Fig. 7. Repair of midline episiotomy. A. Closure of the
rectal mucosa. B. Closure of the anal sphincter. C. Second layered closure of the rectal mucosa using the rectovaginal fascia. D. Anchor stitch placed 1 cm beyond the most superior extent of the episiotomy. E. Use of one suture for closure. F. Completion of repair using a subcuticular suture. (Hankins GDV, Clark SL, Cunningham FG, Gilstrap LC. Operative obstetrics. New York [NY]: McGraw- Hill; 1995. Reproduced with permission of The McGraw- Hill Companies.) A B Episiotomy 15 C D E F 16 Episiotomy Mediolateral Episiotomy Procedure A mediolateral episiotomy requires the same pain prevention as noted for a midline repair. The debate about when to perform the episiotomy is also the same. Most surgeons recommend these procedures be done just before delivery because mediolateral episiotomies tend to bleed more than midline procedures. Once the decision is made, the fingers are inserted into the vagina between the head and the perineum. An incision is then made at approximately a 45-degree angle from the midline to the perineal body ( Fig. 8) . The apex should be in the exact midline of the perineum, not lateral to the midline. This incision can be on the left or right side depending on the preference of the obstetrician. Some authorities sug- gest that repair of an incision on the patients left side is mechanically easier for a right-handed surgeon. It is important to use large, straight sharp scissors to allow the incision to be made in a single cut. The inci- sion will extend approximately 4 cm into the perineum and may reach the ischioanal fossa. If the incision is not deep enough, there will be little relaxation, and a second incision to extend the first will be neces- sary. Although not prohibited, a second incision increases the risk of a zigzag line upon healing. Optimal timing of the episiotomy usually is when the vertex is crowning. Before crowning, there is the risk of exces- sive bleeding because the vessels are not compressed. Repair Immediately after the delivery, the obstetrician should examine the extent of the episiotomy. Upward extension of the vaginal incision should be evaluated carefully, especially if a forceps delivery occurred. Once this evaluation is completed, the repair should begin ( Fig. 9, AD) . Any arterial bleeding should be managed to prevent subsequent hematoma formation. Two fingers are placed in the vagina for traction and to spread the incisional edges. A suture of 2-0 or 3-0 material is then placed approxi- mately 1 cm above the apex. This will prevent retracted vessels from bleeding and disrupting the repair. A running suture using a noncutting needle is then used to close the vaginal mucosal and submucosal areas ( Fig. 9A) . It may be necessary to place additional interrupted sutures in the submucosal space if inadequate tissue is obtained with the mucosal