Bartholin's duct may be incised; at least theoretically, this error could lead to subsequent cyst formations.1 Quilligan and Zuspan24 advise that the mediolateral episiotomy be performed as a two-step procedure. The first incision is made in the soft tissues of the fourchette and the vagina, followed by incision of the perineum, extending in the mediolateral direction. They believe that this allows for an optimal anatomical approximation at the time of repair.
Repair is similar to the midline repair. Blood loss can be greater, however, and for this reason repair often is begun before the placenta has been expressed. Before beginning the repair, the rectal mucosa should be palpated for any defects. If any defects are present, they require initial repair. The vaginal mucosa and underlying supportive tissues are repaired with a running locked suture. The initial stitch is placed 1 cm above the apex of the incision (Fig. 2B). The vaginal closure allows reapproximation of the hymenal ring and subsequent anatomical accuracy. When a deep incision has been made, the levators and deep tissues should be sutured first before the overlying mucosa is closed.
The deep tissues of the perineal body are closed with interrupted fine absorbable suture (Fig. 2C-E). Continuous attention to anatomical approximation is critical. More tissue will appear to be present laterally than medially. Attention made to close the dead space as well as to obtain hemostasis is important, as it is for the median closure. The skin is closed as with the median closure (Fig. 2F). The subcuticular closure is commonly used.1 Vaginal and rectal examination at the conclusion of the procedure is again important to ensure that no suture has been placed in the rectal mucosa and that the closure is adequate.
Although prevention of lacerations has been cited as one indication for performing an episiotomy, it has not, as previously discussed, been a consistent finding when studied further. Care in performance of an episiotomy is clearly necessary to obtain this benefit. The risk of a major laceration by extension of an existing episiotomy can be in the range of 9.5%–13%.1 Lacerations may occur as a result of iatrogenic, fetal, or maternal factors. Iatrogenic causes include the use of forceps, delay in timing or inadequate episiotomy, uncontrolled delivery, or neglected delivery. The fetal factors include large fetal size, malpresentation of malposition, shoulder dystocia, or congenital anomalies. Maternal factors include contracted pelvis, congenital pelvic anomalies, and scarring.
Perineum and Posterior Vagina
Injury to the perineum and posterior wall of the vagina is the most common type of laceration that occurs at the time of delivery. Perineal lacerations are defined according to their extent (Table 3). Some authors do not use the term fourth-degree laceration; instead, they use third-degree complete. In this nomenclature, rupture of the anal sphincter without involvement of the rectum is termed an incomplete third-degree laceration.
First degree: Involvement of mucosa and skin only
A first-degree laceration involves the mucosa and skin only. This type of laceration often does not require repair unless there is uncontrolled bleeding. However, if the laceration exposes a raw surface that may cause increased discomfort, repair may be indicated as well. Repair is performed with fine absorbable suture on a small needle after the area has been properly anesthetized. Interrupted stitches are placed to approximate the torn mucosal edges.
A second-degree laceration frequently mimics a midline episiotomy and is closed in the same fashion. If the torn edges are jagged, trimming the edges may help. The best anatomical approximation is then made in order to restore anatomy. A third-degree laceration involves the deeper structures. The anal sphincter not only is involved but the deep transverse perineal muscle and perhaps the perineal membrane as well. To repair a third-degree extension or laceration, the rectal sphincter and its capsule are first identified. The dead space created around the sphincter should be closed as well. An Allis's clamp is placed on the capsule of the sphincter and pulled to the midline. Figure-of-eight sutures are placed in the capsule from both sides to approximate the sphincter. The rest of the repair resembles a midline approach.
A fourth-degree laceration disrupts all the previously described tissue planes as well as violates the integrity of the rectum, often creating a cloacal communication between the rectum and vagina. An extension into the rectum is important to recognize. If it is not identified and repaired, the risk of fistula formation is increased. Once the apex of the extension into the rectum has been identified, interrupted sutures of fine absorbable material are placed firmly into the submucosa. A Gelpi's self-retaining retractor is often helpful in identifying the apex of the wound. Generally, a second row of sutures is placed on top of the submucosal layer to give strength to the closure as well as to reapproximate the internal and sphincter. After this, the external anal sphincter and perineal body are closed as previously discussed (Fig. 3).
Anterior Vulva and Vagina
Lacerations of the anterior vulva occur frequently in patients in whom the fetal head is forced into the anterior segment of the pelvic outlet during delivery. The lacerations often occur on either side of the midline close to the urethral opening. Pressure alone often controls the bleeding. If suture is needed, a catheter placed in the urethra helps define the urethral margins before closure if these are unclear. Fine suture on an atraumatic needle is necessary for repair. An injury may occasionally extend into the area of the clitoris. The deep and dorsal vessels of this region may bleed excessively. A combination of suture and tamponade is often necessary.
The deeper anterior vaginal lacerations involve the urethral supports and occasionally violate the integrity of the pubococcygeal portion of the levator muscles. Deeper damage may involve the bladder itself or the urethrovesical neck. Vesicovaginal fistulas due to pressure necrosis following prolonged labor are still encountered in Third World countries today.
High Genital Tract
Upper vaginal sulcus lacerations occur often in addition to deep perineal tears. These frequently occur as a result of an inadequate episiotomy at the time of operative delivery. These lacerations can be caused by inexpertly directed forceps or the injudicious use of forceps rotation. Higher genital tract lacerations involve the lateral walls of the vagina in the region of the ischial spines or the posterior lateral vaginal wall. Lateral vaginal wall injuries may extend out to the levator ani muscles and in some instances actually detach the origins of this muscle from its insertion on the pubis.24 Lacerations in the upper posterior vaginal wall may enter the cul-de-sac, providing communication with the peritoneal cavity. The extent of any laceration should be thoroughly determined.
Treatment of vaginal sulcus tears can be awkward because of excessive bleeding and difficulty with exposure. Suitable lighting, patient positioning, anesthesia, and adequate retraction are essential in beginning the repair. Placement of an initial suture as high as possible in the tear, followed by retraction to reach the apex, is often helpful. After repair, a vaginal examination to assess for mucosal defects is imperative in a difficult repair. Repair is at times not adequate for complete hemostasis. In this situation, tamponade by placing a pack in the vagina for 24 hours is especially helpful. Catheter drainage is often necessary secondary to pressure exerted on the urethra.
|CARE OF EPISIOTOMY|
Daily attention should be directed to the episiotomy. Discomfort should progressively abate. Any evidence of infection is then promptly acted on to avoid such serious complications as necrotizing fasciitis. An episiotomy is a wound, and its care parallels that of any other wound. The perineum needs to be kept clean and dry. Unlike most wounds, cleanliness is made difficult by defecation and micturition. Daily cleansing with soap and water is helpful in keeping the area clean and free from secretions. A squeeze bottle of water to irrigate the perineum has also been found to be helpful for maintaining cleanliness as well as for providing comfort.
The use of sitz baths has been long advocated in the relief of perineal pain and wound care. The temperature of the water is now also being debated. Droegemueller28 found that ice chips added to the bath actually diminished edema and reduced pain. He believes that this relief is partially due to reduced swelling but is also attributable to slowed nerve conduction. Prolonged relief occurred with ice in comparison with warm sitz baths in his study. Many patients with perineal incisions or lacerations require oral analgesics for several days after delivery. The requirements for a good postpartum analgesic are that it be rapid acting and highly effective. It should also allow new mothers to be free of pain but alert and should be safe for patients who are still experiencing pain but are ready to be discharged.29 Antiprostaglandins are often sufficient to reduce swelling and offer analgesia. Codeine is sometimes necessary initially. Regardless of what drug is used, symptoms should improve daily.
As with any surgical procedure, episiotomy is not without risk. Extension of an episiotomy to involve deeper structures, lacerations, excessive blood loss, and infection are some of the immediate complications of episiotomy. Dehiscence of the wound and dypspareunia may occur shortly after discharge from the hospital. A relatively rare complication of endometriosis in an episiotomy scar has been reported.30,31,32 A tender nodule producing cyclic symptoms at the site of an episiotomy is highly suggestive of this phenomenon.
The healing process depends on the primary factors involved in tissue healing. If healing is delayed, either from infection, hematoma, or perhaps steroid use, breakdown occurs. Rupture of an episiotomy occurs less than 2% of the time. The area becomes subjectively more painful and appears red and swollen. Patients may be febrile and may have oozing from the site. After separation has occurred, the wound is debrided of necrotic material and a broad-spectrum antibiotic is prescribed. In the past, these wounds were allowed to heal secondarily. Preliminary reports of primary resuturing have described good results.33,34 After a granulation bed is present, the wound is resutured. This often requires hospitalization for aggressive hygiene and debridement. In cases of involvement of the rectum, adequate bowel preparation is necessary before surgical correction, with careful bowel care after repair.34 Fourth-degree episiotomy dehiscences resulting from infection are best managed by a delayed closure technique.
Extension of the episiotomy involving the anal sphincter or rectum has been discussed. It has been reported to be increased with midline episiotomy. Rarely the rectum may be unexpectedly incised or perforated when an episiotomy is performed or during the repair. Special attention to the rectal mucosa after the repair is critical in detection of this complication. If suture material is palpated, the sutures should be removed to prevent rectovaginal fistula formation.
Excess blood loss can occur with episiotomy either at the time of the episiotomy or with hematoma formation after the repair. Thacker and Banta3 estimate that 10% of women who undergo an episiotomy lose at least 300 ml more blood than if they did not have the procedure. Such claims have not been investigated, but the blood loss does not justify blood banking services on a routine basis. Postpartum hemorrhage should raise the question of incomplete episiotomy repair and should be thoroughly investigated.1 Increasing perineal pain and a decreasing hematocrit are signs of possible hematoma formation. The episiotomy should be opened, the clots evacuated, and bleeding points ligated. If the bleeding source cannot be identified, a drain can be placed to ensure drainage and a pack placed.
Because episiotomy is performed through a surface colonized by bacteria, infection rates as low as 0.5% to 3% are surprising.1 Prophylactic antibiotics have not been shown to be helpful in reducing this rate further. A rare but often fatal infectious complication of episiotomy is necrotizing fasciitis.35,36 Shy and Eschenbach reported three deaths from 1969 to 1977 from this cause, accounting for 20% of the maternal mortalities in King County in Seattle.36 It is more common in women with microvascular disease and is characteristically identified after a patient has been discharged.
Dyspareunia is another potential complication of episiotomy but has not often been discussed in the literature. It frequently is an acute cause of sexual abstinence. Scarring of the perineum can also be a reason for long-term dyspareunia. The mediolateral episiotomy has been cited more often to affect intromission, but both approaches can cause discomfort. Robson and Kumar noted soreness and dyspareunia at the episiotomy site in British women; the incidence at 3, 6, and 12 months was 40%, 18%, and 8%, respectively.37 Secondary vaginismus may be produced from the conditioned response to pain with intercourse initially due to an episiotomy. Passive vaginal containment before active thrusting minimizes early episiotomy soreness.38
Episiotomy is beneficial to a certain subgroup of women and should be used in their care. Women for whom a shortened second stage is necessary should undergo an episiotomy. Indications may include maternal exhaustion, a prolonged second stage, or maternal medical factors. It has been stated that a feature of modern medicine is that a technique that provides benefits for a particular group of people tends to be used for wider and wider indications until people who do not require treatment at all are being given it.3 The routine use of episiotomy for all women at the time of delivery remains a practice that some question and that needs further study.
Many of the other cited indications for episiotomy (prevention of lacerations, prevention of fetal injury, symptomatic pelvic relaxation) have not been confirmed by controlled randomized studies. Their prevention depends significantly on the way in which the episiotomy is performed and how it is repaired and for these reasons remains difficult to study. In choosing to perform an episiotomy, it is important to acknowledge the risks of lacerations, excessive blood loss, dyspareunia, postpartum perineal pain, and infection and take steps to minimize these risks. Episiotomy should be used in those instances in which it will benefit a patient, not merely as a routine. Patients should be informed of the risks and benefits, proven and presumed, and be involved in the decision before delivery.
Figures 1 and 2 are reproduced by permission from The C. V. Mosby Co.; artwork by Daisy Stilwell.
11. Lobb MO, Duthie S J, Cooke RWI: The influence of episiotomy on the neonatal survival and incidence of periventricular haemorrhage in very-low-birth-weight infants. Eur J Obstet Gynecol Reprod Biol 22: 17, 1986
16. Borgatta L, Piening SL, Cohen WR: Association of episiotomy and delivery position with deep perineal laceration during spontaneous delivery in nulliparous women. Am J Obstet Gynecol 160: 294, 1989
17. Wilcox LS, Strobino DM, Gigliola B et al: Episiotomy and its role in the incidence of perineal lacerations in a maternity center and a tertiary hospital obstetric service. Am J Obstet Gynecol 160: 1047, 1989