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Approach to episiotomy
Author
Julian N Robinson, MD
Section Editor
Charles J Lockwood, MD
Deputy Editor
Vanessa A Barss, MD
Disclosures
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Aug 2013. |This topic last updated: sep 11, 2012.
INTRODUCTION — Episiotomy refers to a surgical incision of the female perineum performed by
the accoucheur at the time of parturition. It is usually performed with scissors when the perineum is
stretched and distended, just prior to crowning of the fetal head. The purpose is to increase the
diameter of the soft tissue pelvic outlet, thereby preventing perineal lacerations, facilitating delivery,
and reducing the time for expulsion of the infant.
PREVALENCE OF EPISIOTOMY — Episiotomy is one of the most common operations performed
on women [1]. Changing trends in obstetrical practice over time have influenced the decision to
perform an episiotomy and resulted in a decreasing prevalence of the procedure (60.9 percent of
vaginal deliveries in 1979 versus 24.5 percent in 2004) [2]. The prevalence of episiotomy is highest
in Latin America and lower in Europe [3], with reported rates varying widely from 1 percent
(Sweden) to 80 percent (Argentina) [4,5].
The decision to perform an episiotomy appears to be influenced by the type of obstetrical provider.
Specifically, private practitioners and faculty providers are more likely than midwives to use this
procedure (four-fold and two-fold higher, respectively) [6-8]. Maternal position, parity, and use of
epidural anesthesia also appear to play a role in the decision to perform episiotomy. An upright or
lateral maternal childbirth position is associated with fewer episiotomies than the supine or lithotomy
positions [9], while epidural anesthesia and primiparity may increase the incidence [6,10,11].
Episiotomy is more common with operative than spontaneous vaginal deliveries (71 versus 33
percent) [1].
RATIONALE FOR EPISIOTOMY — The purported benefits of episiotomy include [3,12]:

Reduction in third and fourth degree tears

Ease of repair and improved wound healing

Preservation of the muscular and fascial support of the pelvic floor

Reduction in neonatal trauma, such as with the premature infant (soft cranium) or
macrosomic infant (shoulder dystocia)

Reduction in dystocia by increasing the diameter of the soft tissue outlet

Expedited delivery of fetuses with nonreassuring fetal heart rate tracings
The primary reason to perform an episiotomy is to prevent a spontaneous, large, irregular laceration
of the perineum. It has been argued that a controlled surgical incision is usually easier to repair than
a spontaneous laceration. The repair of a surgical incision is also more likely to be anatomically
correct, and thus, less likely to result in long-term complications.
The role of episiotomy in preventing serious pelvic relaxation has not been adequately evaluated.
There is increasing consensus that the median episiotomy is not effective for this purpose. (See
"Fecal incontinence related to pregnancy and vaginal delivery", section on 'Median episiotomy'.)
However, mediolateral episiotomy may be protective [13].
An episiotomy may also be performed to increase the size of the pelvic soft tissue outlet. This may
aid in the delivery of a macrosomic or breech infant, and may shorten the time to expulsion if fetal
compromise is suspected. If a shoulder dystocia is anticipated, it may be prudent to perform an
intentional episiotomy to create more room for the obstetric maneuvers required to relieve the
dystocia. Although episiotomy has been advocated to minimize the risk of intraventricular
hemorrhage in preterm births, there is no evidence that this intervention is effective on a routine
basis [14].
The potential benefits of episiotomy need to be weighed against potential adverse effects resulting
from this procedure, including:

Extension of the incision, leading to third and fourth degree tears

Unsatisfactory anatomic results (eg, skin tags, asymmetry, fistula, narrowing of introitus)

Increased blood loss

Increased postpartum pain

Higher rates of infection and dehiscence

Sexual dysfunction

Possible increased risk of perineal laceration in subsequent deliveries
The risks of these adverse effects are discussed below. (See 'Evidence' below and 'Complications'
below.)
EVIDENCE — There is a lack of high-quality evidence upon which to base recommendations for
routine episiotomy versus no episiotomy, or make recommendations favoring one approach over
another. Studies are often limited by their small size, lack of randomization, absence of suitable
controls, and inability to adjust for large variations in operator ability and technique. There are more
data comparing the role of routine versus restrictive use of episiotomy.
Episiotomy versus no episiotomy — A systematic review of studies of interventions affecting
perineal trauma concluded there was good evidence that avoiding routine episiotomy significantly
decreased perineal trauma (absolute risk difference -0.23, 95% CI -0.35 to -0.11) [15]. This is
important since perineal trauma is a causal factor for postpartum pain [16] and dyspareunia [17].
However, there is no direct evidence that use of episiotomy is associated with a higher prevalence
of postpartum pain. In some studies, women who gave birth with an intact perineum or had a
spontaneous perineal laceration had less pain immediately and three months postpartum than
women who underwent episiotomy [18,19]; however, others have found no significant difference in
postpartum pain between these populations [20,21].
Similar conflicting data exist regarding sexual function. The possibility of sexual dysfunction appears
to be greater when an episiotomy is performed than when it is omitted; however, this effect is of a
limited duration. Women with spontaneous tears rather than episiotomy have been reported to have
less postpartum pain and earlier resumption of sexual intercourse in some series [18,20]. Other
studies with long-term follow-up have not found a higher incidence of dyspareunia in women who
underwent episiotomy [17,22].
It is equally controversial whether episiotomy results in weaker perineal muscle function over the
long-term than no episiotomy [13,18,19,21,23-25]. The literature, which largely consists of poorly
controlled studies, is difficult to interpret since the timing of episiotomy, surgical technique (median
versus mediolateral), and skill of the individual repairing the episiotomy vary significantly.
Furthermore, since episiotomy is usually performed when crowning occurs at the introitus, the
levator muscle has already been pushed aside, stretched, and/or torn. Thus, episiotomy incisions
and lacerations primarily cut through only the urogenital diaphragm structures. It is believed that
much of the strength in the perineal musculature may be regained over time and with pelvic muscle
exercise.
Routine versus restricted use — Systematic reviews have consistently shown that there is no
benefit to routine use of episiotomy [3,26]. Therefore, while episiotomy as a routine procedure in all
spontaneous vaginal births is not recommended, a restricted approach in appropriate clinical
settings is advocated.

A systematic review of randomized trials comparing restrictive use of episiotomy to routine
use found that the restricted use resulted in less posterior perineal trauma (relative risk [RR]
0.88, 95% confidence interval [CI] 0.84-0.92), less suturing (RR 0.74, 95% CI 0.71- 0.77),
and fewer healing complications (RR 0.69, 95%CI 0.56-0.85), although there was more
anterior perineal trauma (RR 1.79, 95% CI 1.55-2.07) [3]. Both median and mediolateral
episiotomies were included in the trials. There were no differences in the incidence of
severe lacerations, dyspareunia, urinary incontinence, and several measures of pain.

Another systematic review concluded that there was no evidence that a policy of routine
episiotomy resulted in significant reductions in laceration severity, pain, or pelvic organ
prolapse compared to a policy of restricted use [26]. A total of 26 randomized controlled
trials which assessed outcomes in the first three months postpartum and prospective
studies which assessed longer-term outcomes were included in the analysis. A subsequent
randomized trial that compared restrictive and routine episiotomy in nulliparas also reported
no difference between groups in the rates of urinary or anal incontinence, with follow-up
four years postpartum [27].

In addition, a decision-tree model showed that a policy of routine episiotomy was more
costly than restricted performance of the procedure [28]. Only procedure related costs up to
one month postpartum were considered in the analysis.
Based on these data, the American College of Obstetricians and Gynecologists support the position
of restricted instead of routine use of episiotomy [12]. Avoidance of routine episiotomy is
recommended for both spontaneous and instrumental deliveries. (See "Operative vaginal delivery".)
Training courses, audits, presence of a staff leader and episiotomy rate feedback for individual
midwives and obstetricians appear to help reduce the use of routine episiotomy [29].
PROCEDURES
Analgesia — Adequate analgesia should be available before performing an episiotomy. Regional
anesthesia, such as an epidural block, may have been administered for analgesia during labor and
delivery. However, if there is no preexisting analgesia, an appropriate technique should be selected
(eg, pudendal nerve block, local field block). (See "Pudendal and paracervical block".)
Timing — The optimal time for cutting the episiotomy is unclear. Excessive blood loss can result
from making the incision too early, but protection of the maternal perineum may be compromised if
it is made too late and the fetal head has already torn perineal muscle and fascia. A reasonable
approach is to perform the procedure with the expectation of delivering the fetus within the next
three to four contractions.
Type — There are inadequate data from randomized trials on which to base a recommendation for
choosing the type of episiotomy incision. Controlled studies have shown that selective use of
mediolateral episiotomy results in a lower rate of third and fourth degree lacerations than median
episiotomies. For this reason, the Royal College of Obstetricians and Gynaecologists recommend
mediolateral rather than median episiotomy, when episiotomy is clinically indicated [30]. The
American College of Obstetricians and Gynecologists also state mediolateral episiotomy may be
preferable to median episiotomy in selected cases [12].
There are two major types of episiotomy: median and mediolateral, as well as several modifications
of these basic types (“J” incision, “T” incision, and lateral incision) (figure 1) and an anterior incision
that is only used in women who have undergone female infibulation [31]. (See 'Other' below and
"Female genital cutting (circumcision)", section on 'Obstetrical issues'.)
Because precise descriptions of the different types of episiotomy have not been standardized, there
can be substantial variations between practitioners in the performance of the same type of
episiotomy. In particular, the angle away from midline can vary significantly depending on the
practitioner and the degree the perineum is stretched when the incision is made. The depth, length,
and angle of the incision appear to be important factors in risk of obstetric anal sphincter injuries
[32].
Median — The median (or midline) episiotomy is the most commonly used technique in the United
States. A vertical incision is begun at the fourchette and extended caudally in the midline. The goal
is to release any restriction imposed offered by the perineal body, which can sometimes be felt as a
band of tissue cephalad and posterior to the vaginal orifice. Therefore, the incision should be
directed internally to minimize the amount of perineal skin incised. The anatomical structures
involved in the incision include the vaginal epithelium, perineal body, and the junction of the
perineal body with the bulbocavernosus muscle in the perineum.

Advantages and disadvantages — The median episiotomy is typically easier to repair than
a mediolateral episiotomy or a spontaneous vaginal/perineal laceration and yields a better
cosmetic result [33]. Another purported benefit is that it is associated with less pain
postpartum. However, the only randomized trial comparing median to mediolateral
episiotomy found no difference in subjective assessment of pain or analgesic requirements
[33]. In addition, there were no differences in patient reports of dyspareunia or sexual
enjoyment, although women who had midline episiotomies were more likely to resume
intercourse within a shorter time after childbirth.
The apex of a median episiotomy points directly towards the maternal anus, so if an extension
occurs, the anal sphincter is at high risk of injury. The incidence of third and fourth degree obstetric
laceration is higher with a median episiotomy compared to that with mediolateral episiotomy or no
episiotomy (RR 2.4-4.6) [18,34-40]. (See "Fecal incontinence in adults", section on
'Pathophysiology'.)
Mediolateral — The mediolateral episiotomy is more commonly employed in Europe and the
Commonwealth countries. The incision is initiated at the fourchette and cut at an angle (usually to
the maternal right for right handed clinicians) that may be almost perpendicular to the midline (80 to
90 degrees); however, after delivery of the infant, this angle becomes smaller, approaching 45
degrees, since the perineum is no longer stretched and distorted by the fetal presenting part. The
final angle of the scar should be at 30 to 60 degrees from the midline to minimize the occurrence of
sphincter injury [32,41]. The incision should be 3 to 5 cm in length.
The anatomical structures incised include the vaginal epithelium, transverse perineal and
bulbocavernosus muscles, and perineal skin. If the incision is large, adipose tissue within
ischiorectal fossa may be exposed.

Advantages and disadvantages — The major advantage of the mediolateral episiotomy is
that the surgical incision is directed away from the maternal anal sphincter, thereby partially
protecting the sphincter and the rectum from injury due to extension [33,34,42,43]. The only
prospective, randomized, controlled trial evaluating this issue found that the incidence of
third/fourth degree lacerations with median and mediolateral episiotomy was 11 and 2
percent, respectively [33].
Retrospective studies have reported mediolateral episiotomy was associated with a two- to
six-fold reduction in these injuries compared to no episiotomy or a midline episiotomy
[34,43-45], and one sphincter injury would be prevented for every five forceps (or 12
vacuum) deliveries performed with mediolateral episiotomy [46]. However, routine use of
mediolateral episiotomy did not result in significant reduction of anal sphincter tears
compared to no episiotomy, only selective use appeared to be effective [34]. Randomized
trials are needed to clarify optimal use of this procedure.
The mediolateral episiotomy incises a greater volume of muscle with a rich vascular supply
than the median procedure, thus it is associated with more blood loss [47,48]. The repair is
also more technically challenging. Some reports suggested mediolateral episiotomy was
associated with more postpartum pain and dyspareunia than either midline or no episiotomy
[19], but this has not been confirmed in randomized trials [33].
J incision — This technique is favored by some practitioners, but is not widely used. The purpose
of the "J" incision is to combine the advantages of the median and mediolateral techniques, while
avoiding their disadvantages. The incision starts at the fourchette, is initially extended caudally in
the midline and then curved laterally at an angle, similar to the letter "J". The anatomical structures
incised include the vaginal epithelium, perineal body, and the junction of the perineal body with the
bulbocavernosus muscle and perineal skin. Ideally, the transverse perineal muscle is spared
because the lateral part of the incision should be below this muscle; however, it is difficult to ensure
that it is not incised.

Advantages and disadvantages — This hybrid of a median and mediolateral episiotomy
may optimize the advantages and minimize the disadvantages of the composite techniques.
The apex of the incision points away from the rectum to guide any further extension away
from this structure. Postpartum pain and dyspareunia are probably similar to that with the
mediolateral technique, while ease of repair lies between the median and mediolateral
procedures. Unfortunately, there are no reliable scientific data on which to base
conclusions.
Other — There are various modifications of the above techniques that may be preferred by
individual practitioners. These procedures are usually modifications of the median episiotomy, such
as the addition of bilateral transverse cuts to the apex to create an inverted "T" [49]. This procedure
increases the area of the vaginal opening more than a single cut (figure 2).
The lateral episiotomy is begun at 1 to 2 cm lateral to midline, and the incision is directed laterally
toward the ischial tuberosity. It is rarely used.
An anterior episiotomy is known as deinfibulation (or defibulation). It is only indicated in the setting
of previous female circumcision (ie, female genital mutilation). The fused labia minora are incised in
the midline toward the pubis to reveal the external urethral meatus; the clitoral remnants should not
be incised. (See "Female genital cutting (circumcision)".)
Repair — Surgical repair of episiotomy and perineal lacerations is discussed separately. (See
"Repair of episiotomy and perineal lacerations associated with childbirth".)
COMPLICATIONS — The most common complications of episiotomy are bleeding, infection,
dehiscence, and extension (table 1). Bleeding can usually be controlled with pressure or sutures,
although a hematoma may occasionally develop. (See "Management of hematomas incurred as a
result of obstetrical delivery".)
Signs of episiotomy infection include fever, wound tenderness, and purulent discharge, typically
occurring six to eight days following delivery. Most infections will resolve with local perineal care.
Opening the incision to drain an abscess may be necessary (see "Skin abscesses, furuncles, and
carbuncles", section on 'Treatment'). The area can be allowed to heal spontaneously if the defect is
small; large defects are repaired surgically (see 'Dehiscence' below). In rare cases, necrotizing
fasciitis or a fistula may occur. (See "Necrotizing soft tissue infections" and "Vulvar abscess" and
"Rectovaginal, anovaginal, and colovesical fistulas".)
All of these problems can occur from childbirth alone, in the absence of episiotomy, so it is difficult
to determine whether there is excess risk due to this procedure without appropriately controlled
studies. A large randomized trial of selective versus liberal use of episiotomy demonstrated that the
former policy resulted in fewer healing complications and fewer patients reporting perineal pain [5].
However, reduced use of episiotomy was associated with higher rates of perineal trauma, especially
anteriorly [3,5,20].
Extension — Extension of the episiotomy to create a third or fourth degree laceration or deep
vaginal tear is one of the more common complications of episiotomy. The prevalence of third or
fourth degree lacerations by type of episiotomy among women delivering their first vaginal birth has
been reported to be: no episiotomy (1 percent), mediolateral episiotomy (9 percent), and median
episiotomy (20 percent) [50].
Risk factors for severe lacerations include late timing, inadequate length of the incision,
macrosomia, previous third or fourth degree laceration (in multiparous women), midline episiotomy,
instrumental vaginal delivery, Asian ethnicity, occiput posterior position, and nulliparity [51-56]. One
group used a classification and regression tree to analyze data from over 25,000 term vaginal births
and estimated the risk of a third/fourth degree laceration was almost 70 percent in the setting of
forceps delivery performed with an episiotomy for an infant with birthweight over 3600 grams [57].
Dehiscence — Dehiscence is a particularly onerous complication of episiotomy. It is reported to
occur after 0.1 to 2 percent of procedures, but data regarding a preceding third versus fourth
degree laceration are scanty [58]. One case-cohort series of 390 women who underwent repair of a
fourth degree perineal tear found approximately 5 percent had postpartum perineal complications:
dehiscence only (1.8 percent), infection and dehiscence (2.8 percent), infection only (0.8 percent)
[59].
Although closure of these defects was routinely delayed for two or more months after delivery, early
repair (within two weeks of delivery) has become common and appears successful [60-62]. Prior to
surgical repair, one group recommends debriding the area of all necrotic tissue and sutures,
irrigating daily, and administering intravenous antibiotics if there is evidence of infection [58]. A
mechanical bowel preparation using an oral solution is given the night before surgery.
When the wound is free of exudate and is granulating, it is closed in a manner similar to that with a
primary repair. Postoperatively, a low residue diet is prescribed initially and advanced to a regular
diet. Nothing is placed in the rectum or vagina until the wound is healed. Sitz baths, heat lamp to
the perineum, and mild analgesics help to relieve patient discomfort. This is discussed in more
detail separately. (See "Repair of episiotomy and perineal lacerations associated with childbirth".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The
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Here are the patient education articles that are relevant to this topic. We encourage you to print or
e-mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on “patient info” and the keyword(s) of interest.)

Basics topics (see "Patient information: Maternal injuries from childbirth (The Basics)")
SUMMARY AND RECOMMENDATIONS — An episiotomy is performed to enlarge the pelvic soft
tissue outlet and thereby prevent severe spontaneous perineal lacerations, facilitate delivery, and
shorten the time to fetal expulsion. (See 'Rationale for episiotomy' above.)

We recommend avoiding routine episiotomy (median or mediolateral), given there is no
proven benefit to this practice (Grade 1A). We suggest use of episiotomy be limited to
deliveries with a high risk of severe perineal laceration, significant soft tissue dystocia, or
need to facilitate delivery of a possibly compromised fetus (Grade 2C). (See 'Routine
versus restricted use' above.)

There is inadequate evidence that episiotomy results in more postpartum pain than not
performing an episiotomy. The possibility of sexual dysfunction appears to be greater when
an episiotomy is performed than when it is not; however, this effect is of a short duration.
(See 'Evidence' above.)

Episiotomy reduces the rate of anterior perineal trauma. (See 'Evidence' above.)

Median episiotomy is associated with less blood loss and is easier to perform and repair
than the mediolateral procedure. However, median episiotomy is also associated with a
higher risk of injury to the maternal anal sphincter and rectum than mediolateral
episiotomies or spontaneous obstetrical lacerations. When episiotomy is indicated, we
suggest a mediolateral rather than median approach (Grade 2C). (See 'Median' above and
'Mediolateral' above.)
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REFERENCES
1. Weber AM, Meyn L. Episiotomy use in the United States, 1979-1997. Obstet Gynecol 2002;
100:1177.
2. Frankman EA, Wang L, Bunker CH, Lowder JL. Episiotomy in the United States: has anything
changed? Am J Obstet Gynecol 2009; 200:573.e1.
3. Carroli G, Belizan J. Episiotomy for vaginal birth. Cochrane Database Syst Rev 2000; :CD000081.
4. Röckner G, Fianu-Jonasson A. Changed pattern in the use of episiotomy in Sweden. Br J Obstet
Gynaecol 1999; 106:95.
5. Routine vs selective episiotomy: a randomised controlled trial. Argentine Episiotomy Trial
Collaborative Group. Lancet 1993; 342:1517.
6. Robinson JN, Norwitz ER, Cohen AP, Lieberman E. Predictors of episiotomy use at first
spontaneous vaginal delivery. Obstet Gynecol 2000; 96:214.
7. Gerrits DD, Brand R, Gravenhorst JB. The use of an episiotomy in relation to the professional
education of the delivery attendant. Eur J Obstet Gynecol Reprod Biol 1994; 56:103.
8. Howden NL, Weber AM, Meyn LA. Episiotomy use among residents and faculty compared with
private practitioners. Obstet Gynecol 2004; 103:114.
9. Gupta JK, Hofmeyr GJ, Shehmar M. Position in the second stage of labour for women without
epidural anaesthesia. Cochrane Database Syst Rev 2012; 5:CD002006.
10. Newman MG, Lindsay MK, Graves W. The effect of epidural analgesia on rates of episiotomy use
and episiotomy extension in an inner-city hospital. J Matern Fetal Med 2001; 10:97.
11. Hueston WJ. Factors associated with the use of episiotomy during vaginal delivery. Obstet Gynecol
1996; 87:1001.
12. American College of Obstetricians-Gynecologists. ACOG Practice Bulletin. Episiotomy. Clinical
Management Guidelines for Obstetrician-Gynecologists. Number 71, April 2006. Obstet Gynecol
2006; 107:957.
13. Räisänen S, Vehviläinen-Julkunen K, Gissler M, Heinonen S. Hospital-based lateral episiotomy and
obstetric anal sphincter injury rates: a retrospective population-based register study. Am J Obstet
Gynecol 2012; 206:347.e1.
14. Bottoms S. Delivery of the premature infant. Clin Obstet Gynecol 1995; 38:780.
15. Eason E, Labrecque M, Wells G, Feldman P. Preventing perineal trauma during childbirth: a
systematic review. Obstet Gynecol 2000; 95:464.
16. Macarthur AJ, Macarthur C. Incidence, severity, and determinants of perineal pain after vaginal
delivery: a prospective cohort study. Am J Obstet Gynecol 2004; 191:1199.
17. Signorello LB, Harlow BL, Chekos AK, Repke JT. Postpartum sexual functioning and its relationship
to perineal trauma: a retrospective cohort study of primiparous women. Am J Obstet Gynecol 2001;
184:881.
18. Klein MC, Gauthier RJ, Robbins JM, et al. Relationship of episiotomy to perineal trauma and
morbidity, sexual dysfunction, and pelvic floor relaxation. Am J Obstet Gynecol 1994; 171:591.
19. Sartore A, De Seta F, Maso G, et al. The effects of mediolateral episiotomy on pelvic floor function
after vaginal delivery. Obstet Gynecol 2004; 103:669.
20. Sleep J, Grant A, Garcia J, et al. West Berkshire perineal management trial. Br Med J (Clin Res Ed)
1984; 289:587.
21. Thranov I, Kringelbach AM, Melchior E, et al. Postpartum symptoms. Episiotomy or tear at vaginal
delivery. Acta Obstet Gynecol Scand 1990; 69:11.
22. Sleep J, Grant A. West Berkshire perineal management trial: three year follow up. Br Med J (Clin
Res Ed) 1987; 295:749.
23. Fleming N, Newton ER, Roberts J. Changes in postpartum perineal muscle function in women with
and without episiotomies. J Midwifery Womens Health 2003; 48:53.
24. Röckner G, Jonasson A, Olund A. The effect of mediolateral episiotomy at delivery on pelvic floor
muscle strength evaluated with vaginal cones. Acta Obstet Gynecol Scand 1991; 70:51.
25. Handa VL, Blomquist JL, McDermott KC, et al. Pelvic floor disorders after vaginal birth: effect of
episiotomy, perineal laceration, and operative birth. Obstet Gynecol 2012; 119:233.
26. Hartmann K, Viswanathan M, Palmieri R, et al. Outcomes of routine episiotomy: a systematic
review. JAMA 2005; 293:2141.
27. Fritel X, Schaal JP, Fauconnier A, et al. Pelvic floor disorders 4 years after first delivery: a
comparative study of restrictive versus systematic episiotomy. BJOG 2008; 115:247.
28. Borghi J, Fox-Rushby J, Bergel E, et al. The cost-effectiveness of routine versus restrictive
episiotomy in Argentina. Am J Obstet Gynecol 2002; 186:221.
29. Faruel-Fosse H, Vendittelli F. [Can we reduce the episotomy rate?]. J Gynecol Obstet Biol Reprod
(Paris) 2006; 35:1S68.
30. Royal College of Obstetricians and Gynaecologists. The management of third- and fourth-degree
perineal tears. Green-top guideline No. 29, March 2007.
31. Kalis V, Laine K, de Leeuw JW, et al. Classification of episiotomy: towards a standardisation of
terminology. BJOG 2012; 119:522.
32. Stedenfeldt M, Pirhonen J, Blix E, et al. Episiotomy characteristics and risks for obstetric anal
sphincter injuries: a case-control study. BJOG 2012; 119:724.
33. Coats PM, Chan KK, Wilkins M, Beard RJ. A comparison between midline and mediolateral
episiotomies. Br J Obstet Gynaecol 1980; 87:408.
34. Shiono P, Klebanoff MA, Carey JC. Midline episiotomies: more harm than good? Obstet Gynecol
1990; 75:765.
35. Labrecque M, Baillargeon L, Dallaire M, et al. Association between median episiotomy and severe
perineal lacerations in primiparous women. CMAJ 1997; 156:797.
36. Helwig JT, Thorp JM Jr, Bowes WA Jr. Does midline episiotomy increase the risk of third- and
fourth-degree lacerations in operative vaginal deliveries? Obstet Gynecol 1993; 82:276.
37. Robinson JN, Norwitz ER, Cohen AP, et al. Episiotomy, operative vaginal delivery, and significant
perinatal trauma in nulliparous women. Am J Obstet Gynecol 1999; 181:1180.
38. KALTREIDER DF, DIXON DM. A study of 710 complete lacerations following central episiotomy.
South Med J 1948; 41:814.
39. Harris RE. An evaluation of the median episiotomy. Am J Obstet Gynecol 1970; 106:660.
40. Beynon CL. Midline episiotomy as a routine procedure. J Obstet Gynaecol Br Commonw 1974;
81:126.
41. Eogan M, Daly L, O'Connell PR, O'Herlihy C. Does the angle of episiotomy affect the incidence of
anal sphincter injury? BJOG 2006; 113:190.
42. Legino LJ, Woods MP, Rayburn WF, McGoogan LS. Third- and fourth-degree perineal tears. 50
year's experience at a university hospital. J Reprod Med 1988; 33:423.
43. Poen AC, Felt-Bersma RJ, Dekker GA, et al. Third degree obstetric perineal tears: risk factors and
the preventive role of mediolateral episiotomy. Br J Obstet Gynaecol 1997; 104:563.
44. Anthony S, Buitendijk SE, Zondervan KT, et al. Episiotomies and the occurrence of severe perineal
lacerations. Br J Obstet Gynaecol 1994; 101:1064.
45. de Vogel J, van der Leeuw-van Beek A, Gietelink D, et al. The effect of a mediolateral episiotomy
during operative vaginal delivery on the risk of developing obstetrical anal sphincter injuries. Am J
Obstet Gynecol 2012; 206:404.e1.
46. de Leeuw JW, de Wit C, Kuijken JP, Bruinse HW. Mediolateral episiotomy reduces the risk for anal
sphincter injury during operative vaginal delivery. BJOG 2008; 115:104.
47. Stones RW, Paterson CM, Saunders NJ. Risk factors for major obstetric haemorrhage. Eur J Obstet
Gynecol Reprod Biol 1993; 48:15.
48. Combs CA, Murphy EL, Laros RK Jr. Factors associated with postpartum hemorrhage with vaginal
birth. Obstet Gynecol 1991; 77:69.
49. May JL. Modified median episiotomy minimizes the risk of third-degree tears. Obstet Gynecol 1994;
83:156.
50. Owen, J, Hauth, JC. Episiotomy infection and dehiscence. In: Gilstrap, LC III, Faro, S (eds)
Infections in Pregnancy, Alan R Liss, New York 1990.
51. Hudelist G, Gelle'n J, Singer C, et al. Factors predicting severe perineal trauma during childbirth:
role of forceps delivery routinely combined with mediolateral episiotomy. Am J Obstet Gynecol
2005; 192:875.
52. Jones KD. Incidence and risk factors for third degree perineal tears. Int J Gynaecol Obstet 2000;
71:227.
53. Angioli R, Gómez-Marín O, Cantuaria G, O'sullivan MJ. Severe perineal lacerations during vaginal
delivery: the University of Miami experience. Am J Obstet Gynecol 2000; 182:1083.
54. Nager CW, Helliwell JP. Episiotomy increases perineal laceration length in primiparous women. Am
J Obstet Gynecol 2001; 185:444.
55. de Leeuw JW, Struijk PC, Vierhout ME, Wallenburg HC. Risk factors for third degree perineal
ruptures during delivery. BJOG 2001; 108:383.
56. Bodner-Adler B, Bodner K, Kaider A, et al. Risk factors for third-degree perineal tears in vaginal
delivery, with an analysis of episiotomy types. J Reprod Med 2001; 46:752.
57. Hamilton EF, Smith S, Yang L, et al. Third- and fourth-degree perineal lacerations: defining high-risk
clinical clusters. Am J Obstet Gynecol 2011; 204:309.e1.
58. Ramin SM, Gilstrap LC 3rd. Episiotomy and early repair of dehiscence. Clin Obstet Gynecol 1994;
37:816.
59. Goldaber KG, Wendel PJ, McIntire DD, Wendel GD Jr. Postpartum perineal morbidity after fourthdegree perineal repair. Am J Obstet Gynecol 1993; 168:489.
60. Ramin SM, Ramus RM, Little BB, Gilstrap LC 3rd. Early repair of episiotomy dehiscence associated
with infection. Am J Obstet Gynecol 1992; 167:1104.
61. Hankins GD, Hauth JC, Gilstrap LC 3rd, et al. Early repair of episiotomy dehiscence. Obstet
Gynecol 1990; 75:48.
62. Arona AJ, al-Marayati L, Grimes DA, Ballard CA. Early secondary repair of third- and fourth-degree
perineal lacerations after outpatient wound preparation. Obstet Gynecol 1995; 86:294.
Topic 4478 Version 18.0
GRAPHICS
Types of episiotomy incisions
1 = Median incision, 1+2 = "T" incision, 3 = "J" incision, 4 = Mediolateral incision, 5 =
Lateral incision
Diameter of the introitus
The upper figures show the introitus and perineum before and after making a
traditional midline episiotomy. In the lower sequence of figures, the diameter of the
introitus is significantly enlarged by an inverted T type episiotomy compared to the
classical midline incision.
Adapted from: Delancy, J, Schaffer, J, Brubaker, L. Pelvic-floor injury. Is it inevitable? OBG
Management 2001; 13:76. Copyright © 2001, Dowden Health media.
Complications attributed to episiotomy
Infection
Hematoma
Third and fourth degree extension
Cellulitis
Dehiscence
Abscess
Dyspareunia
Altered sexual function
Perineal pain
Incontinence: urinary, fecal, flatus
Rectovaginal fistula
Impaired pudendal nerve conduction
Necrotizing fasciitis
Adapted from data in Ramin, SM, Gilstrap, LC. Clin Obstet Gynecol 1994; 37:816.
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