Chapter 21: Episiotomy, Lacerations, Uterine Rupture, and Inversion

EPISIOTOMY

An episiotomy (perineotomy) is an incision into the perineum to enlarge the space at the outlet, thereby facilitating the birth of the child.

Maternal Benefits

1. A straight incision is simpler to repair and heals better than a jagged, uncontrolled laceration

2. The structures in front are protected as well as those in the rear. By increasing the room available posteriorly, there is less stretching of and less damage to the anterior vaginal wall, bladder, urethra, and periclitoral tissues

3. The second stage of labor is shortened

Fetal Benefits

Proposed fetal benefits of episiotomy include cranial protection, especially for premature infants, reduced perinatal asphyxia, less fetal distress, better APGAR scores, less fetal acidosis, and reduced complications from shoulder dystocia. Episiotomy may be useful to facilitate the management of shoulder dystocia.

Indications

1. Prophylactic: To preserve the integrity of the pelvic floor

2. Arrest of progress by a resistant perineum

   1. Thick and heavily muscled tissue

   2. Operative scars

   3. Previous well-repaired episiotomy

3. To obviate uncontrolled tears, including extension into the rectum

   1. When the perineum is short with little room between the back of the vagina and the front of the rectum

   2. When large lacerations seem inevitable

4. Fetal reasons

   1. Premature and infirm babies

   2. Large infants

   3. Abnormal positions such as occipitoposteriors, face presentations, and breeches

   4. Fetal distress, where there is need for rapid delivery of the baby and dilatation of the perineum cannot be awaited

   5. Operative vaginal delivery

   6. Shoulder dystocia

Current data and clinical opinion suggest that there are insufficient objective evidence-based criteria to recommend episiotomy, especially routine use of episiotomy, and that clinical judgment remains the best guide for use of this procedure.

Timing of Episiotomy

There is a proper time to make the episiotomy. When made too late, the procedure fails to prevent lacerations and to protect the pelvic floor. When made too soon, the incision leads to needless loss of blood. The episiotomy is made when the perineum is bulging, when a 3- to 4-cm diameter of fetal scalp is visible during a contraction, and when the presenting part will be delivered with the next three or four contractions. In this way, lacerations are avoided, overstretching of the pelvic floor is prevented, and excessive bleeding is obviated.

There are three types of episiotomy: (1) midline; (2) mediolateral, left or right; and (3) lateral episiotomy, which is no longer used (Fig. 21-1A).

Midline Episiotomy

Technique

In making the incision, two fingers are placed in the vagina between the fetal head and the perineum. Outward pressure is made on ...