This document provides instructions for performing and repairing an episiotomy. It begins by stating the objectives of being able to perform a mediolateral episiotomy and repair an episiotomy. It then discusses preparing for and performing a mediolateral episiotomy, including using local anesthesia. The document outlines repairing an episiotomy in 4 steps: suturing the vaginal epithelium, muscles, and skin in separate layers. Emphasis is placed on proper technique and patient comfort during the repair process.

1. 4A
Skills workshop:
Performing and
repairing an
episiotomy
done without adequate analgesia. Usually 10–15
Objectives ml 1% lignocaine (Xylotox) supplies adequate
analgesia for performing an episiotomy. Be very
careful that the local anaesthetic is not injected
When you have completed this skills into the presenting part of the fetus.
workshop you should be able to:
• Perform a mediolateral episiotomy. C. Types of episiotomy
• Repair an episiotomy. There are two methods of performing an
episiotomy:
PERFORMING AN 1. Mediolateral or oblique.
2. Midline.
EPISIOTOMY
The midline episiotomy has the danger that it
can extend into the rectum to become a third
A. The purpose of an episiotomy degree tear while the mediolateral episiotomy
often results in more bleeding. This skills
1. To aid the delivery of the presenting part workshop will only deal with the mediolateral
when the perineum is tight and causing episiotomy because it is used most frequently,
poor progress in the second stage of labour. is safe and requires the least experience.
2. To prevent third degree perineal tears.
3. To allow more space for operative or
D. Performing a mediolateral episiotomy
manipulative deliveries, e.g. forceps or
breech deliveries. The incision should only be started during
4. To shorten the second stage of labour, e.g. a contraction when the presenting part is
with fetal distress. stretching the perineum. Doing the episiotomy
too early may cause severe bleeding and
B. Preparation for an episiotomy will not immediately assist the delivery. The
incision is started in the midline with the
If you anticipate that an episiotomy may be scissors pointed 45 degrees away from the
needed, you should inject local anaesthetic into anus. It is usually directed to the patient’s left
the perineum. An episiotomy should not be

2. THE SECOND STAGE OF LABOUR 85
Figure 4A-1: The method of performing a left mediolateral episiotomy
but can also be to the right. Two fingers of the Suturing the episiotomy usually stops the
left hand are slipped between the perineum venous bleeding but arterial bleeders need to
and the presenting part when performing a be tied off.
mediolateral episiotomy.
E. Problems with episiotomies REPAIRING AN
1. The episiotomy is done too soon: This EPISIOTOMY
can result in excessive bleeding as the
presenting part is not pressing on the
perineum. An episiotomy will not help the F. Preparations for repairing an episiotomy
descent of a high head. 1. This is an uncomfortable procedure for the
2. Extension of the episiotomy by tearing: patient. Therefore, it is essential to explain
This is not only a problem in a midline to her what is going to be done.
episiotomy. Mediolateral episiotomies 2. The patient should be put into the
may also tear through the anal sphincter lithotomy position if possible.
into the rectum. However, extension of 3. It is essential to have a good light that must
mediolateral episiotomies is less likely to be able to shine into the vagina. A normal
occur than a midline episiotomy. ceiling light usually is not adequate.
3. Excessive bleeding may occur: 4. Good analgesia is essential and is usually
• When the episiotomy is done too early. provided by local anaesthesia which is
• From a mediolateral episiotomy. given before the episiotomy is performed.
• After the delivery. As 20 ml of 1% lignocaine may be safely
Arterial bleeders may have to be temporarily infiltrated, 5–10 ml usually remains to be
clamped, while venous bleeding is easily given in sensitive areas. An episiotomy
stopped by packing a swab into the wound. should not be sutured until there is good
analgesia of the site.

3. 86 INTRAPAR TUM CARE
Figure 4A-2: The method of safely handling a needle
Figure 4A-3: An episiotomy wound
5. In order to prevent blood which drains needle for the vaginal epithelium and
out of the uterus from obscuring the muscles, and one on a cutting needle for
episiotomy site, a rolled pad or tampon the skin. With smaller episiotomies one
should be carefully inserted into the vagina packet on a round needle and one on a
above the episiotomy wound. As this is cutting needle will be sufficient. Non-
uncomfortable for the patient, she should absorbable suture material such as nylon
be reassured while this is being done. and dermalon are very uncomfortable and
6. Absorbable suture material should be used should not be used. Remember that the
for the repair. Three packets of chromic patient has to sit on her wound.
0 are required. Two on a round (taper)

4. THE SECOND STAGE OF LABOUR 87
Figure 4A-4: Suturing the vaginal epithelium
G.. The following important principles There are four important steps in the repair of
apply to the suturing of an episiotomy an episiotomy wound.
1. The apex of the episiotomy must be Step 1
visualised and a suture put in at the apex.
Place a suture (stitch) at the apex (the highest
2. Dead space must be closed.
point) of the incision in the vaginal epithelium.
3. The same opposing tissue must be brought
Then insert one or two more continuous
together using the skin vaginal epithelium
sutures in the vaginal epithelium. Do not
juncture as an anatomical landmark.
complete suturing the vaginal epithelium when
4. Tissues must be brought together but not
the episiotomy is large or deeply cut but leave
strangulated by excessive tension on the
this suture and do not cut it. When placing the
sutures.
suture at the apex, be very careful not to prick
5. Haemostasis must be obtained.
your finger with the needle.
6. The needles must be handled with a pair
of forceps and not by hand, and should be Step 2
removed from the operating field as soon Insert interrupted sutures in the muscles. Start
as possible. at the apex of the wound. The aim is to bring
the muscles together firmly and to eliminate
H. The method of suturing an episiotomy any ‘dead space’, i.e. any spaces between the
Three layers have to be repaired: muscles where blood can collect. Remember
that the sutures must be inserted at 90 degrees
1. The vaginal epithelium. to the line of the wound.
2. The muscles.
3. The perineal skin. When suturing the muscles, be careful not
to put the suture through the rectum. If you

5. 88 INTRAPAR TUM CARE
Figure 4A-5: Suturing the muscles
Figure 4A-6: The correct position of the skin and vaginal epithelium

6. THE SECOND STAGE OF LABOUR 89
Figure 4A-7: The repair of the skin
make sure that the point of the needle is seen Step 4
when crossing from the one side to the other
Use interrupted sutures with an absorbable
of the deepest part of the wound, the stitch
suture material to repair the perineal skin.
will not be too deep. ‘Figure 8’ stitches (double
Mattress sutures may be used. Do not pull the
stitches) are used to suture the muscle layer.
sutures tight as they only need to bring the
When the muscles have been correctly sutured
edges of the skin together. Sutures that are too
the cut edges of the vaginal epithelium and
tight become uncomfortable for the patient.
the skin should be lying close together. The
markers for correct alignment are: When the suturing is complete:
1. The remains of the hymen. 1. Remove the pad from the vagina. Be gentle
2. The junction of the skin and the vaginal as this will be uncomfortable for the patient.
epithelium. The skin is recognised by the 2. Put a finger into the rectum and feel if a
darker pigmentation. suture has been placed through the rectal
wall by mistake.
Step 3
3. Make sure that the uterus is well
Return to the vaginal epithelium and complete contracted.
the continuous catgut suture, ending at the 4. Get the patient out of the lithotomy
junction with the skin. Do not pull the sutures position and make sure that she is
tight as they only need to bring the edges of comfortable.
the vaginal epithelium together.