5/2/2017 ApproachtoepisiotomyUpToDate

OfficialreprintfromUpToDate
www.uptodate.com2017UpToDate

Approachtoepisiotomy

Authors: LoriRBerkowitz,MD,CarolineEFoustWright,MD,MBA
SectionEditor: CharlesJLockwood,MD,MHCM
DeputyEditor: KristenEckler,MD,FACOG

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jan2017.|Thistopiclastupdated:Jan26,2017.

INTRODUCTIONEpisiotomyisperformedtoenlargethebirthoutletandfacilitatedeliveryofthefetus.
Routineuseofepisiotomyhasfallenoutoffavorbasedonevidenceofincreasedcomplicationswithuse.
Episiotomyisnowperformedonanindividualizedbasis.Episiotomyisconsideredwhentheclinical
circumstancesplacethepatientathighriskofathirdorfourthdegreelacerationorwhenthefetalheart
tracingisofconcernandhasteningvaginaldeliveryiswarranted.Mediolateralepisiotomyisassociatedwitha
lowerriskofthirdandfourthdegreelacerationthanamedianepisiotomy.

Thistopicwillreviewtheindications,risks,benefits,andprocedureforepisiotomy.Therepairofepisiotomy
andobstetricanalsphincterlacerationarepresentedseparately.

(See"Repairofepisiotomyandperineallacerationsassociatedwithchildbirth".)
(See"Effectofpregnancyandchildbirthonanalsphincterfunctionandfecalincontinence".)

DEFINITIONEpisiotomyisthesurgicalenlargementoftheposterioraspectofthevaginabyanincisionto
theperineumduringthelastpartofthesecondstageoflabor[1].Theincisionisperformedwithscissorsor
scalpelandistypicallymidline(median)ormediolateralinlocation.(See'Proceduresandselection'below.)

PREVALENCEANDRISKFACTORSSincethe1996WorldHealthOrganizationrecommendationforan
episiotomyrateofapproximately10percent[2],ratesofepisiotomyhavegenerallybeenindecline.Inthe
UnitedStates,theepisiotomyratedroppedfrom17.3to11.6percentfrom2006to2012[3].

InastudyfromaUnitedStatesinsurancedatabase,demographiccharacteristicsassociatedwithreceiptof
episiotomyincludedwhiteraceandcommercialinsurance[3].Hospitalfactorsincludingrurallocationor
academiccenterwereassociatedwithreducedratesofepisiotomy.Otherstudieshavereportedthatprivate
practitionershavetwotofourfoldincreasedutilizationofepisiotomiescomparedwithtrainees,academic
faculty,ormidwives[35].

ADVANTAGESOFRESTRICTEDUSEOFEPISIOTOMYRoutineuseofepisiotomyisnolonger
recommendedbecauseofinsufficientobjectiveevidencebaseddatademonstratingbenefitordefiningthe
criterionforitsuse[1,6,7].Inaddition,restricteduseofepisiotomydecreasestheriskofsevere(ie,thirdand
fourthdegree)obstetriclacerations.Inametaanalysisofeighttrialscomparingrestrictiveversusroutineuse
ofepisiotomy,restrictiveepisiotomy(28percentepisiotomyrate)resultedinlesssevereperinealtrauma
(relativerisk[RR]0.67,95%CI0.490.91),lesssuturing(RR0.71,95%CI0.610.81)andfewerwound
complications(RR0.69,95%CI0.560.85)butmoreanteriorperinealtrauma(RR1.84,95%CI1.612.10)
comparedwithroutineuseofepisiotomy(75percentepisiotomyrate)[1].Therewerenodifferencesinsevere
combinedvaginal/perinealtrauma,dyspareunia,urinaryincontinence,orseverepainmeasures.Asanterior
perineallacerationsarelessmorbidthanposteriorperineallacerations,particularlyseverelacerations,
restricteduseofepisiotomyisassociatedwithmorebenefitsthanroutineuse.

Inthepast,routineuseofepisiotomywasbelievedtohaveseveralbenefitshowever,thebodyofevidence
doesnotsupportthesebeliefs[8]:

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ReductionoftraumatothefetalheadAlthoughepisiotomyhasbeenadvocatedtominimizetheriskof
intraventricularhemorrhageinpretermbirths,thereisnoevidencethatthisinterventioniseffectiveona
routinebasis[9].(See"Longtermneurodevelopmentaloutcomeofpreterminfants:Epidemiologyand
riskfactors".)

EaseofrepairandimprovedwoundhealingIthasbeenhistoricallyarguedthatacontrolledsurgical
incisioniseasiertorepairandmorelikelytobeanatomicallycorrectthanrepairofaspontaneous
laceration,andthuslesslikelytoresultinlongtermcomplications.Intheabsenceofepisiotomy
extension,episiotomyincisioniseasiertorepairthanmostjaggedspontaneousdeepseconddegree
lacerations.However,datademonstratingimprovedlongtermoutcomeswithepisiotomyarelacking.
(See"Repairofepisiotomyandperineallacerationsassociatedwithchildbirth".)

PreservationofthemuscularandfascialsupportofthepelvicfloorEpisiotomyalsodoesnotprotect
pelvicfloorstrengthandmayresultinaweakenedpelvicfloormusculaturewhencomparedwith
spontaneouslaceration[1014].Inaddition,neithermidlinenormediolateralepisiotomiesareprotective
againstfutureurinaryorfecalincontinencewhencomparedwithspontaneousvaginaldelivery[10,15].

PreventionofanalsphincterlacerationThereisincreasingconsensusthatthemedianepisiotomyisnot
effectiveforthispurpose,andinfacthasbeenassociatedwithincreasedrateofsevereperineal
lacerations[1,16].Inametaanalysisof22observationalstudiesthatincludedover651,000women(2.4
percentwithseverelacerations),medianepisiotomywasassociatedwithanearlyfourfoldincreasedrisk
ofthirdorfourthdegreeperineallacerations(oddratio[OR]3.82,95%CI1.967.42)[16].Ofnote,
mediolateralepisiotomydidnotincreasetheriskofsevereperineallaceration(OR1.72,95%CI0.81
3.65).(See"Effectofpregnancyandchildbirthonanalsphincterfunctionandfecalincontinence",section
on'Medianepisiotomy'.).

PreventionofshoulderdystociaInasystematicreviewof14studiesincludingover9700casesof
shoulderdystocia,onlyonestudyevaluatedtheeffectofepisiotomyonpreventionofshoulderdystocia,
andtheresultwasnotsignificant[17].Whileepisiotomydoesnotappeartopreventshoulderdystocia,its
useinthemanagementofshoulderdystociaislessclear.(See'Whentoconsiderepisiotomy'below.)

ADVERSEOUTCOMESOFEPISIOTOMYWhenconsideringtheuseofepisiotomy,theclinicianbalances
thepotentialbenefitsofepisiotomyagainstpotentialadverseeffectsresultingfromthisprocedure,including:

Extensionoftheincision,leadingtothirdandfourthdegreetears,particularlyformedianepisiotomy
[1,16].

Riskofunsatisfactoryanatomicresults(eg,skintags,asymmetry,fistula,narrowingofintroitus).

Increasedbloodloss[18].

Higherratesofinfectionanddehiscence[18].

Increasedriskofsevereperineallacerationinsubsequentdeliveries[19].

WHENTOCONSIDEREPISIOTOMYThedecisiontoperformepisiotomyisheavilydependentonthe
opinionofthedeliveringclinicianandisbasedontheclinicalscenarioatthetimeofdelivery[6,8].Thereare
nospecificsituationsinwhichepisiotomyisessential.Itisareasonableoptionwhentheclinicianbelieves
enlargingthebirthoutlettofacilitatedeliveryofthefetuswillbenefitthemotherorbabyandwarrantsmaternal
exposuretothepotentialadverseoutcomesassociatedwiththeprocedure.Forexample:

ExpeditedeliveryofthefetusEpisiotomycanbehelpfulinsituationswhereexpediteddeliveryofthe
fetusisdesiredduringthesecondstageoflabor,suchaswithacategoryIIIfetalheartratetracingthat
doesnotrespondtoresuscitativemeasures.Episiotomyisonlyhelpfulifdeliveryisbeingblockedby
perinealtissue(ie,episiotomywillnotimprovematernalexpulsiveefforts).(See"Managementof

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intrapartumcategoryI,II,andIIIfetalheartratetracings",sectionon'CategoryIIItracings:definitionand
management'.)

OperativevaginaldeliveryEpisiotomycanbeusedtofacilitateplacementoftheforcepsorvacuum
extractorinwomenwithanarrowvaginaloutlet.Incontrasttohistoricalrecommendations,multiple
societiesadviseagainstroutineepisiotomywithoperativevaginaldeliverythedecisiontoperforman
episiotomyduringanoperativevaginaldeliveryisatthediscretionoftheclinician[6,2024].Asmedian
episiotomyduringanoperativevaginaldeliverytriplestheriskofananalsphincterinjurycomparedwith
operativevaginaldeliveryalone,medianepisiotomyisnotadvised[25,26].

Whenepisiotomyisperformed,mediolateralepisiotomyisassociatedwithalowerriskofanalsphincter
injurycomparedwithmedianepisiotomy[16].Inasystematicreviewandmetaanalysisof15studies
comparingmediolateralorlateralepisiotomywithnoepisiotomyinprimiparouswomenundergoing
vacuumassisteddelivery,mediolateralorlateralepisiotomywasassociatedwithanapproximately50
percentreductioninriskofanalsphincterlacerationcomparedwithnoepisiotomy(oddsratio0.53,95%
CI0.370.77)[27].Basedonthisstudy,19womenwouldhavetoundergomediolateralorlateral
episiotomyduringvacuumextractiontopreventoneanalsphincterlaceration.Forclinicianswhoelectto
performanepisiotomytofacilitatedelivery,weadviseamediolateralorlateralincision.Weevaluateall
nulliparouswomenundergoingoperativevaginaldeliveryforpossibleepisiotomyandarelikelytoperform
amediolateralorlateralepisiotomyinwomenwithashortperineum.

Ofnote,operativevaginaldeliveryisanindependentriskfactorforadvancedperineallaceration[16].
(See"Effectofpregnancyandchildbirthonanalsphincterfunctionandfecalincontinence",sectionon
'Operativevaginaldelivery'.)

ShoulderdystociaInsomecasesofshoulderdystocia,performinganepisiotomycanincreasespace
fortheoperator'sfingersandthusfacilitatedeliveryoftheposteriorshoulderandotherinternal
procedures,butdoesnotappeartopreventshoulderdystociaorreleasetheimpactedanteriorshoulder.
Routineuseofepisiotomytomanageshoulderdystociaisnotadviseduntilmoredatafromrandomly
assignedtrialsareavailabletodeterminethebalanceofbenefitorharm[6].Episiotomydoesnotprevent
shoulderdystocia.Asystematicreviewof14studiesevaluatingepisiotomyatthetimeofshoulder
dystociareportedconflictingresultsforneonatalandmaternaloutcomeswhenshoulderdystociawas
managedwithepisiotomy[17].Inthereview,conclusionsregardingtheroleofepisiotomyinthe
managementofshoulderdystociawerefurtherlimitedbecausetheoriginalstudiesdidnotroutinely
adjustforpotentialconfounders(eg,macrosomia,parity,operativevaginaldelivery,andnonrandom
studydesign).(See"Shoulderdystocia:Intrapartumdiagnosis,management,andoutcome",sectionon
'Initialsteps'.)

PROCEDURESANDSELECTIONThemostcommontypesofepisiotomyarethemedian(midline)and
mediolateral(figure1).OtherlesscommonincisionsincludetheJtypeandTshape.Thedecisiontoperform
anepisiotomyisaclinicaljudgement,androutineuseofepisiotomyisnotadvised[1,6].

Mediolateralversusmedian(midline)episiotomyWhenperformingepisiotomy,ourpreferenceisa
mediolateralepisiotomybecauseofthereductioninanalsphincterlaceration(ie,thirdorfourthdegree
obstetricinjury)withmediolateralepisiotomycomparedwithmedianepisiotomy[16,28].Inattempttolimitanal
sphincterlaceration,theRoyalCollegeofObstetriciansandGynaecologistsadvisesmediolateralincisions
whenepisiotomyisperformed,andtheAmericanCollegeofObstetriciansandGynecologistsstatesthat
mediolateralepisiotomymaybepreferabletomedianepisiotomyinselectedcases[22,29].

Theselectionofmedianversusmediolateralepisiotomybalancesthedifferingrisksofthetwoprocedures.
Medianepisiotomyisassociatedwithahigherriskofanalsphincterlacerationthanmediolateralepisiotomy
[16].Mediolateralepisiotomyisassociatedwithincreasedbloodloss[30,31].Inaddition,mediolateral
episiotomyhashistoricallybeenthoughttoresultinmoreperinealpainanddyspareunia.However,whilethere
areconflictingdata,thebalanceofevidencesuggeststhattherearenodifferencesinpainoutcomesbetween

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thetwoprocedures[3235].Onestudyreportedgreaterpaininwomenwithamediolateralepisiotomyincised
60degreesoffthemidlinecomparedwithwomenwhoseepisiotomywascut40degreesoffofmidline,which
couldpartlycontributetothedifferingstudyoutcomes[36].Ofnote,analsphincterinjuryitselfhasbeen
associatedwithincreasedperinealpain[37].

Median(midline)Themedianepisiotomystartswithin3mmofthemidlineoftheposteriorfourchetteand
extendsdownwardsbetween0and25degreesofthesagittalplane[6].Themedianepisiotomyismore
commonlyperformedintheUnitedStates.

MediolateralThemediolateralepisiotomybeginswithin3mmofthemidlineintheposteriorfourchetteand
isdirectedlaterallyatanangleofatleast60degreesfromthemidlinetowardstheischialtuberosity[6].The
mediolateralepisiotomyismorecommonlyusedinEurope.

JincisionTheJincisionislesswidelyused.Theincisionstartsatthefourchette,isinitiallyextended
caudallyinthemidline,andthencurvedlaterallyatanangle,similartotheletterJ.Theanatomicalstructures
incisedincludethevaginalepithelium,perinealbody,andthejunctionoftheperinealbodywiththe
bulbocavernosusmuscleandperinealskin.Ideally,thetransverseperinealmuscleissparedbecausethe
lateralpartoftheincisionshouldbebelowthismusclehowever,itisdifficulttoensurethatitisnotincised.

Thishybridofmedianandmediolateralepisiotomiesmaytheoreticallyoptimizetheadvantagesandminimize
thedisadvantagesoftheindividualtechniques.Forexample,theapexoftheincisionpointsawayfromthe
rectumtoguideanyfurtherextensionawayfromthisstructure.However,therearenodataonwhichtobase
conclusions.

OtherTherearevariousmodificationsoftheabovetechniquesthatmaybepreferredbyindividual
practitioners(figure1).

TepisiotomyTheTepisiotomyisamodificationofthemedianepisiotomyinwhichbilateraltransverse
incisionsaremadeattheinferiorapextocreateaninvertedTshapedincision[38].Thisprocedure
increasestheareaofthevaginalopeningmorethanamedianepisiotomyalone(figure2).

LateralepisiotomyThelateralepisiotomyisbegunat1to2cmlateraltomidline,andtheincisionis
directedlaterallytowardtheischialtuberosity.Itisrarelyused.

AnteriorepisiotomyAnanteriorepisiotomyisknownasdeinfibulation(ordefibulation).Itisonly
indicatedinthesettingofpreviousfemalecircumcision(ie,femalegenitalmutilation).Thefusedlabia
minoraareincisedinthemidlinetowardthepubistorevealtheexternalurethralmeatustheclitoral
remnantsshouldnotbeincised.(See"Femalegenitalcutting(circumcision)".)

PERFORMINGEPISIOTOMYOncethedecisionismadetoperformanepisiotomy,weobtainverbal
consentfromthepatient,ensurethewomanhasadequateanesthesia,performtheprocedure,andcomplete
thedelivery.

PatienteducationandconsentIdeally,informationaboutperineallacerationandepisiotomyisshared
withwomenaspartoftheirprenatalcare.Ourpracticegiveswomenadocumentreviewingeventsand
proceduresthatcanoccurduringlaboranddelivery(eg,cesareandelivery,assistedvaginaldelivery,or
episiotomy).

Wefindthefollowingtext(orscript)helpfulincounselingwomen:

Manywomenwillgetsmalltearsaroundthevaginalopening.Sometimesadoctorormidwifewillcut
sometissuetomaketheopeningbigger(episiotomy).Mostwomenwithtearsoranepisiotomywillneed
stitches.Thestitcheswilldissolveduringhealing.Theareawillbeswollenandsoreforafewdays.
Rarely,infectionmayoccur.Atearorcutmayextendtotherectum.Mostoften,afterrepair,thisheals
withnoproblems.Rarely,continuedproblemswithbowelmovementsmayoccur.

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Inadditiontoantenataleducation,weverballyconsentthepatientbeforeperforminganepisiotomy.Inthe
deliveryroom,wediscusswhywebelievetheepisiotomywillbebeneficialtothewomanand/orbaby,therisks
ofepisiotomyincludingrectalsphincterinjury,andalsotherisksofnotperformingepisiotomy,suchasdelayed
delivery.

AnesthesiaoptionsAneuraxialanesthetic(ie,spinalorepidural),pudendalblock,orlocalanesthetic(eg,
5to20mLof1percentlidocaineinjectedintotheplannedepisiotomysite)canprovideadequateanesthesia
forperforminganepisiotomy.(See"Pudendalandparacervicalblock",sectionon'Pudendalblock'and
"Neuraxialanalgesiaforlaboranddelivery(includinginstrumenteddelivery)",sectionon'Neuraxial
techniques'.)

TimingAreasonableapproachistoperformtheprocedurewhenthedeliveryofthefetusisanticipated
withinthenextthreetofourcontractions.Theoptimaltimeforcuttingtheepisiotomyisnotknown.Ina
prospectivecohortstudythatcomparedepisiotomypriortocrowningwithepisiotomyperformedatcrowning,
episiotomyperformedpriortocrowningwasassociatedwithincreasedvaginaltrauma,longermean
episiotomylength,andgreatermeanestimatedbloodloss[39].

ProcedurePriortoperforminganepisiotomy,theclinicianwilltypicallyplaceoneortwofingersinsidethe
posteriorvaginalwalltoprotectthefetalscalpduringincision.Theincisionisperformedwitheitherscissorsor
scalpel.

MedianepisiotomyForamedian(midline)incision,theperineumisincisedverticallywithin3mmof
themidline,oratthe6o'clockposition,startingattheintroitus(figure1).Thegoalistoreleaseany
restrictionimposedbytheperinealbody,whichcansometimesbefeltasabandoftissuecephaladand
inferiortothevaginalorifice.Theincisionisdirectedinternallytominimizetheamountofperinealskin
incised.Thelengthoftheincisionisdeterminedbypatientanatomyandperceivedneed.Asthegeneral
goalofepisiotomyistofacilitatedeliveryofthefetalhead,theincisionismadelongenoughtoexpedite
thatprocessbutavoidtherectum.

Theanatomicalstructuresinvolvedintheincisionincludethevaginalepithelium,perinealbody,andthe
junctionoftheperinealbodywiththebulbocavernosusmuscleintheperineum.

MediolateralepisiotomyForamediolateralincision,theincisionismadeatthevaginalintroitusina
lateraldirection(figure1).Theincisionisinitiatedatthefourchetteandcutatanangle(usuallytothe
maternalrightforrighthandedclinicians)thatmaybealmostperpendiculartothemidline(80to90
degreesasthefetalheadiscrowning)however,afterdeliveryoftheinfant,thisanglebecomessmaller,
approaching45degrees,sincetheperineumisnolongerstretchedanddistortedbythefetalpresenting
part.Thefinalangleoftheincisionshouldbeat30to60degreesfromthemidlinetominimizethe
occurrenceofsphincterinjury[40,41].Theincisionisusuallybetween3and5cminlength.

Theanatomicalstructuresincisedincludethevaginalepithelium,transverseperinealand
bulbocavernosusmuscles,andperinealskin.Iftheincisionislarge,adiposetissuewithinischiorectal
fossamaybeexposed.

DeliveryandrepairDuringdeliveryofthefetalhead,supportoftheperineumatthemostinterioraspect
oftheincisionmayhelpreduceextensions.(See"Managementofnormallaboranddelivery",sectionon
'Deliveryofthenewborn'.)

Followingdeliveryofthefetusandtheplacenta,athoroughexaminationoftheperineum,includingarectal
examination,isperformedtodetermineextentoftheincisionandanyfurtherlacerationsorextensionsthat
mightwarrantrepair.Repairofobstetriclacerationsandepisiotomyincisionsispresentedseparately.(See
"Repairofepisiotomyandperineallacerationsassociatedwithchildbirth".)

COMPLICATIONSCommoncomplicationsofepisiotomyincludeextensionoftheincisiondeeperintothe
perineumortheanalsphinctercomplex,infection,breakdown,postpartumpain,anddyspareunia(table1).

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Althoughvulvovaginalhematomascanoccurafterepisiotomies,thiscomplicationisrare[42].

Aprospective,nonrandomlyassigned,observationalstudyreportedthatepisiotomywasassociatedwith
a3cmlongerperineallacerationcomparedwithnoepisiotomy(ie,spontaneouslaceration)[43].Eighty
percentoftheepisiotomiesweremidline.

Inametaanalysisof22studies,midlineepisiotomywasassociatedwithnearlyfourtimestheriskof
obstetricanalsphincterinjuries(oddsratio3.82,95%CI1.967.42)[16].Dataarelessclearfor
mediolateralepisiotomies[6].Inadditiontotheriskofanalincontinence,obstetricanalsphincterinjuries
havebeenassociatedwithpostponedcoitalonsetanddyspareuniaoneyearpostpartum[37].

Acasecontrolstudyofover104,000deliveriesreportedanincidenceof0.1perineallaceration
breakdownsperdelivery(allvaginaldeliverieswereincluded)[44].Episiotomywasanindependentrisk
factorforbreakdownofperinealrepair(typeofepisiotomywasnotspecified).

IMPACTONFUTUREDELIVERIESEpisiotomyuseatthetimeoffirstvaginaldeliveryappearstoincrease
theriskofasevereobstetriclacerationinasubsequentvaginaldelivery.Inareviewofover6000deliveries
thatcomparedwomenwithepisiotomyatfirstdeliveryversusthosewithout,womenwithpriorepisiotomyhad
agreaternumberofsevereperineallacerations(4.8versus1.7percent)andmoreseconddegreelacerations
(51.3versus26.7percent)atthetimeofsubsequentdelivery[19].Logisticregressionmodelingpredicteda
fivefoldincreasedriskofanalsphinctercomplexlacerationsforwomenwithpriorepisiotomy(oddsratio5.25,
95%CI2.969.32).Althoughthetypeofepisiotomywasnotidentifiedinthisstudy,themajorityof
episiotomieswerelikelymedianincisionsasthesearemostcommonintheUnitedStates,wherethestudy
wasperformed.

SUMMARYANDRECOMMENDATIONS

Episiotomyisthesurgicalenlargementoftheposterioraspectofthevaginabyanincisiontothe
perineumduringthelastpartofthesecondstageoflabor.Thepurposeistowidenthebirthoutletand
facilitatevaginaldelivery.(See'Definition'above.)

Forwomenundergoingvaginaldelivery,werecommendagainstroutineepisiotomy(Grade1B).Routine
episiotomyisassociatedwithhigherratesofsevereperinealtraumaandwoundcomplicationscompared
withrestricteduseofepisiotomy.Thedecisiontoperformepisiotomyismadeonacasebycase,or
restricted,basisratherthanperformingtheprocedureroutinely.(See'Advantagesofrestricteduseof
episiotomy'above.)

Episiotomymaybehelpfulinsomeclinicalsettings.Thedecisiontoperformepisiotomyisheavily
dependentontheopinionofthedeliveringclinicianandisbasedontheclinicalscenarioatthetimeof
delivery.Therearenospecificsituationsinwhichepisiotomyisessential.Situationsinwhichepisiotomy
canbehelpfulincludetheneedforexpeditedvaginaldelivery,operativevaginaldelivery,andshoulder
dystocia.(See'Whentoconsiderepisiotomy'above.)

Whenanepisiotomyistobeperformed,wesuggestamediolateralepisiotomy(Grade2C).Mediolateral
episiotomyreducestheriskofanalsphincterlaceration(ie,thirdorfourthdegreeobstetricinjury)
comparedwithmedianepisiotomy.(See'Mediolateralversusmedian(midline)episiotomy'above.)

Oncethedecisionismadetoperformanepisiotomy,patientconsentisobtained,adequateanesthesiais
provided,andthefetalscalpisprotectedbytheclinicianpriortoincision.(See'Performingepisiotomy'
above.)

Foramedianepisiotomy,theperineumisincisedverticallywithin3mmofthemidline,or6o'clock
position,ontheintroitus.(See'Procedure'above.)

Foramediolateralepisiotomy,theincisionismadeatthevaginalintroitusinalateraldirection.(See
'Procedure'above.)

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Commoncomplicationsofepisiotomyincludeextensionoftheincisionintotheperineumoranalsphincter
complex,infection,postpartumpain,anddyspareunia.(See'Complications'above.)

Episiotomyuseatthetimeofthefirstvaginaldeliveryappearstoincreasetheriskofasevereobstetric
lacerationinasubsequentvaginaldelivery(See'Impactonfuturedeliveries'above.)

ACKNOWLEDGMENTTheeditorialstaffatUpToDatewouldliketoacknowledgeJulianNRobinson,MD,
whocontributedtoanearlierversionofthistopicreview.

UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.

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Topic4478Version28.0

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5/2/2017 ApproachtoepisiotomyUpToDate

GRAPHICS

Typesofepisiotomyincisions

1=medianincision,1+2="T"incision,3="J"incision,4=mediolateralincision,5=
lateralincision.

Graphic70476Version4.0

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5/2/2017 ApproachtoepisiotomyUpToDate

Diameteroftheintroitus

Theupperfiguresshowtheintroitusandperineumbeforeandaftermakingatraditional
midlineepisiotomy.Inthelowersequenceoffigures,thediameteroftheintroitusis
significantlyenlargedbyaninvertedTtypeepisiotomycomparedwiththeclassicalmidline
incision.

Adaptedfrom:DelancyJ,SchafferJ,BrubakerL.Pelvicfloorinjury.Isitinevitable?OBG
Management200113:76.Copyright2001,DowdenHealthmedia.

Graphic78159Version2.0

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Complicationsattributedtoepisiotomy

Infection

Hematoma

Thirdandfourthdegreeextension

Cellulitis

Dehiscence

Abscess

Dyspareunia

Alteredsexualfunction

Perinealpain

Incontinence:urinary,fecal,flatus

Rectovaginalfistula

Impairedpudendalnerveconduction

Necrotizingfasciitis

Datafrom:RaminSM,GilstrapLC.Episiotomyandearlyrepairofdehiscence.ClinObstetGynecol199437:816.

Graphic77532Version2.0

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5/2/2017 ApproachtoepisiotomyUpToDate

ContributorDisclosures
LoriRBerkowitz,MD Nothingtodisclose CarolineEFoustWright,MD,MBA Nothingto
disclose CharlesJLockwood,MD,MHCM Consultant/AdvisoryBoards:Celula[Aneuploidyscreening(No
currentproductsordrugsintheUS)]. KristenEckler,MD,FACOG Nothingtodisclose

Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseare
addressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobe
providedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofallauthorsandmustconform
toUpToDatestandardsofevidence.

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