Restricted episiotomy

and perineal repair

By : Surakshya Bhattarai
WHD,MN 1st year
BHNC, NAMS
Roll no: 10
 Table of contents
• Global Scenario
• Introduction
• Research on restricted episiotomy versus routine
episiotomy
• Objective
• Purpose
• Indication
• Timing
• Type
• Methods of episiotomy
• Complication
• Injuries to birth canal/ types of tear
 Global Scenario
• Episiotomies were first described in the 1700s as
being useful for “difficult deliveries” – when a
woman couldn’t push out the baby after it was
properly positioned in her vagina.
• The procedure gained traction in the early 1900s
when Ob/Gyns made the argument that episiotomies
could preserve pelvic floor function by decreasing
vaginal muscle damage and could protect the baby’s
brain during delivery because the head would have to
push against less tissue – both of which we know to
be false today.
 Cont’d…

• But back then, these arguments were difficult

to dispute.
• In 1979, nearly 61 percent of women received
episiotomies during delivery as a standard of
care, especially first-time moms.
• During the 2000s, doctors began to use
episiotomies less frequently.
• By 2004, the rate was about 25 percent.
 Cont’d…
• In 2006, the American College of Obstetricians and
Gynecologists (ACOG) issued a recommendation
against routine episiotomy in all patients. By
2012, fewer than 12 percent of women who delivered
vaginally received an episiotomy.

• Following the advice of its experts, in 2012 a national

group evaluating maternity care set a target for the
rate of its use below 5 percent.
 Cont’d…

• Throughout the world as many as 50 to 60% of

patients who deliver vaginally in the will have
an episiotomy. Rates of episiotomy vary
throughout the rest of the world and may be as
low as 30% in some European countries.
(UT southwestern Medical centre 2017)
WHO recommendation on episiotomy policy
• Routine or liberal use of episiotomy is not
recommended for women undergoing spontaneous
vaginal birth.(WHO, 17 February 2018).

• Although the review evidence on comparative effects of

episiotomy policies was presented as
selective/restrictive versus routine/liberal use of
episiotomy, due to the beneficial effects of selective/
restrictive compared with routine/liberal episiotomy
policy, the lack of evidence on the effectiveness of
episiotomy in general, and the need to discourage the
excessive use of routine episiotomy across all settings.
•
 Cont’d…
• The GDG felt that it was important to emphasize that
routine/liberal use of episiotomy is “not
recommended”, rather than recommending the
selective/restrictive use of episiotomy.
• The GDG acknowledged that, at the present time,
there is no evidence corroborating the need for any
episiotomy in routine care, and an “acceptable” rate
of episiotomy is difficult to determine. The role of
episiotomy in obstetric emergencies, such as fetal
distress requiring instrumental vaginal birth, remains
to be established. 
•  
 Contd….

• If an episiotomy is performed, effective local

anaesthesia and the woman’s informed consent
is essential. The preferred technique is a medio-
lateral incision, as midline incisions are
associated with a higher risk of complex
obstetric anal sphincter injury (OASI). A
continuous suturing technique is preferred to
interrupted suturing.
 Routine antibiotic prophylaxis is not recommended
for women with episiotomy
(1 September2015,WHO).

Antibiotics should be administered when there are clinical

signs of infection of an episiotomy wound.
• Second-degree perineal tear is anatomically similar to
an episiotomy and does not warrant the use of
prophylactic antibiotics.
• In a situation where an episiotomy wound extends to
become a third- or fourth-degree perineal tear,
prophylactic antibiotics should be administered as
recommended in this guideline.
 Introduction
• Episiotomy is the surgical enlargement of the vaginal
orifice by an incision on the perineum during the last
part of the second stage of labour or delivery.
• Episiotomy, incision of the perineum at the time of
vaginal childbirth, is a common surgical procedure
experienced by women.
• A surgically planned incision on the perineum and
the posterior vaginal wall during the second stage of
labour.
 Cont’d…

• Episiotomy is a common practice for all

women delivering for the first time.
• The reason for its popularity included
substitution of a straight surgical incision,
which was easier to repair, for the ragged
laceration that might result in its absence.
 Restricted episiotomy
• Episiotomy is no longer recommended as a
routine procedure.
• There is no evidence that routine episiotomy
decreases perineal damage, future vaginal
prolapse or urinary incontinence.
• Infact routine episiotomy is associated with an
increase of 3rd and 4th degree tears and
subsequent anal sphincter muscle dysfunction.
Comparison: Policy of selective/restrictive compared
with routine or liberal use of episiotomy, WHO 2018)

• Maternal outcomes
Short term morbidity
 May reduce severe perineal/vaginal trauma (mainly
third- and fourth-degree tears) compared with routine or
liberal episiotomy.
 Reduce the need for perineal suturing
Long term morbidity
 Little or no effect of selective/restrictive versus routine
or liberal episiotomy on dyspareunia
 Cont’d…
Short-term morbidity: Low-certainty evidence
suggests that a policy of selective/restrictive episiotomy
may reduce severe perineal/vaginal trauma (mainly
third- and fourth-degree tears) compared with routine or
liberal episiotomy (11 trials, 6177 women, RR 0.70,
95% CI 0.52–0.94).
• The impact increased when only the trials with a
larger than 30% difference in episiotomy rate
between study arms were included (8 trials, 4877
women, RR 0.55, 95% CI 0.38–0.81; moderate-
certainty evidence).
• Subgroup
Cont’d…
analysis by parity suggests that the
episiotomy policy might not make a difference to
perineal/vaginal trauma in multigravid women, but
the evidence is very uncertain.

• A selective/restrictive episiotomy policy may reduce

the need for perineal suturing (excluding episiotomy
repair) (6 trials, 4333 women, RR 0.68, 95% CI 0.58–
0.78); however, the data in some trials may have
included episiotomy repair, making the evidence
uncertain.
 Contd…
• Low-certainty evidence suggests that selective/
restrictive episiotomy may have little or no
effect on perineal infection (3 trials, 1467
women, RR 0.90, 95% CI 0.45–1.82).
 Cont’d…
Long-term morbidity: 
• For long-term morbidity at 6 months or more after
childbirth, low-certainty evidence suggests there may
be little or no effect of selective/restrictive versus
routine or liberal episiotomy on dyspareunia (pain
during intercourse) (3 trials, 1107 women, RR 1.14,
95% CI 0.84–1.53).
• Evidence on other long-term morbidity is sparse and
very uncertain (urinary incontinence, genital
prolapse), or lacking (faecal incontinence, sexual
dysfunction).
Assessment of restrictive episiotomy use and impact
on perineal tears in the Burgundy's Perinatal
Network(2016).

• Strong impact in Burgundy of the French

guidelines for the practice of restrictive
episiotomy for both ND and for ID without
increasing sphincter tears and in decreasing
spontaneous morbidity.
 A study conducted by an International Journal of
Obstetrics and gynecology Restrictive versus routine
episiotomy among Southeast Asian term
pregnancies(2019, Thailand).

• Restrictive episiotomy resulted in more intact

perineum in multiparous women. Restrictive
episiotomy increased the risk of vaginal
laceration in primiparous and multiparous
women but did not lead to more suturing.
A study conducted by International journal of
reproduction contraception obstetrics and
gynaecology on Comparison of use of restrictive
episiotomy versus routine episiotomy in
primigravidae undergoing vaginal birth at a
tertiary care hospital found (2017)
RESULTS 
• Vaginal and paraurethral tears were noted in 14%
primigravidae in the routine episiotomy group and
22.22% in the restrictive episiotomy group with
no statistically significant association
 Cont’d…
• Number of cases sustaining perineal tear in
restrictive group was 15.55% and extension of
episiotomy in the routine group was 26% with
no statistically significant association.
• Requirement of suturing was far less in
restrictive group (20%) as compared to routine
group (100%), as 64.45% of the patients in
restrictive group delivered with an intact
perineum.
 Cont’d…
• The restrictive use of episiotomy does not
prolong the second stage of labour and has
requirement of significantly less pain relief
compared to the routine group.
• Complication rate was higher in the routine
group and perineal laceration and pain
severity, was less in restrictive episiotomy
group
 National Research
Hospital based randomized prospective comparative
conducted on Maternal Morbidity in Vaginal Delivery with
or without Episiotomy in Nulliparous Women in the
Obstetrics and Gynaecology department of a teaching
hospital(2017) found that

• Anterior perineal laceration rate was high in no episiotomy

group than episiotomy group but overall few morbidities were
in no episiotomy group than in episiotomy group. So,
episiotomy should not be considered to prevent insignificant
anterior perineal lacerations.
 Objective of episiotomy

To enlarge the
To minimize
vaginal orifice so as
overstretching and
to facilitate easy and
rupture of perineal
safe delivery of foetus
muscle and fascia to
spontaneous or
reduce the stress and
manipulative in
strain on fetal head.
emergency condition
 Purpose of episiotomy
• To minimize overstretching perineal muscles
• To enlarge vaginal introitus
• To speed up delivery in fetal distress in
second stage of labour
• To minimize the risk of intracranial damage
during preterm and breech delivery
• To an assisted delivery such as forceps or
ventouse extraction
 Indication
• Complicated vaginal delivery(breech, shoulder
dystocia, forceps , vacuum extraction)
• Scarring from female genital cutting or poorly
healed third or fourth degree tear
• Fetal distress
 Timing of episiotomy
• An episiotomy involves incision of fourchette the
superficial muscle,skin of perineum and posterior
vaginal wall.
• Incision should be given when presenting part is
directly applied to these tissues.
• Performing episiotomy too early will fail to release
presenting part and hemorrhage from cut vessels occur.
• If perform too late, difficult to perform an incision and
infiltration of local anesthesia and useless if tear
already begun.
 Type of incison
• Mediolateral
• Median
• Lateral
• J shaped
 Mediolateral
• The incision begins at the midpoint of fourchette and is
directed at 45 degree angle to midline toward a one
midway between ischial tuberosity and anus to avoid
dangers of damage to anal sphincter and bartholin’s gland.
• It is widely used
• Severe perineal/vaginal trauma occurred more frequently
in the trials of midline incisions than in trials of medio-
lateral incisions suggesting that mediolateral incisions are
safer than midline incisions.
(WHO, feburary 2018)
 Advantages
• Extension to the rectum is less likely
• Avoid danger of damage to anal sphincter and
bartholin’s gland
 Disadvantage
• Blood loss is greater
• Repair is more difficult
• during healing area is more painful
• possible damage to pubococcygeal muscle
 Median/midline
• The incision commences from the centre of
fourchette and extends posteriorly along the
middle for about 2.5cm
 Advantage
• Easy to repair
• Generally less painful
• minimal blood loss
 Disadvantage
• Higher incidence of damage to the anal
sphincter
 Lateral
• The incision starts from about 1 cm away from
the centre of the fourchette and extends
laterally.
 J shaped
• The incision begins in the centre of the
fourchette and is directed posteriorly along the
midline for about 1.5cm and then directed
downwards along 5 r 7o’clock position to
avoid anal sphincter
 Methods of episiotomy
• Steps of medio-lateral episiotomy
• Step I method of infiltration
 The perineum is thoroughly swabbed with
antiseptic lotion and draped properly
 Draw a local anaesthesia e.g lignocaine or other
which is commonly used in labour room 10ml of
1% xylocaine
Two fingers are inserted into the vagina along the
line of the proposed incision
 Cont’d…
 The needle is inserted beneath the skin for 4-5cm
following the same line
 the piston of syringe should be withdrawn prior to
injection to check whether the needle is in blood
vessels
 If the blood is aspirated the needle should be
repositioned and the procedure repeated until no blood
is withdrawn.
Lignocaine is continously injected as the needles
slowly withdrawn.
 Cont’d…
 Wait 2 minutes and then pinch the incision sites
with forceps. If the woman feels the pinch, wait
for 2 minutes and then retest
For more effective, about 1/3 of the amount is
used at first and two further injection are made,
either side of the incision line
• Step II: The incision
 Two fingers are placed in the vagina between
the presenting part and posterior vaginal wall.
 Cont’d…
 The incision is made by a curved straight blunt
pointed sharp scissors. One blade of the scissor is
placed inside in between the fingers and posterior
vaginal wall and the other on the skin.
 The incision should be made at the height of the
uterine contraction on stretched perineum an 3-4 cm of
baby’s head is visible
A single deliberate cut 4-5 cm long is made at the
correct angle from the centre of the fourchette
extending laterally either to the left or right diagonally
in a straight line which runs about 2.5cm away from
the anus.
 Contd….
 Delivery of the head should follow
immediately ,therefore controlled head and
support the perineum to prevent or avoid the
extension of episiotomy. If there is any delay
in delivery of head, pressure should be applied
to the episiotomy site to minimize bleeding.
 Repair of episiotomy and Tear
• Timing of repair: The repair is done soon after the delivery
of the placenta
• Methods of repairing episiotomy or tear
• Step I
 Light should be adequate
Maintain aseptic technique
Wear sterile gloves and clean the perineum
 Infiltrate the perineum if not before
 Oozing during this period should be controlled by pressure
with sterile guaze swab and bleeding by the artery forceps
 Cont’d…
 If repair field is obscured by oozing of blood,
vaginal pack can be inserted and is placed high
up.
• Step II Repair
 The repair is done in three layers. The
principle to be followed are:
• perfect homeostasis
• To obliterate the dead space
• Suture without tension
 Cont’d…
• The repair is done under following order
1. Vaginal mucosa and submucosal tissues-
continuous suture
2. Perineal muscles-interrupted suture or
continuous suture
3. Skin and subcutaneus tissues: Subcutaneous
suture
 Cont’d…
• The vaginal mucosa is to be suture first
• The first suture is place at or just above 1cm the apex of
episiotomy or repair
• The vaginal walls are repaired by continuous 1-0/but in
IMPAC(catgut 2-0) suture of polyglycolic catgut using
curved round body needle from above downward till
the fourchette is reached
• At the opening of the vagina,bring together the cut
edges of the vaginal opening.Bring the needle under the
vaginal opening and out through the incision and tie.
 Cont’d…
• Step III
Repair of the perineal muscles is done by
interrupted or continuous suture using Catgut 1-
0(But in IMPAC catgut 2-0) while the deeper
tissues are repaired by 2-3 interrupted suture
 The suture are not to be tied tightly
• Step IV
 The perineal skin is apposed by interrupted or
subcutaneous 1 suture
 Cont’d…
• After completion of repair, clean the perineum,
check the repair, apposition of the skin margins etc
• A sterile sanitary pad is put on the vulval perineum
• Clean the buttock, change wet clothes, make the
woman comfortable
• Interpret woman about care of sutures, cleanliness,
diet, pelvic floor exercise etc
• Ask her to inform immediately if severe pain and
increase swelling, bleeding etc
• Record and report the finding and performance
 Complication
• Immediate: Extension of the incision, vulval
haematoma, infection , wound dehiscence
• Remote: Dyspareunia, endometriosis
 Health education
• Eat a diet high in fibre and fluids to prevent
constipation
• Ask the women to walk with thighs apposed
• Encourage for sitz bath.
• Not to use squatting position since the wound is
healing.
•  Perineal hygiene
• Change sanitary pads at least every 4 hours to help
prevent infection. squirt warm tap water over the
perineum, beginning at the front and moving toward
the back .
 Cont’d…
• Sit in a tub of warm water
• Always wash hands thoroughly before and after
going to the bathroom.
• Always keep the wound clean & dry after each
urination & defecation.
•  kegal’s exercise (Squeeze the perineal muscles as
if you were trying to stop the flow of urine, Hold
for 5 to 10 seconds and then relax, Do this
exercise 10 times a day to regain muscle strength).
 Injuries to the birth canal
• Maternal injuries following birth are quite common
and contribute significantly to maternal morbidity in
their later life. Eg. Cystocele, rectocele and
uterovaginal prolapse
• Injuries to the vulva: laceration of the vulval skin
posteriorly and paraurethral tear on the aspect of labia
minora are common site
• Injuries to the perineum: Minor injury is quite
common especially during first birth but gross injury
is as a result of mismanagement of 2 nd stage of labour
 Various degree of vaginal tear
• First degree vaginal tear
• Second degree vaginal tear
• Third degree vaginal tear
• Fourth degree vaginal tear
 First degree vaginal tear
Involves the
• Vaginal mucosa
• Connective tissue
• Perineal skin
 Second degree vaginal tear
Involves the
• Vaginal mucosa
• Perineal skin
• Superficial perineal muscles (bulbocavernosus,
the transverse perineal muscles and
pubococcygeus)
 Third degree vaginal tear
Involves the
• Vaginal mucosa
• Perineal skin
• Superficial perineal muscles (bulbocavernosus,
the transverse perineal muscles and
pubococcygeus)
• External anal sphincter
• Deep perineal muscles
 Fourth degree vaginal tear
Involves the
• Perineal and vaginal mucus membrane
• Perineal muscle
• Rectal sphincter
• Anterior wall of the rectum
Steps of repair (first and second degree)

• Prepare the necessary equipments

• Patient explanation
• Provide emotional support and encouragement
• Ensure that the uterus is contracted
• Examine the vagina, perineum and cervix, rule out
third and fourth degree tears
 Place a gloved finger into the anus
 Gently lift the finger to identify the sphincter
 Feel for the tone and tightness of the sphincter
• Infiltrate beneath the vaginal mucosa, skin of
perineum and deeply perineal muscle with 10ml of
0.5% lignocaine solution.
• Repair the vaginal mucosa using continuous suture
with chromic catgut 1-0/but in IMPAC(catgut 2-0)
 Start the repair about 1 cm above the apex of
vaginal tear. Continue to suture to the level of
vaginal opening.
 At the vaginal opening, bring together the cut
edges of vaginal opening.
Cont’d…
  Bring the needle under the vaginal opening and
out through the perineal tear and tie.
• Repair the perineal muscles using interrupted
sutures with catgut 1-0 but in IMPAC (Catgut 2-0)
• Repair the skin using interrupted or subcuticular
suture with catgut 1-0 starting at the vaginal
opening.
• If the tear was deep, make sure no stitches are in
the rectum. Place a gloved finger in the anus to
feel for stitches.
Cont’d…
• Wash the perineal area with antiseptic solution,
clean and dry the area, clean away all soiled
linens and position a clean sanitary pad over
the vulva and perineum.
• Dispose all bloody linens in a closed or
closable container.
• Gently lay the woman’s legs down together at
the same time and make her comfortable.

Cont’d…
 Post procedure
• Explain the client the nature of procedure
• Infection prevention
 Keep the area clean
 Dry the perineum after urination
 Clean with mild soap water and rinse the
perineum after each bowel movement
 Frequently change perineal pads
• Leave the perineum open to air as much as
possible
 Why Continuous Suturing?
• Fewer sutures
• Fewer trauma
• Heal better
• Less painful because less thread used
 Why chromic catgut?
• Flexible
• Strong
• Durable
• Minimal tissue reaction
 References
• Ranabhat, R. and Niraula, H. (2017). A Text Book of
Midwifery and Reproductive Health, first edition, National
Center For Health Professions Education
• Tuitui, R. (2018). Manual of Midwifery-II (Intrapartum Care),
thirteen edition, Vidyarthi Pustak Bhandar
• Gautam, S and Subedi, D. (2016). Midwifery Nursing Part-II,
edition, Medhavi Publication.
• Dutta, D. (2018). Textbook of Obstetrics, ninth edition, jaypee
brothers
 References
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• J Gynecol Obstet Biol Reprod (Paris). 2016
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