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How to perform an episiotomy

Midwives magazine: Issue 5 :: 2012

Routine episiotomies are no longer standard or recommended practice, but there are instances when a midwife may need to perform the procedure. Kim Gibbon outlines the best practice.

Surgical Incision - Mediolateral episiotomy
Surgical incision - Mediolateral episiotomy
An episiotomy is a surgical procedure where an incision is made in the perineum to enlarge the vaginal opening to improve fetal and maternal outcomes (American College of Obstetricians and Gynaecologists, 2006; Downe, 2009). It was considered a routine procedure and was practised widely by midwives in the UK from 1967 (Thomas and Cameron, 2007). There is, however, no evidence of short- or long-term maternal benefit that supports the use of routine episiotomy (Carroli and Mignini, 2009). The procedure has also been associated with increased risk of severe perineal trauma (Dudding et al, 2008; Eason et al, 2000; Renfrew et al, 1998; Albers et al, 1999).

Episiotomy rates were reported at 54% in 1978 (NCT, 2003) but dramatically declined to 14% of UK births by 2003 (Government Statistical Service, 2003). While routine episiotomies are no longer standard or recommended practice (NICE, 2007), there are clinical indications that suggest a midwife or obstetrician may need to perform the procedure.

There is continuing controversy preventing consensus about the clinical reasons to perform an episiotomy (Carroli and Mignini, 2009). Sleep and Grant (1987) recommend that episiotomy should be restricted to fetal indications. Other indications, such as button holing, rigid perineum or previous scarring are not justifiable reasons to perform an episiotomy (Enkin et al, 2000). Notwithstanding this evidence, midwifery judgement will always be required. Therefore, a policy of restricted use of episiotomy is advocated.

The reasons for episiotomy are to:
► Aid the delivery of the presenting part when the perineum is tight and causing poor progress in the second stage of labour
► Allow more space for operative or manipulative deliveries, such as forceps, shoulder dystocia or breech delivery (NICE, 2007; RCOG, 2005)
► Prevent damage of the fetus during a face or breech presentation, or during instrumental delivery
► Shorten the second stage of labour for fetal distress (Sleep, 1995) or maternal medical condition
► Accommodate issues associated with female genital mutilation to the benefit of both mother and baby (Hakim, 2001).

Episiotomy is contraindicated when there is a high head. In these circumstances, descent will not be assisted.

There are a variety of methods for performing an episiotomy, but only two are commonly used. These are mediolateral – the preferred method used in the UK (recommended by NICE, 2007; Kettle, 2011) – and the median or midline technique favoured by the US.

Mediolateral episiotomy (UK)
Mediolateral episiotomy (UK)
Using the mediolateral approach, the incision begins at the midpoint of the fourchette to avoid damage to the Bartholin’s gland (Kettle, 2011). It is then directed at a 45° angle to the midline towards a point between the ischial tuberosity and the anus. This line avoids the danger of damage to the anal sphincter, but it is difficult to repair and is associated with more bleeding (Power et al, 2006).

Median episiotomy US
Median episiotomy (US)

For the median or midline technique, the incision follows the natural line of insertion of the perineal muscles (Downe, 2009). It is associated with reduced blood loss but a higher incidence of damage to the anal sphincter (Coats et al, 1980; Thacker and Banta, 1983). It is easier to repair and results in less pain and dyspareunia (Steen, 2008). The evidence to support either technique remains inconclusive (Carroli and Mignini, 2009).

Consent is required for episiotomy, as it woud be for any surgical procedure. Women must be given a full explanation of the nature of the procedure and the situations under which its use will be proposed (Carroli and Belizan, 1999). Ideally, this should occur in the antenatal period so that the woman’s consent can be sought and documented at this stage. Further explanation should be given to the woman when a decision to use episiotomy is made to provide reassurance and confirm consent.

Timing is important. If the procedure is undertaken too early, the presenting part will not be pressing on the perineum, and therefore complications associated with increased bleeding may occur. The actual procedure is relatively simple – local anaesthesia is given, followed by the incision, appropriate control of bleeding, and repair of trauma after the birth.

The woman should be made comfortable, positioned with her legs apart to maximise visibility to the perineal area, which should be cleansed using the locally approved aseptic technique.

For anaesthesia, it is normal to use lidocaine at a concentration of 0.5% in 10ml, or at a higher concentration of 1% in 5ml. For the higher concentration, the smaller volume confers an advantage, with less swelling of the perineum. At this higher concentration 10ml to 15ml is normally adequate for appropriate anaesthesia.

To protect the fetal head, the midwife will insert two fingers into the vagina, which should follow the proposed incision line. For example, when using the mediolateral incision, the needle should be inserted into the perineal tissue at the centre of the fourchette and should be directed to midway between the ischial tuberosity and anus.

To confirm that the needle has not penetrated a blood vessel, the syringe piston should be withdrawn and if blood is aspirated the needle must be repositioned. Maximum anaesthetic effect is achieved by injecting one third of the lidocaine in this initial position and then a further third to each side of the proposed incision. Some midwives will choose to make a single injection.

After sufficient time for the anaesthesia to take effect, the incision should be made. The midwife once again inserts two fingers into the vagina along the proposed line of the incision. A pair of mayo scissors with straight blades and blunt ends is normally used. They should be sharp. A single cut should be made. This should be 4cm to 5cm in length and should extend from the centre of the fourchette in a mediolateral direction avoiding damage to the anal sphincter. Ideally the incision is made during a contraction, when there is a clear view due to stretched tissues and a reduced likelihood of severe bleeding.

Immediately after the incision, controlled birth of the head should occur, ensuring that there is no extension of the episiotomy incision. If birth of the head does not occur, pressure must be applied to the episiotomy site between contractions to reduce bleeding. Without such compression there is an increased probability of postpartum haemorrhage.

On completion of the third stage, the midwife should thoroughly examine the vagina, perineum and rectal area to assess any trauma for prompt repair.

Kim Gibbon
Senior midwifery lecturer University of Chester


Illustrations by Ben Hassler


References

Albers L, Garcia J, Renfrew M, McCandlish R, Elbourne D. (1999) Distribution of genital tract trauma in childbirth and related postnatal pain. Birth 26(1): 11-7.

American College of Obstetricians and Gynaecologists. (2006) ACOG Practice Bulletin No. 71: Episiotomy. Clinical management guidelines for obstetrician-gynaecologists. Obstetrics and Gynaecology 107(4): 957-62.

Carroli G, Belizan J. (1999) Episiotomy for vaginal birth. Cochrane Database of Systematic Reviews 3: CD000081.

Carroli G, Mignini L. (2009) Episiotomy for vaginal birth. Cochrane Database of Systematic Reviews. 1: CD000081.

Coats PM, Chan KK, Wilkins M, Beard RJ. (1980) A comparison between midline and mediolateral episiotomies. BJOG 87(5): 408-12.

Downe S. (2009) The transition and the second stage of labour: physiology and the role of the midwife: In: Fraser DM, Cooper MA. (Eds). Myles textbook for midwives. Churchill Livingstone: Edinburgh.

Dudding TC, Vaizey CJ, Kamm MA. (2008) Obstetric anal sphincter injury: incidence, risk factors, and management. Annals of Surgery 247(2): 224-37.

Eason E, Labrecque M, Wells G, Feldman P. (2000) Preventing perineal trauma during childbirth: a systematic review. Obstetrics and Gynecology 95(3): 464-71.

Enkin M, Keirse M, Neilson J, Crowther C, Duley L, Hodnett E, Hofmeyr J. (2000) A guide to effective care in pregnancy and childbirth (third edition). Oxford University Press: Oxford.

Government Statistical Service. (2003) NHS maternity statistics, England: 2001-02. HMSO: London.

Kettle C. (2011) The pelvic floor: In: Macdonald S, Magill-Cuerden J. (Eds). Mayes’ midwifery. Bailliere Tindall: Edinburgh.

NCT. (2003) NCT evidence based briefing: episiotomy and the perineum. See: www.nct.org.uk/professional/research/reviews-evidence/nct-research-overviews (accessed 13 August 2012).

NICE. (2007) Intrapartum care: care of healthy women and their basics during childbirth. NICE: London.

Power D, Fitzpatrick M, O’Herlihy C. (2006) Obstetric and anal sphincter injury: how to avoid, how to repair: a literature review. Journal of Family Practice 55(3): 193-200.

RCOG. (2005) Shoulder dystocia. Green-top guideline 42. RCOG: London.

Renfrew MJ, Hannah W, Albers L, Floyd E. (1998) Practices that minimize trauma to the genital tract in childbirth: a systematic review of the literature. Birth 25(3): 143-60.

Sleep J. (1995) Postnatal perineal care revisited. In: Alexander J, Levy V, Roch S. (Eds.). Aspects of midwifery practice: a research based approach. Macmillan: London.

Sleep J, Grant AM. (1987) West Berkshire perineal management trial: three year follow-up. BMJ 295: 249-51.

Steen M. (2008) Understanding perineal pain: women’s descriptions. BJM 15(5): 383-93.

Thacker SB, Banta HD. (1983) Benefits and risks of episiotomy: an interpretative review of the English language literature 1860-1980. Obstetrical and Gynaecological Survey 36(6): 322-38.

Thomas E, Cameron H. (2007) Midwives’ management of episiotomy at a district general hospital. BJM 15(11): 680-3.