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An episiotomy or perineotomy is defined as an incision made into the perineal body and vagina to create room for the presenting part of the fetus and facilitate vaginal delivery. It is the most common operation in obstetrics, yet it is highly controversial. It is thought to prevent perineal tearing by substituting a straight surgical incision for a ragged spontaneous laceration that may have a worse outcome after repair. Several studies, however, have shown that the notion of decreased postoperative pain and improved healing with an episiotomy compared to a tear may not be true.

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Early studies on episiotomy in the 1940s and 1950s seemed to indicate that an episiotomy was protective of the vagina, urogenital diaphragm, and perineum.1,2 However, more recent studies have refuted these findings.3–5 A study of nearly 25,000 deliveries demonstrated that the episiotomy rate from 1980 to 1984 decreased from 73 percent to 45 percent.6 The incidence of second-degree tears increased from 0.7 percent to 2 percent but the incidence of third-degree lacerations was unchanged at about 5 per 1000.6 This study further supports the notion that a decreased frequency of episiotomies does not increase the incidence of extended tears.

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The perineal body is the center of the hub of a wheel that includes the transverse perineal muscles, the capsule of the external anal sphincter muscle, and the bulbospongiosus muscle (Figure 111-1). Connective tissue serves as the insertion site for many of the pelvic floor muscles. The perineal body attaches to the ischial tuberosities and to the inferior pubic rami through the perineal membrane and superficial transverse perineal muscles. The ischiocavernosus muscles attach to the anterior and lateral aspects of the structure. The perineal body is connected to the muscles of the pelvic diaphragm laterally. The perineal body is anchored posteriorly to the coccyx by the anal sphincter. The mediolateral episiotomy transects the superficial muscles of the perineum whereas the midline episiotomy does not.

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FIGURE 111-1
Graphic Jump Location

The anatomy of the perineum. The skin and subcutaneous tissues have been removed.

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An episiotomy may be performed in the midline or mediolaterally (Figure 111-2).7–10 The choice between the two types of episiotomy is largely dependent upon the experience of the practitioner. Factors that influence type of episiotomy include, but are not limited to, the site of prior episiotomies, position of the presenting fetal part, the thickness or rigidity of the patient’s perineum, and the obstetric perception of an impending severe laceration that risks a fourth-degree extension. A mediolateral incision may be prudent when an extended episiotomy is required or when the risk of a fourth-degree laceration is significant.11–13Never perform a lateral (Figure 111-2A) or a Schuchardt (Figure 111-2D) episiotomy in the Emergency Department. These are associated with significant complications.7

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