Episiotomy

Annissa Febriani
 History

• A report dating back to 1741 suggested the first surgical opening of the perineum to prevent severe
perineal tears (Ould 1741)
• The general idea is to make a controlled incision in the perineum, for enlargement of the vaginal
orifice, to facilitate difficult deliveries.
 Episiotomy and Repair Technique
Updated: Apr 19, 2021
Author: Justin R Lappen, MD; Chief Editor: Christine Isaacs, MD
Christine Isaacs, MD Associate Professor, Department of Obstetrics
and Gynecology, Division Head, General Obstetrics and
Gynecology, Medical Director of Midwifery Services, Virginia
Commonwealth University School of Medicine

Christine Isaacs, MD is a member of the following medical

societies: American College of Obstetricians and Gynecologists
https://emedicine.medscape.com/article/2047173-technique#c4

• Despite a lack of supporting data, episiotomy was widely adopted into obstetric practice after 1920 and came to
be considered standard of care by many American obstetric care providers.
• By 1979, episiotomy was performed in approximately 63% of all deliveries in the United States, with higher rates
among nulliparas. In Great Britain in the same era, episiotomy rates ranged from 14-96% among nulliparas and
from 16-71% among multiparas.
• In the 1970s and 1980s, however, obstetric providers began to question the routine use of episiotomy. A growing
body of evidence began to emerge that demonstrated the potential consequences of episiotomy, including
increased risk of extension to severe perineal lacerations, dyspareunia, and future pelvic floor dysfunction.
• As a result, the use of episiotomy has decreased from its 20th-century peak. For example, the number of
episiotomies performed annually in the United States fell from over 1.6 million in 1992 to 716,000 in 2003 as a
more restricted use of the procedure was adopted.
Anatomy of the female perineum, with potential sites for episiotomy
incision indicated. Image courtesy of Wikimedia Commons
(Blausen.com staff in Blausen gallery 2014. Wikiuniversity Journal of
Medicine.
Available at:
https://commons.wikimedia.org/wiki/File:Blausen_0355_Episiotomy.p
ng).
Crowning of an infant's head, with potential sites for episiotomy incision
indicated. Image courtesy of Wikimedia Commons (Blausen.com staff in
Blausen gallery 2014. Wikiuniversity Journal of Medicine.
Available at:
https://commons.wikimedia.org/wiki/File:Blausen_0294_Delivery_Crownin
g.png)
 Purpose of Episiotomy

1. To shorten the second stage of labour, e.g. with fetal distress.

2. To aid the delivery of the presenting part when the perineum is tight and
causing poor progress in the second stage of labour.
3.To prevent third-degree perineal tears.
4.To allow more space for operative or manipulative deliveries, e.g. forceps
deliveries

Bettercare Learning Programmes Maternal Care

 Indications

• An ACOG Practice Bulletin published in 2006 and reaffirmed in 2016 concluded that median episiotomy is
associated with higher rates of injury to the anal sphincter and rectum than mediolateral episiotomy and
recommending restricted use of episiotomy in clinical practice (level A recommendation).
• ACOG further concluded that routine episiotomy does not prevent pelvic floor damage leading to incontinence and
that mediolateral episiotomy may be preferable to midline episiotomy when clinically indicated (level B
recommendation).
• The ACOG recommendations also noted that although most lacerations during vaginal delivery are first-and second-
degree lacerations, more severe third-and fourth-degree lacerations that result in obstetric anal sphincter injuries
(OASIS) may occur in up to 11% of women giving birth vaginally.
• In 2007, NICE and RCOG published similar guidelines recommending against routine episiotomy and advocating
mediolateral episiotomy in clinically indicated cases. The NICE and RCOG guidelines also outline the recommended
technique for performing a mediolateral episiotomy.
• In 2015, RCOG updated their guidelines on the Management of Third- and Fourth-Degree Perineal Tears adding the
following:
1. Evidence for the protective effect of episiotomy is conflicting
2. Mediolateral episiotomy should be considered in instrumental deliveries
3. Major society recommendations recognize a restricted role for episiotomy to assist with difficult deliveries (eg,
shoulder dystocia, although dissents from this recommendation have been expressed ), to facilitate delivery in the
context of nonreassuring fetal status, or possibly to avoid a serious maternal laceration
• According to a Cochrane database review, the implementation of a selective episiotomy policy in women undergoing
non-operative vaginal delivery, resulted in significantly fewer women with severe perineal trauma when compared to
women who underwent routine episiotomy. However, there is still no solid supporting evidence for the benefits of its
use as a stand-alone elective procedure.
• An article from Sultan AH in 2019 states the World Health Organization has yet to establish the role of episiotomy. For
this reason, indications remain guarded and should be determined on a case by case basis by the healthcare team.
Situations where healthcare providers may consider an episiotomy include: assisting an operative vaginal delivery,
shoulder dystocia, or fetal distress.

1. Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev. 2017 Feb
08;2:CD000081. [PMC free article] [PubMed] [Ref list]
2. Helewa ME. Episiotomy and severe perineal trauma. Of science and fiction. CMAJ. 1997 Mar 15;156(6):811-3. [PMC free article] [PubMed] [Ref list]
3. Marty N, Verspyck E. [Perineal tears and episiotomy: Surgical procedure - CNGOF perineal prevention and protection in obstetrics guidelines]. Gynecol
Obstet Fertil Senol. 2018 Dec;46(12):948-967. [PubMed] [Ref list]
Contraindications

• Cannot be performed without consent of the patient.

• Relative contraindications to the procedure include inflammatory bowel
disease and severe perineal malformations.
• Episiotomy should not be performed unless vaginal delivery is considered to
be possible.
 Types of Episiotomy

• The different types of episiotomy incisions include the midline, the modified-
median, the mediolateral, J-shaped, lateral, anterior, and radical.
• The two most common techniques are midline (the US and Canada) and
mediolateral (Europe).
• the selective use of episiotomy still has utility and should be performed based
on clinical judgment and maternal or fetal indications. To this day, some
countries still perform episiotomy routinely.
1. Sultan AH, Thakar R, Ismail KM, Kalis V, Laine K, Räisänen SH, de Leeuw JW. The role of mediolateral episiotomy during operative vaginal
delivery. Eur J Obstet Gynecol Reprod Biol. 2019 Sep;240:192-196. [PubMed] [Ref list]
2. Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev. 2017 Feb
08;2:CD000081.
 Preparation
• Informed consent : Education and written information regarding episiotomies increases acceptance and
reduces anxiety levels in patients during the birthing process
• Ensure good lighting
• Ensure adequate anesthesia. Check the equipment before starting the procedure. An episiotomy should
not be done without adequate analgesia.
The local anaesthetic is injected below the skin and vaginal epithelium in the area where the episiotomy
will be cut. The nerve fibres that relay pain stimuli are below the skin and epithelium. Usually 10–15 ml
1% lignocaine (Xylotox) supplies adequate analgesia for performing an episiotomy.
Be very careful that the local anaesthetic is not injected into the presenting part of the fetus.

1. Kettle C, Dowswell T, Ismail KM. Continuous and interrupted suturing techniques for repair of episiotomy or second-degree tears. Cochrane Database Syst
Rev. 2012 Nov 14;11:CD000947. [PMC free article] [PubMed]
2. Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD000081.
3. Alexander JW, Karantanis E, Turner RM, Faasse K, Watt C. Patient attitude and acceptance towards episiotomy during pregnancy before and after information
provision: a questionnaire. Int Urogynecol J. 2020 Mar;31(3):521-528. [PubMed]
The method of performing a left mediolateral episiotomy

• The incision should only be started during a contraction

when the presenting part is stretching the perineum.
• Doing the episiotomy too early may cause severe
bleeding and will not immediately assist the delivery.
• The incision is started in the midline and most
posterior in the vaginal opening (introitus) with the
scissors pointed at 45° away from the anus.
• It is usually directed to the patient’s left but can also be
to the right. 2 fingers of the left hand are slipped
between the perineum and the presenting part when
performing a mediolateral episiotomy.
 Important principles apply to the suturing
of an episiotomy
1.The apex (highest point) of the episiotomy must be visualised and a suture put in at the apex.
2.Dead space must be closed.
3.The same opposing tissue must be brought together using the skin vaginal epithelium
juncture as an anatomical landmark.
4.Tissues must be brought together but not strangulated by excessive tension on the sutures.
5.Haemostasis must be obtained.
6.The needles must be handled with a pair of forceps and not by hand and should be
safeguarded (Figure 9A-2) and removed from the operating field as soon as possible.
 Repairing an episiotomy

• This is an uncomfortable procedure for the patient. Therefore, it is essential to explain what is going to be done.
1. The patient should be put into the lithotomy position if possible.
2. It is essential to have a good light that must be able to shine into the vagina. A normal ceiling light usually is not
adequate.
3. Good analgesia is essential and is usually provided by local anaesthesia which is given before the episiotomy is
performed. As 20 ml of 1% lignocaine may be safely infiltrated, 5–10 ml usually remains to be given in sensitive
areas. An episiotomy should not be sutured until there is good analgesia of the site.
4. In order to prevent blood which drains out of the uterus from obscuring the episiotomy site, a rolled pad or tampon
should be carefully inserted into the vagina above the episiotomy wound. As this is uncomfortable for the patient, she
should be reassured while this is being done.
5. Absorbable suture material should be used for the repair. Three packets of chromic 0 are required. Two on a round
(taper) needle for the vaginal epithelium and muscles, and one on a cutting needle for the skin. With smaller
episiotomies one packet on a round needle and one on a cutting needle may be sufficient.
6. Non-absorbable suture material such as nylon and dermalon are very uncomfortable and should not be used.
Remember that the patient has to sit on her wound.
The method of suturing an episiotomy

• Three layers have to be repaired:

1.The vaginal epithelium.
2.The muscles.
3.The perineal skin.
4 important steps in the repair of an episiotomy
wound.
Step 1
1. Place a suture (stitch) at the apex of the incision in
the vaginal epithelium.
2. Then insert one or two more continuous sutures in
the vaginal epithelium. Do not complete suturing
the vaginal epithelium when the episiotomy is large
or deeply cut but leave this suture and do not cut it.
3. When placing the suture at the apex, be very
careful not to prick your finger with the needle.
Step 2
• Insert interrupted sutures in the muscles. Start at
the apex of the wound. The aim is to bring the
muscles together and to eliminate any ‘dead space’,
i.e. any spaces between the muscles where blood
can collect. Remember that the sutures must be
inserted at 90 degrees to the line of the wound.
• When suturing the muscles, be careful not to put
the suture through the rectum. If you make sure
that the point of the needle is seen when crossing
from the one side to the other of the deepest part of
the wound, the stitch will not be too deep. ‘Figure
8’ stitches (double stitches) are used to suture the
muscle layer. When the muscles have been
correctly sutured the cut edges of the vaginal
epithelium and the skin should be lying close
together.
• The markers for correct alignment are:
1. The remains of the hymen.
2. The junction of the skin and the vaginal epithelium.
The skin is recognised by the darker pigmentation.
Step 3
• Return to the vaginal
epithelium and complete
the continuous catgut
suture, ending at the
junction with the skin. Do
not pull the sutures tight as
they only need to bring the
edges of the vaginal
epithelium together.
Step 4
• Use interrupted sutures with an
absorbable suture material to
repair the perineal skin.
• Do not pull the sutures tight as
they only need to bring the
edges of the skin together.
• Sutures that are too tight
become uncomfortable for the
patient due to the inflammatory
response causing swelling of the
tissue.
 When the suturing is complete

1.Remove the pad from the vagina. Be gentle as this will be uncomfortable for
the patient.
2.Put a finger into the rectum and feel if a suture has been placed through the
rectal wall by mistake.
3.Make sure that the uterus is well contracted.
4.Get the patient out of the lithotomy position and make sure that she is
comfortable.
 • Bleeding : The perineum and surrounding tissues have an
extensive vasculature, and the blood supply to these areas is
increased by the physiologic changes of pregnancy and labor.
Complications • Signs and symptoms of episiotomy infection include fever, focal
tenderness at the wound site, and purulent or malodorous
drainage.
• If an abscess forms, drainage may be required, or spontaneous
extension to wound breakdown may ensue. In rare cases, necrotizing fasciitis
higher-order may occur; this can be life-threatening if not appropriately
Bleeding Infection evaluated and treated.
perineal
lacerations
• Routine antibiotic prophylaxis is not recommended after an
episiotomy or repair of an obstetric laceration.
complications in • The American College of Obstetricians and Gynecologists
Dehiscence subsequent dyspareunia (ACOG) does not recommend universal prophylaxis due to lack of
vaginal deliveries
evidence, but the Royal College of Obstetricians and
Gynaecologists (RCOG) recommends routine prophylaxis owing
to the severity of the outcomes following infection.
pelvic floor inappropriate
dysfunction
urinary fistulas
wound scarring • can occur with or without wound infection. Small defects may
heal spontaneously without closure; however, many defects
require surgical closure.
• Historically, delayed closure (2-3 months after delivery) was
performed. Over the past 20 years, early closure has been reported
to represent an appropriate and successful approach . Measures
such as debridement or parenteral antibiotic therapy may be
necessary before wound closure
 Problems with
episiotomies

1. The episiotomy is done too soon: This can result in excessive bleeding as the presenting part is not pressing
on the perineum. An episiotomy will not help the descent of a high head.
2. Extension of the episiotomy by tearing: This is not only a problem in a midline episiotomy. Mediolateral
episiotomies may also tear through the anal sphincter into the rectum. However, extension of mediolateral
episiotomies are less likely to occur than a midline episiotomy.
3. Excessive bleeding may occur:
1. When the episiotomy is done too early.
2. From a mediolateral episiotomy.
3. After the delivery.
• Arterial bleeders may have to be temporarily clamped, while venous bleeding is easily stopped by packing a
swab into the wound. Suturing the episiotomy usually stops the venous bleeding but arterial bleeders need to
be tied off.
Perineal trauma
NICE (NICE; RCOG) recommend perineal or genital trauma
caused by either tearing or episiotomy at birth should be defined
1. first degree – injury to skin only;
2. second degree – injury to the perineal muscles but not the
anal sphincter;
3. third degree – injury to the perineum involving the anal
sphincter complex:
3a – less than 50% of external anal sphincter thickness torn;
3b – more than 50% of external anal sphincter thickness torn;
3c – internal anal sphincter torn
4. fourth degree – injury to the perineum involving the anal
sphincter complex (external and internal anal sphincter) and
anal epithelium.

Obstetric anal sphincter injuries (OASIS) includes third- and fourth-degree perineal tears.
(RCOG 2007).
• Cedera sfingter anal obstetrik (OASIS) berhubungan
dengan morbiditas ibu yang signifikan termasuk
nyeri perineum, dispareunia (hubungan seksual
yang menyakitkan) dan inkontinensia anal, yang
dapat menyebabkan gejala sisa psikologis dan fisik.
• Banyak wanita tidak mencari pertolongan medis
karena malu. The two recognised methods for the
repair of damaged external anal sphincter (EAS)
are end-to-end (approximation) repair and
overlap repair.
• Data yang tersedia menunjukkan bahwa pada
follow-up satu tahun, perbaikan pada teknik overlap
dibandingkan dengan Teknik end to end.
• Pada akhir 36 bulan tampaknya tidak ada perbedaan
dalam flatus atau inkontinensia feses antara kedua
teknik.
 Preoperasi - Persiapan alat & bahan

• Needle holder, gunting metzenbaum,

gunting benang, pinset chirurgis, klem
Allis, retraktor,
• kassa steril dan handscoen.
• cairan irigasi, lidokain 1%, dan benang
polyglactin 2-0 (Vicryl).
• penerangan yang adekuat

30
 Pilihan benang

• Mukosa anorektal : Benang polyglactin 3-0  mengurangi iritasi

dibandingkan dengan polydioxanone (PDS).
• Sfingter ani eksterna dan/atau sfingter ani interna : baik dengan
menggunakan monofilamen seperti PDS 3-0 atau modern braided
seperti polyglactin 2-0  hasil sama.

31
Prosedur

Mukosa rektum didekatkan

kompleks sfingter ani dijahit
Eksplorasi dan identifikasi dengan jahitan satu-satu
secara end-to-end
sfingter ani dan apeks (interrupted) menggunakan
enggunakan benang
mukosa anus benang polyglactin 910
polyglactin 910 (Vicryl) 2/0
(Vicryl) 3/0
Penjahitan Mukosa Rektum

Eksplorasi dan identifikasi sfingter ani dan apeks mukosa anus

Mukosa rektum didekatkan dengan jahitan satu-satu

(interrupted) menggunakan benang polyglactin 910 (Vicryl) 3/0

kompleks sfingter ani dijahit secara end-to-end menggunakan

benang polyglactin 910 (Vicryl) 2/0
33
 Sfingter Ani

• Sfingter ani interna

• struktur fibrosa yang mengkilap, putih, terletak diantara tepat diatas mukosa rektum
diantara sfingter ani eksterna

• Sfingter ani eksterna 34

• otot yang berbentuk pita melingkar yang dilapisi kapsul fibrosa.

 Penjahitan Sfingter

2 tehnik penjahitan sfingter ani

eksterna
• Tumpang tindih (overlapping)  ahli
bedah kolorektal, reparasi sekunder
• Ujung ke ujung (end to end) 
tradisional, ahli obstetri

35

Methods for surgical repair of anal sphincter tears: Overlap technique (Kiri) dan end-to-end technique (Kanan).
 Penjahitan Sfingter – End-to-End

• Interrupted
membawa ujung-ujung sfingter
ani kedua sisi, tiap kuadran (arah
jam 12,3,6,9), jahitan terputus,
bila tak cukup  3 tempat

37
 Penjahitan Sfingter - Overlap
membawa ujung sfingter dg jahitan matras,
kontak permukaan jaringan >>

• diseksi jaringan sekitar sfingter ani eksterna

• jahitan dari atas ke bawah melalui lapisan superior dan inferior
• dari bawah ke atas melalui lapisan inferior dan superior
• sisi proksimal lap superior di atas (overlap) sisi distal lap inferior
(1-2cm)
• dibuat 2 jahitan lagi serupa jahitan pertama
• sesudah ketiga jahitan terpasang, masing-masing diikat tanpa
strangulasi
• simpul ditempatkan pada bagian atas ujung sfingter yang
overlap
38
 Identifikasi otot
Jahit mukosa vagina
bulbokavernosus dan Identifikasi apeks mukosa Setelah penjahitan mukosa
posterior dengan jahitan
transversus perinealis lalu vagina lalu dibuat jahitan vagina, dilakukan
satu-satu menggunakan
dilakukan penjahitan satu- sudut 1 cm diatas apeks penjahitan kulit perineum
benang polyglactin 910 2/0
satu menggunakan benang mukosa vagina posterior secara subkutikuler
hingga cincin hymen
Polyglactin 910 2/0
 Pasca-operasi
Prinsip Perawatan Perawatan Luka secara Perawatan
Pascaoperasi Mandiri lokal secara Diet
mandiri
• Mengatasi nyeri dan • Luka harus dijaga tetap
pencegahan infeksi sehingga bersih dan kering, terutama
penyembuhan berjalan setelah BAK dan BAB Antibiotika Laksatif
dengan sempurna • Sitz bath dapat dilakukan
• Perawatan harus bisa untuk menjaga agar luka
dilakukan mandiri oleh tetap bersih
pasien di rumah • Untuk mencegah Antinyeri Follow Up
pembengkakan dapat
dilakukan kompres dengan
es
• Pemakaian tampon tidak
dianjurkan
• Hindari duduk lama
40
Perawatan Luka secara Mandiri – Sitz Bath

Suhu : 113°F (45°C) Lama 20 menit

Menyebabkan penyembuhan
dan menurunkan insidensi
infeksi dengan cara : Keringkan dengan lap bersih
meningkatkan rasa nyaman, sesudahnya
penurunan nyeri,
meningkatkan sirkulasi
41
 Antibiotik Analgesik Pelunak Feses
• Awalnya diberikan AB • Nyeri berkorelasi • Diusahakan pasien
I.V dilanjutkan oral dengan besar dan buang air besar tiap
selama 5-7 hari luasnya luka hari dengan feses
• dapat dipilih broad • Pemberian obat-obat yang lunak
spectrum seperti gol. anti Inflamasi • Diet tinggi serat,
gol.penicilin atau Non steroid dapat banyak minum
sefalosporin digunakan. • obat pelunak feses
• Perawatan luka dapat dilanjutkan 10-
dengan mengompres 14 hari
es dapat
menghilangkan nyeri
karena menurunkan
edema dan membuat
vasokontriksi.

42
 Follow Up

Breast Uterine

BUBBLE - REDA
Bladder Bowel

Episiotomy
• Redness
Lochea • Edema
• Discharge
• Approximation 43
 Follow Up

• Minggu I, II, VI dan 3 bulan

• Minggu I & II
• keluhan terkait jahitan (nyeri, edema, keadaan
benang dan jaringan sekitarnya), BAK, BAB

• Minggu VI
• sama dengan minggu I dan II, dispareunia, libido turun

• Bulan III
• gangguan BAK, BAB, dispareunia,
• Periksa USG, anal manometri, elektromiografi,
pudendal nerve terminal motor latency, MRI
44
 Prognosis

• Prognosis perbaikan ruptur perineum tingkat tiga dan

empat adalah baik,
• 60-80 % kasus tidak memiliki keluhan terutama setelah 12
bulan pascaoperasi (Williams et al., 2006).
• insidens kejadian 20 - 50 % masih didapatkan inkontinensia ani
pascaperbaikan sfingter ani. (Sultan, 1994)

1. Williams, A., Adams, E.J., Tincello, D.G., Alfirevic, Z., Walkinshaw, S.A., Richmond, D.H.,
2006. How to repair an anal sphincter injury after vaginal delivery: results of a randomised
controlled trial. BJOG. 113:201-7.
2.Sultan, A.H., Kamm, M.A., Hudson, S.N., Bartram, C.I., 1994. Third degree obstetric anal 45
sphincter tears: risk factors and outcome of primary repair. BMJ. 308:877-91
 Cara persalinan yang akan datang
• Persalinan pervaginam dapat
dipertimbangkan pada kondisi sebagai
berikut
• Wanita tidak memiliki keluhan
• Tidak ada bukti adanya defek sfingter ani
yang diperoleh dari pemeriksaan endoanal
atau manometri
• Persalinan diawasi oleh ahli yang
berpengalaman.

• Junizaf, 2011 :
• Penderita pasca reparasi ruptura perinei
total lama dan pasca sfingterorafi dapat
hamil seperti biasa, tetapi harus 46

melahirkan dengan operasi sesar

 Kesimpulan
• Pilihan benang adalah menggunakan Polyglactin
910
• Mukosa rektum dapat dijahit satu-satu dengan
atau tanpa menembus mukosa
• Sfingter ani dijahit secara end-to-end
• Perawatan pascaoperasi yang baik sangat
menentukan keluaran yang baik pula.

47
THANK YOU