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14 Episiotomy

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

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