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  • What are the indications for performing an episiotomy?

  • What are the relative advantages and disadvantages of the various types of episiotomies?

  • What steps can be taken during the repair of third- and fourth-degree perineal lacerations to reduce the risk of complications?

  • What steps can be taken during the postpartum period for patients with third- or fourth-degree perineal lacerations to reduce the risk of complications?

CASE 62-1

You are called to assess an 18-y.o. G1 at 40 0/7 weeks gestation in the second stage of labor. She has been pushing for over 2 hours, and while the nurse reports that the fetal vertex has descended to the +3 station, she also reports that the effectiveness of her expulsive efforts have started to wane. The FHR tracing has developed repetitive variable decelerations to the 60s. You examine the patient and discuss the situation with her, and ultimately decide to proceed with a forceps-assisted vaginal delivery.

  • Is an episiotomy indicated in this situation?

  • If so, what type of episiotomy should be cut, and at what point in the procedure?

Laceration of the perineum may occur with any vaginal delivery, and it is so common that repair of such lacerations is considered a routine part of immediate postpartum care. The risk of complications associated with perineal lacerations increases dramatically with the increased levels of anatomy affected. This fact, along with other theoretical benefits, led to the popularization of routine episiotomy in the United States in the 1920s and 1930s.1 Episiotomy, more precisely termed perineotomy, refers to the enlargement of the distal birth canal via incision of the perineum in order to facilitate delivery of the fetus. For reasons that will be explored in detail later in this chapter, routine episiotomy has fallen out of favor, but the procedure is still an important tool in the obstetric and gynecological (OB/GYN) hospitalist’s arsenal. The roles of the OB/GYN hospitalist as an expert physician in difficult or emergent deliveries and as a leader in perinatal quality and safety necessitate familiarity with current recommendations in both complex laceration repair and the use of episiotomy. The aim of this chapter is to provide an overview of current best practices related to both episiotomy and perineal laceration repair.



The perineal body is commonly injured during vaginal delivery. It is a midline, fibromuscular tissue mass that is approximately 2 to 4 cm deep and 2 to 4 cm in anteroposterior diameter and is located between the distal posterior vagina and the anus. It is comprised of the attachments of the bulbospongiosis and superficial, transverse perineal muscles and the external anal sphincter (Fig. 62-1). The blood supply to the perineum is derived from branches of the internal pudendal artery, approaching the perineal structures from lateral to medial (Fig. 62-2).2


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