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An episiotomy is a surgical procedure performed during childbirth where an incision is made to widen the vaginal opening. There are two main types of episotomy: a midline (or median) episiotomy, which starts close to the midline of the perineum and extends downward in a straight line, and a mediolateral episiotomy, which begins similarly but extends laterally at a 60-degree angle. Episiotomy repairs are dictated by the severity of the perineal laceration following the infant's delivery; this procedure is generally treated like second-degree tears, with layered closure of the vaginal, muscular, and skin tissues. Continuous, non-locking sutures are often used to minimize pain and promote better healing. Despite its benefits in some cases, the routine use of episiotomy has been debated. Research shows that it may not reduce the severity of postpartum pelvic floor issues or improve long-term outcomes. Instead, episiotomy can increase the risk of anal incontinence and other complications, particularly if the incision extends into an obstetric anal sphincter injury. This activity for healthcare professionals is designed to enhance the learner's competence in performing an episiotomy procedure, evaluating the degree of perineal lacerations, and implementing an appropriate repair and interprofessional management approach to improve patient outcomes. Objectives: Identify the indications for an episiotomy. Select the proper technique for an episiotomy. Implement appropriate postoperative care for a patient undergoing an episiotomy. Collaborate with an interprofessional team to provide care for patients who undergo an episiotomy. Access free multiple choice questions on this topic.

An episiotomy, a surgical incision made at the end of the second stage of labor to widen the vaginal opening, helps facilitate delivery.[1][2] Ideally, an episiotomy relieves pressure on the perineum during difficult deliveries, resulting in an easily repairable incision when compared to uncontrolled vaginal trauma.[3] The primary types of episiotomy are the midline (or median), which begins near the center of the perineum and extends straight downward, and the mediolateral, which starts similarly but angles 60 degrees to the side.[1][2] Other less frequently used episiotomy incisions include the modified median, J-shaped, lateral, anterior, and radical.[4] After childbirth, performing a thorough perineal examination is necessary to assess trauma, and a rectal examination is vital to detect any anal sphincter injuries. In the United States, episiotomy was a widely used technique until 2006, when the American College of Obstetricians and Gynecologists (ACOG) made a recommendation against its routine use. However, episiotomy still has select indications and should be performed based on clinical judgment and maternal or fetal factors. Episiotomies, particularly the midline type, are linked with higher rates of obstetric anal sphincter injuries (OASIS).[1][2] Please see StatPearls' companion resource, "Obstetric Perineal Lacerations," for more information.

Although intended to widen the vaginal opening and reduce perineal trauma during delivery, episiotomy carries risks such as perineal pain, dyspareunia, and sexual dysfunction. Complications include bleeding, infection, extended tears into the anal sphincter, scarring, and even more serious outcomes like vaginal prolapse or fistulas. In some cases, severe perineal tears occur despite episiotomy, raising questions about its effectiveness in preventing trauma. Episiotomy has also been associated with complications during future deliveries.[7] Risk factors that increase the likelihood of complications include smoking, obesity, fourth-degree lacerations, operative vaginal deliveries, and the use of postpartum antibiotics. In cases where a woman is at a higher risk for complications related to perineal trauma or pelvic floor disorders, follow-up in a specialized clinic is beneficial. If any signs of anal sphincter dysfunction appear during recovery, an endoanal ultrasound should be performed to evaluate the extent of damage. If significant damage or persistent symptoms are noted, secondary anal sphincter repair might be necessary.[7]

Managing an episiotomy and the postpartum repair requires a collaborative, interprofessional approach to enhance patient-centered care, outcomes, patient safety, and team performance. Physicians, midwives, and advanced practitioners must be skilled in performing these incisions and repairing lacerations, employing strategies to prevent severe injuries and ensuring timely intervention. Nurses are critical in assessing lacerations, providing immediate care, and supporting patients throughout healing. Pharmacists contribute by managing pain relief and recommending appropriate medication regimens to prevent infections. Clear and continuous interprofessional communication is essential to coordinate care effectively, ensuring that each team member is informed about the patient's condition and treatment plan. This cohesive teamwork promotes a holistic approach to care, addressing the physical and emotional needs of the patient, ultimately improving recovery and quality of life.

The nurse usually sets up the tray for episiotomy and assist the surgeon. Once the surgery is over, the nurse will often apply a dressing. In the post-delivery phase, the nurse will monitor the patient for pain and urinary incontinence.  Patients receive training on how to take sitz baths and clean the perineum. If there is swelling, the nurse will apply ice packs which also decrease the pain. The sutures used to close an episiotomy do not require removal, and will reabsorb in the tissues within 6 to 8 weeks. Finally, patients must learn how to perform Kegel exercises to help tighten up the pelvic floor muscles.