II. Precautions
- Routine episiotomy offers no maternal benefits
- Limit use to fetal indications
- Hartmann (2005) JAMA 293:2141-8 [PubMed]
III. Grading of perineal Lacerations
- First degree Laceration
- Vaginal Laceration
- Perineal skin torn
- Second degree Laceration
- First degree Laceration and
- Perineal muscles torn
- Third degree Laceration
- Second degree Laceration and
- External anal sphincter torn
- Fourth degree Laceration
- Third degree Laceration and
- Complete anal sphincter tear and
- Rectal mucosa may also be torn
IV. Preparation
-
Suture
- Polyglactin 910 (Vicryl)
- Vicryl 3-0 on CT-1 needle
- Used to close vaginal mucosa and perineal muscles
- Vicryl 4-0 on SH needle
- Used to close perineal skin
- Used to close rectal mucosa
- Efficacy
- Polyglactin is less associated with discomfort
- Greenberg (2004) Obstet Gynecol 103:1308-13 [PubMed]
- Vicryl 3-0 on CT-1 needle
- Polydioxanone sulfate (PDS)
- PDS 2-0 on CT-1 needle
- Used to close external anal sphincter
- PDS 2-0 on CT-1 needle
- Polyglactin 910 (Vicryl)
-
Anesthetic
- Lidocaine 1%
- Syringe 10 cc with 27 gauge 1.5 inch needle
- Instruments
- Needle driver
- Suture scissors
- Forceps with teeth
- Gelpi or Deaver retractor (as needed)
- Allis Clamps (2)
V. Management: Vaginal Laceration Repair
- Description
- Closure of vaginal mucosa (behind hymenal ring)
- Vaginal tears may involve both sides of vaginal floor
-
General
- Indicated in first through fourth degree Lacerations
- Repaired with Vicryl 3-0 on CT-1 needle
- Anchor Suture 1 cm above apex of vaginal Laceration
- Use Running stitch (continuous) to close vaginal mucosa
- Locking Suture is optional (used for hemostasis)
- Each pass should include
- Vaginal mucosa
- Rectovaginal fascia (important for vaginal support)
- Continue RunningSuture up to hymenal ring
- May be tied off proximal to hymenal ring or
- May be passed under hymenal ring to perineum
- May be used for closing perineal skin (see below)
VI. Management: Perineal muscle repair
- Description
- Bulbocavernosus and transverse perineal muscle closed
-
General
- Indicated in second through fourth degree Lacerations
- Repaired with Vicryl 3-0 on CT-1 needle
- Close each muscle body with interrupted figure 8 Suture
- Closure of bulbocavernosus muscle
- Located immediately below introitus
- Located above transverse perineal muscle
- Closure of transverse perineal muscle
- Located above external anal sphincter
- Closure of bulbocavernosus muscle
VII. Management: External anal sphincter repair
- Description
- Closure of external anal sphincter
-
General
- Indicated in third and fourth degree Lacerations
- Repaired with Polydioxanone (PDS) 2-0 on CT-1 needle
- Identify external anal sphincter ends
- Clamp each external anal sphincter muscle
- Must include rectal sphincter sheath (capsule)
- Must be included in closure for adequate strength
- Close external anal sphincter
- Option 1: End to end external anal sphincter closure
- Standard method, but may be replaced by Option 2
- Associated with poorer functional outcomes
- Kammerer-Doak (1999) Am J Obstet Gynecol 181:1317 [PubMed]
- Close sphincter with 4 interrupted figure 8 Sutures
- Posterior (3:00) position
- Inferior (6:00) position
- Superior (12:00) position
- Anterior (9:00) position
- Standard method, but may be replaced by Option 2
- Option 2: Overlapping external anal sphincter closure
- Option 1: End to end external anal sphincter closure
VIII. Management: Rectal mucosa and internal sphincter repair
- Description
- Closure of rectal mucosa
- Closure of internal anal sphincter
-
General
- Indicated in fourth degree Lacerations
- Closed with Vicryl 4-0 on SH needle
- Gelpi retractor used to maximize visualization
- Close rectal mucosa with RunningSuture
- Start at apex of rectal mucosal tear
- Keep Suture passes closely spaced
- Do not Suture complete thickness of rectal mucosa
- Risk of Anal Fistula formation
- Continue Suture to anal verge on perineal skin
- Close internal anal sphincter
- Allis clamp placed at each end of internal sphincter
- Close internal anal sphincter with PDS 2-0
IX. Management: Perineal skin repair
- Description
- Bulbocavernosus and transverse perineal muscle closed
-
General
- Indicated in first through fourth degree Lacerations
- Closure of perineal skin is controversial
- May be associated with higher rate perineal pain
- Some advocate closure only as needed
- Indicated if skin not well approximated
- Repair materials
- Running deep Suture
- Running subcuticular Suture
X. Complications
- Chronic perineal pain including Dyspareunia
- Associated with perineal skin closure
- Urinary and Fecal Incontinence
- Associated with third and fourth degree tears
-
Anal Fissure
- Associated with fourth degree tears
XI. References
- Leeman (2003) Am Fam Physician 68:1585-90 [PubMed]
- Marquardt in Pfenninger (1994) Procedures, p. 785-93
- Miller (1989) Obstetrics Illustrated, p. 374-6
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Related Studies
Concepts | Therapeutic or Preventive Procedure (T061) |
ICD10 | 90472-00 |
SnomedCT | 72197005, 150009005, 177222006 |
English | Episiotomy with repair, episioplasty, episiorrhaphy, Repair of episiotomy, Episiorrhaphy (procedure), episiotomy repair, episiotomy repair (treatment), Episiorrhaphy, Suturing of episiotomy, Repair of episiotomy (procedure), Episiorrhaphy (procedure) [Ambiguous], Repair;episiotomy |
Spanish | episiorrafia (procedimiento), episiorrafia (concepto no activo), episiorrafia, reparación de episiotomía (procedimiento), reparación de episiotomía, sutura de episiotomía |