In a strict sense, episiotomy is incision of the pudenda. Perineotomy is incision of the perineum. In common parlance, however, the term episiotomy often is used synonymously with perineotomy, a practice that we follow here. The incision may be made in the midline, creating a median or midline episiotomy. It may also begin in the midline but be directed laterally and downward awayfrom the rectum, termed a mediolateral episiotomy.
Purposes of Episiotomy
Although still a common obstetrical procedure, the use of episiotomy has decreased remarkably over the past 25 years. Weber and Meyn (2002) used the National Hospital Discharge Survey to analyze use of episiotomy between 1979 and 1997 in the United States. Approximately 65 percent of women delivered vaginally in 1979 had anepisiotomy compared with 39 percent by 1997. By 2003, the rate had decreased to approximately 18 percent (Martin and colleagues, 2005). Through the 1970s, it was common practice to cut an episiotomy for almost all women having their first delivery. The reasons for its popularity included substitution of a straight surgical incision, which was easier to repair, for the ragged laceration thatotherwise might result. The long-held beliefs that postoperative pain is less and healing improved with an episiotomy compared with a tear, however, appeared to be incorrect (Larsson and colleagues, 1991).
Another commonly cited but unproven benefit of routine episiotomy was that it prevented pelvic floor complications—that is, vaginal wall support defects and incontinence. A number of observationalstudies and randomized trials, however, showed that routine episiotomy is associated with an increased incidence of anal sphincter and rectal tears (Angioli, 2000; Eason, 2000; Nager and Helliwell, 2001; Rodriguez, 2008, and all their colleagues).
Carroli and Mignini (2009) reviewed the Cochrane Pregnancy and Childbirth Group trials registry. There were lower rates of posterior perineal trauma,surgical repair, and healing complications in the restricted-use group. Alternatively, the incidence of anterior perineal trauma was lower in the routine-use group.
With these findings came the realization that episiotomy did not protect the perineal body and contributed to anal sphincter incontinence by increasing the risk of third- and fourth-degree tears. Signorello and associates (2000) reportedthat fecal and flatus incontinence were increased four- to sixfold in women with an episiotomy compared with a group of women delivered with an intact perineum. Even compared with spontaneous lacerations, episiotomy tripled the risk of fecal incontinence and doubled it for flatus incontinence. Episiotomy without extension did not lower this risk. Despite repair of a third-degree extension, 30 to40 percent of women have long-term anal incontinence (Gjessing and co-workers, 1998; Poen and colleagues, 1998). Finally, Alperin and associates (2008) recently reported that episiotomy performed for the first delivery conferred a fivefold risk for second-degree or worse lacerations with the second delivery.
For all of these reasons, the American College of Obstetricians and Gynecologists (2006)has concluded that restricted use of episiotomy is preferred to routine use. We are of the view that the procedure should be applied selectively for appropriate indications. These include fetal indications such as shoulder dystocia and breech delivery, forceps or vacuum extractor deliveries, occiput posterior positions, and instances in which failure to perform an episiotomy will result in perinealrupture. The final rule is that there is no substitute for surgical judgment and common sense.
Timing of Episiotomy
If performed unnecessarily early, bleeding from the episiotomy may be considerable during the interim between incision and delivery. If it is performed too late, lacerations will not be prevented. Typically, episiotomy is completed when the head is visible during a contraction...