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opening. The most common practice is to repair the episiotomy after the delivery of the placenta.
What You Need: 1% Lidocaine without epinephrine (approx. 20-30cc), sterile gloves, gauze bandages,
prep solution, 2-0, 3-0, and 4-0 absorbable suture (Vicryl or Chromic) for the repair, scissors or a scalpel to
make the episiotomy incision, suture forceps and needle holders.
What to Do:
Episiotomy: Indicated to assist in the delivery of a large infant or one with shoulder dystocia after perineal
massage has failed to stretch the tissue adequately. It is better to cut an episiotomy than to have the baby
tear the perineal tissue into the rectum.
- If no anesthesia has been given, administer 5-10 cc of Lidocaine along the midline of the perineum and
posterior vagina. Remember not to administer more than 50cc of Lidocaine total, and to aspirate prior to
injecting. If the perineum is very thin and well stretched, anesthesia may not be necessary. - Place the first two fingers into the posterior vagina between the fetal head and the vaginal wall, with one
finger on either side of midline. - Cut between the fingers, through the vaginal wall and the perineum, but do not to incise the anal sphincter
or its capsule. (Figure 3-12) - If pressure from the fetal head does not control bleeding, press a 4x4 bandage against the incised tissue
to stop hemorrhage. - An alternate site for the episiotomy is the mediolateral position (approximately 4:30 on a clock face).
Classifications of perineal episiotomies and lacerations
First Degree: Extends only through the vaginal and perineal skin
Second Degree: Extends deeply into the soft tissues of the perineum down to, but not including, the external
anal sphincter
Third Degree: Extends through the perineum and anal sphincter
Fourth Degree: Extends through the perineum, anal sphincter, and rectal mucosa to expose the lumen of
the rectum
First Degree Episiotomy or Laceration Repair
- Test the area to be sutured for residual sensation. If necessary, administer Lidocaine into the tissue as
with typical wound repair. - If the edges of lacerated tissue are less than 1 cm apart and not bleeding, repair is not necessary.
- Place the first stitch (2-0 or 3-0) 1 cm deep (proximal) to the end of the vaginal portion of the episiotomy
(or laceration) and tie it. - Continue with locking, continuous sutures 1 cm from each wound edge, 1 cm apart and 0.5 cm deep
through to the introitus or hymenal ring (or distal end of the laceration). Ensure the edges of the
hymenal ring lay approximated. Do not cut the suture in episiotomy repair. - With another suture, sew a running subcuticular suture from the anal end of the skin wound back up
toward the vagina to close the perineum. - Take the end of the suture back under the hymenal ring and tie it in the vagina.
Second Degree Episiotomy Repair: (see figure 3-13 and 3-14)
- Repair vaginal wound as in First Degree Repair down to the hymenal ring. Do not cut the suture.
- With another suture, sew 3 - 4 deep, interrupted stitches in the subcutaneous fascia, muscle and fat of
the perineum. - Take the suture from the vagina under the hymenal ring and approximate the edges of the perineal fascia
with continuous non-locking suture sewing toward the anus. - Sew a running subcuticular suture back up toward the vagina to close the perineum.
- Take the end of the suture back under the hymenal ring and tie it in the vagina.
- Do not suture any tear near the ureter without inserting a Foley catheter to avoid inadvertent urethral
closure.