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Episiotomy, also known as perineotomy, is a surgical incision of the perineum and the posterior vaginal wall, generally performed during the second stage of labour to quickly enlarge the aperture for childbirth. The procedure involves cutting through the area between the vaginal opening and the anus, with the incision made during the crowning of the foetal head when the perineal muscles are stretched thin. The type of episiotomy performed may vary based on the patient's condition and the clinician's practices. The two most common types of episiotomy are midline and mediolateral. While the former is performed directly above the anus, the latter is cut slightly to one side of the perineum.
| Characteristics | Values |
|---|---|
| Definition | A surgical incision of the perineum and the posterior vaginal wall |
| Procedure | A cut through the area between the vaginal opening and the anus to make the vaginal opening larger for childbirth |
| Types | Midline, Mediolateral, Median, Lateral, J-shaped |
| When | During the second stage of labour, when the baby's head has stretched the vaginal opening to several centimetres |
| Benefits | Faster delivery, reduced risk of severe perineal tears, reduced risk of obstetric anal sphincter injury, preservation of pelvic floor muscle function, reduced risk of incontinence, cranial protection for the baby, less fetal acidosis |
| Risks | Damage to the anal sphincter muscle, pain, infection, hematoma, scarring, dyspareunia, damage to the ipsilateral nerve and surrounding muscle, erectile and gland tissues |
| Alternatives | Perineal massage, natural tearing |
| Aftercare | Stitches to repair the cut, ice packs, shallow baths, medicated creams or local numbing sprays, pain relievers, Kegel exercises |
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What You'll Learn
Midline episiotomy
An episiotomy is a surgical procedure performed during childbirth to widen the vaginal opening. It involves cutting the perineum, which is the muscular area between the vagina and anus. The goal of this procedure is to ease the baby's passage and prevent severe tears during childbirth.
The midline episiotomy is one of the most common types of episiotomies performed, especially in the United States. It involves making a straight incision in the perineal body, starting close to the midline of the perineum and extending downward. The incision begins at the hymenal ring and passes through the connective tissue that connects the bulbocavernosus muscle, the superficial transverse perineal muscles, and the perineal membrane. It is important to note that the depth of the incision is limited to avoid including the anal sphincter.
The benefits of a midline episiotomy include a reduced likelihood of severe perineal tears and preservation of pelvic floor muscle function. It also carries a lower risk of fecal and urinary incontinence compared to other types of episiotomies. Additionally, it offers cranial protection for the infant, especially in cases of prematurity, and reduces fetal acidosis.
However, there are also risks associated with midline episiotomies. One of the main disadvantages is the increased risk of tears extending into or through the anal muscles, which can result in long-term problems such as fecal incontinence. There is also a higher risk of damage to the external anal sphincter muscle, which can lead to incontinence issues or the formation of a fistula. Additionally, the procedure itself can increase the risk of infection and other complications, and proper repair of higher-degree lacerations can be complex.
The repair process for a midline episiotomy involves suturing the muscular tissue of the perineal body, including the bulbocavernosus muscles and the transverse perineal muscles. Continuous, non-locking sutures are often used to minimize pain and promote better healing. Adequate anesthesia is essential during the procedure to ensure the patient's comfort, and precise timing and technique are necessary to minimize potential complications.
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Mediolateral episiotomy
An episiotomy is a cut made during vaginal delivery to give the baby more room to move out of the birth canal. The procedure has become controversial, with many medical professionals not recommending its use. However, it is still performed in some cases, with the two most common types being midline and mediolateral episiotomies.
A mediolateral episiotomy is the second most common type of episiotomy performed, involving a cut made slightly to one side of the perineum. This type of incision is more common in parts of the world outside the US. A mediolateral episiotomy is often performed during assisted vaginal births, particularly during forceps and vacuum births. It is also chosen when the mother has existing rectal issues.
The procedure involves making an incision of about 3-4 cm in length at an angle of at least 45 degrees relative to the perineal body. The cut includes the vaginal epithelium, transverse perineal muscle, bulbocavernosus muscle, and perineal skin. The bulbospongiosus muscle is usually repaired during the procedure.
Mediolateral episiotomies are associated with a higher risk of injury to the ipsilateral nerve and surrounding muscle, erectile, and gland tissues. Deep cuts may also expose the ischiorectal fossa and damage the external anal sphincter muscle, leading to incontinence issues. However, mediolateral episiotomies are considered to have a slightly lower risk of damaging the anus and anal sphincter compared to midline incisions.
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Perineal body
The perineal body, also referred to as the "central tendon of the perineum", is a fibromuscular structure located in the midline of the perineum. The perineum is the most inferior part of the pelvic outlet, lying between the thighs and separated from the pelvic cavity superiorly by the pelvic floor. The perineal body is composed of collagen and elastic fibres, along with both skeletal and smooth muscle. It lies beneath the skin and minimal subcutaneous tissue and is quite variable in terms of size and consistency.
The perineal body is a central convergence point where fibres of several muscles interlace and overlap. These include the bulbospongiosus, external anal sphincter, both the superficial and deep transverse perineal muscles, as well as smooth and skeletal muscle strands from the external urethral sphincter, levator ani muscles, and the muscular layers of the rectum. In the male body, the central tendon of the perineum is located between the anus and the bulb of the penis. In contrast, in the female body, it lies between the anus and the posterior limit of the vulvar orifice, acting as a tear-resistant body between the vagina and the external anal sphincter.
The perineal body is critical for maintaining the integrity of the pelvic floor, especially in female individuals. Childbirth can lead to damage (stretching/tearing) of the perineal body, potentially causing a prolapse of the pelvic viscera. This may be avoided by an episiotomy, a surgical cut in the perineum that inevitably causes damage to the vaginal mucosa but prevents uncontrolled tearing of the perineal body. The most common type of episiotomy in the US is the midline episiotomy, which is performed directly above the anus. The second type is the mediolateral episiotomy, which is cut slightly to one side of the perineum and is more common in other parts of the world.
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Perineal muscles
The perineum is the area of the body between the anus and the vagina or penis. The perineal body is a mass of dense
During an episiotomy, an incision is made in the perineal body, cutting through the connective tissue that unites the bulbocavernosus muscle, the superficial transverse perineal muscles, and the perineal membrane. The perineal body is one of the areas of the human body that is not well understood. It is simply a mass of dense connective tissue.
There are two types of episiotomies: midline and mediolateral. The most common type in the US is the midline episiotomy, which is performed directly above the anus. This type of incision has an increased risk of damaging the anus and anal sphincter. The mediolateral episiotomy is more common in other parts of the world and is cut slightly to one side of the perineum. This type of incision has a higher risk of injury to the ipsilateral nerve and surrounding muscle, erectile, and gland tissues.
The indications for an episiotomy vary and are largely based on clinical opinion. Suggested benefits for the mother include a reduction in the likelihood of severe perineal lacerations and obstetric anal sphincter injury, as well as preservation of pelvic floor muscle function and a reduced risk of fecal and urinary incontinence. Potential benefits for the fetus include cranial protection and reduced fetal acidosis.
It is important to note that episiotomies are not necessary for every birth, and many medical professionals do not recommend them. The natural tissue stretch during childbirth can accommodate the baby, and tears, if they occur, are usually not as deep as a cut from an episiotomy.
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Postpartum issues
An episiotomy is a minor incision made during childbirth to widen the vaginal opening and reduce perineal trauma during delivery. The midline and mediolateral are the two most common types of episiotomies. The midline episiotomy is performed directly above the anus, while the mediolateral episiotomy is performed slightly to one side of the perineum.
To reduce the risk of postpartum issues, adequate anaesthesia and precise timing and technique are necessary. Additionally, patients should be closely monitored during postpartum recovery and advised to report any abnormal symptoms, such as foul-smelling vaginal discharge, dysuria, severe perineal or pelvic pain, fever, and heavy vaginal bleeding. In cases of obstetric anal sphincter injuries (OASIS), patients should be scheduled for a follow-up visit within two weeks.
The decision to perform an episiotomy should be carefully considered, as there are alternative options to facilitate delivery. For example, the tissue stretches naturally to accommodate the baby, and if tearing occurs, it is usually not as deep as a cut from an episiotomy. Furthermore, the routine use of episiotomy has become controversial, and many medical professionals do not recommend them.
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Frequently asked questions
An episiotomy is a surgical incision of the perineum and the posterior vaginal wall, usually performed during the second stage of labour.
The muscles cut during an episiotomy include the bulbocavernosus, the superficial transverse perineal muscles, and the perineal membrane. The perineal body, a mass of dense connective tissue, is also transected.
There are two main types of episiotomy: midline and mediolateral. The midline episiotomy is an incision made directly above the anus, while the mediolateral episiotomy is cut slightly to one side of the perineum.
Some possible complications of an episiotomy include pain, infection, hematoma, and scarring, which can lead to long-term issues like dyspareunia and pelvic floor dysfunction. There is also a risk of damage to the anal sphincter muscle, rectal muscle, and surrounding tissues.
