Episiotomy
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Direct answer
An episiotomy is a surgical incision of the perineum made at crowning of the head to enlarge the introitus, and current practice — WHO and Indian teaching alike — is restricted rather than routine use: reserved for indications (instrumental or breech delivery, shoulder dystocia, fetal distress in the second stage, a rigid or short perineum, previous third or fourth degree repair, an imminent extensive tear), not cut for every primigravida, since routine cutting does not prevent severe perineal damage and increases sphincter injury in midline cuts. The mediolateral cut is standard: made with the head crowning 3-4 cm, starting at the posterior fourchette and directed at 60 degrees to the midline (to spare the external anal sphincter), blunt-tipped scissors, length about 3-4 cm. Repair is in layers — vaginal mucosa (continuous 2-0), perineal muscles (2-0), and skin (subcuticular), after haemostasis and a rectal examination to exclude sphincter injury.
What you must remember
- Restricted-use policy: episiotomy on indication, not routinely — acceptable rates run well under 30 per cent, and the "all primigravida" habit is explicitly discouraged.
- Mediolateral geometry: from the posterior fourchette at 60 degrees from the midline with the head distending the perineum — the stretched perineum delivers the effective angle away from the sphincter; midline cutting carries the highest sphincter injury risk and is avoided in India.
- Timing and length: at crowning, about 3-4 cm, under local or epidural analgesia — lignocaine 1 per cent, 10 mL infiltrated before cutting if no block exists.
- Indications worth listing: instrumental delivery, breech vaginal birth, shoulder dystocia, fetal distress shortening the second stage, rigid or short perineum, previous anal sphincter repair, and occasional maternal (cardiac) indications to shorten pushing.
- Repair order: haemostasis, then a rectal examination (occult sphincter tear?), then vaginal mucosa from the apex down with continuous 2-0 polyglactin, perineal body muscles, subcuticular skin — the apex is never missed, since bleeding from above is the commonest cause of haematoma.
- Aftercare: analgesia (paracetamol, diclofenac if suitable), ice packs for 24 hours, Sitz baths after, laxatives, and a check for haematoma, infection or breakdown at review.
- Complications: extension to the sphincter or rectum, haematoma, infection, painful scar and dyspareunia, and increased blood loss compared with an intact perineum.
- The comparison exam staple: a clean cut is easier to repair than a ragged tear, but cutting prophylactically in every woman does not reduce overall severe trauma — the nuance the one-best-answer tests.
Performing and repairing one
A primigravida at term, forceps delivery for delay in the second stage. The epidural is topped up, or 10 mL of 1 per cent lignocaine infiltrated along the planned line. At the next contraction with the perineum bulging and the head crowning 3-4 cm, two fingers of the left hand inside the vagina shield the fetal head (the examined detail), and the right hand cuts with blunt-tipped scissors from the posterior fourchette directed 60 degrees mediolaterally, one clean stroke, 3-4 cm. The head is then delivered controlled between contractions.
Repair after the third stage, lithotomy, good light: a rectal examination first to exclude an occult sphincter tear. The apex of the vaginal incision — higher than it looks — starts a continuous 2-0 suture running down to the fourchette; the perineal body muscles follow with 2-0, the skin subcuticularly or left open with deeper layers approximated. A final rectal examination confirms no suture breach, no retained sponge, a dry wound. Aftercare: paracetamol plus diclofenac (if suitable), ice packs for 24 hours, Sitz baths from day two, stool softener, review at 7-10 days.
Where students slip
The angle is the mark-loser: candidates say 45 degrees or "midline", while the teachable answer is mediolateral at about 60 degrees from the midline at crowning — the principle being that the cut travels away from the external anal sphincter. The second slip is routine-versus-restricted: stems describing "primigravida, routine practice" test whether you know restricted use is the standard. Third, repair-sequence questions — start at the apex, check by rectal examination before and after — with the aftercare bundle of ice, analgesia and laxatives completing the practical credit.
Frequently asked questions
When is an episiotomy indicated?
For instrumental or breech delivery, shoulder dystocia, fetal distress needing a short second stage, a rigid or short perineum, previous sphincter repair, or an imminent severe tear — restricted use, not routine.
Which direction is the standard episiotomy cut?
Mediolateral — from the posterior fourchette, about 60 degrees from the midline at crowning, sparing the sphincter; midline cutting risks third and fourth degree extension.
In what order is an episiotomy repaired?
Vaginal mucosa from the apex downward with continuous 2-0, then the perineal muscles, then subcuticular skin — preceded and followed by a rectal examination.
Does routine episiotomy prevent severe perineal tears?
No — trials show restricted use achieves equal or better outcomes; routine use increases extensions and sphincter injury in midline cuts. The evidence-based policy is restrictive.
What post-repair care reduces complications?
Analgesia, ice packs for 24 hours, Sitz baths, perineal hygiene, laxatives, and early review for haematoma, infection or breakdown.