10/19/2014 1

Episiotomy: When will we cut it out?

Alice Teich, PGY1
Dept of Family and Social Medicine
April 27, 2010

10/19/2014 2
Case
3/26/10
HPI: 16yo G1P0010 @38w1d by LMP (7/5/09) EDD 4/8/10 c/w 11w sono p/w
CTX q5min since 3pm today. LOF en route to hospital (~30min ago.) No
VB, +FM
PNI: Intake BP 102/50 (102-132/50-90). Weight gain 31lbs (intake 158 -->189)
Adolescent pregnancy: saw SW, and nutritionist. Attended all prenatal
appointments. Has WIC and Medicaid filled out.
PNL: wnl/unremarkable
Sonos: 9/20/09 dating sono @11w
11/14/09 anatomy scan @ 19wks. No anat. Anomalies. Fetus 50%tile
2/17/10 no anat. Anomalies @31w. Fetus 55%tile w adequate interval
growth. AFI 14.
PObHx: 2008 TOP 1st trim. D&C. uncomplicated
PGynHx: no cysts/fibroids/STIs/abnl pap.
12/reg/5.
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Case continued..
PMH: asthma -no intubations or hospitalizations. Albuterol PRN
PSH: D&C only
Meds: PNV
Allergies: NKDA
SH: lives w mom. No tob/EtOH/drugs at all. In high school. FOB involved.
FH: non-contributory.

PE: BP: 112/60 HR 74 Tmax: 36.6
FHT: 140/mod/+accels, -decels (EFM)
Toco: CTX q2-3 min (monitored externally)
SVE: 9/10/0 Vsono EFW: 3100g (Leopolds)

A/P: 16yo G1P0010 @38w1d in active labor
Admit to L&D -- anticipate NSVD

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Case continued..
Pt c/o pain and need to make bm. Found to be FD and ready to push.
SVE: 10/100/+1
Toco: CTX q2-3min
Pt is in significant pain while pushing and requesting pain medication: infants
head has been crowning for approx 2 minutes/too late for epidural or IV
analgesia.
Pt is screaming, thrashing around, and FHT begins to decel to 70s, 80s, then
comes back up to 120s, then decels again. Pt repositioned to lateral decub on
both sides, but unable to stay in these positions, given discomfort.
Episiotomy is cut midline, attempt made to deliver head for approx 30
seconds, then additional space cut, creating 2nd degree episiotomy. Infant is
quickly delivered without instrumentation.
Delivery of vigorous female infant w apgars of 9/9. Cord clamped, cut, and
gases sent. 3 cord placenta delivered spontaneously and intact. Fundus firmed
with fundal massage and pitocin administration. Lidocaine administered
locally and 2nd degree episiotomy repaired with 2-0 and 3-0 vicryl w/o further
complication. No 3rd degree extension into rectal sphincter. Hemostasis
achieved. EBL ~500cc.



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Episiotomy
Definition: a surgical incision of the perineum
usually performed at point when perineum is
stretched and distended, just prior to crowning
of the fetal head.

Median/Midline: vertical incision from fourchette
straight back towards anus
Easier to repair
Mediolateral episiotomy: incision ~ perpendicular to
midline, with angle becoming smaller (~45) beyond
fetal presenting part
Less extension to rectum
J incision: hybrid

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Episiotomy
Quic kTimeand a
Graphi cs dec ompres sor
are needed to see thi s pi cture.
The purpose is to increase the diameter of the soft
tissue pelvic outlet, thereby preventing perineal
lacerations, facilitating delivery, and reducing the
time for expulsion of the infant.
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Episiotomy:
One of the most common operations
performed on women
Prevalence is decreasing

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Indication for Episiotomy?

The only indication for episiotomy that cannot be categorically
dismissed is for fetal concerns (non-reassuring tracing, etc) that
arise urgently during advanced labor.

Other historical indications for episiotomy are not evidence-based
and are proven to do more harm than good.
Nulliparity
Imminent tear
Shoulder dystocia
Need for vacuum or forceps delivery


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Not an Indication for Episiotomy

Nulliparity
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Not an Indication for Episiotomy
Tearing is imminent
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Not an Indication for Episiotomy
Severe Shoulder dystocia

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Not an Indication for Episiotomy
Using vacuum or forceps for delivery
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Other enduring myths about episiotomy

It prevents pelvic floor weakness
It is easier to repair than a tear
It heals better than a tear
It minimizes intraventricular hemorrhage in
preterm infants
Episiotomy
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Evidence against routine use of
episiotomy:
Increases the following:
Wound extension, dehiscence, infection, and healing time
Blood loss
Postpartum pain
Likelihood of leaking stool and gas (bowel incontinence)
Dyspareunia
+/- urine incontinence


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Episiotomy: Why is it still performed?
High-intervention standards for childbirth
Practice style and values of individual providers
Practice style and values in specific birth settings
Influence of colleagues
Influence of medical education
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Avoiding episiotomy:
As early as possible in pregnancy:
Encourage pts to learn about episiotomy as part of
learning about pregnancy, labor and delivery
Encourage pts to create a birth plan that takes into
account their values, preferences
Even if you have been the provider for a pt
throughout their entire pregnancy and especially if
you havent, ask pts about their birth plans again at
the time of labor/admission.


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Avoiding episiotomy

Kegel exercises
Perineal massage
Warm Compresses
Slowed, spontaneous pushing during second
stage of labor
Upright birthing position
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References
http://www.childbirthconnection.org
Hartmann K, Viswanathan M, Palmieri R, Gertlehner G,
Thorp J, Lohr KN. Outcomes of routine episiotomy: a
systematic review. JAMA 2005; 293:2141-8
UptoDate
ACOG PRACTICE BULLETIN. CLINICAL MANAGEMENT
GUIDELINES FOR OBSTETRICIAN/GYNECOLOGISTS
NUMBER 71, APRIL 2006