Episiotomy

Midline episiotomy - easier to heal, less painful, but can extend to anus
Mediolateral - unlikely to extend to anus
Anatomic structures - vaginal epithelium, transverse perineal muscle, bulbocavernosus muscle, perineal skin
ACOG recommends restricting episiotomies, and prefers mediolateral to median (Level A, 2006)
Current data is of poor quality in regards to benefits to mother or baby
Procedure avoids spontaneous tearing and/or aids in difficult delivery:
- Shoulder dystocia (contentiously the only indication)
- If possible, avoid even in these situations:
  - Baby is large or in breech
  - Labor is going too quickly
  - Extraction instruments needed (forceps, vacuum assisted)
Contraindications:
- IBD
- Perineal malformations

Procedure (Mediolateral)

May be performed on either side
Anesthetic to include local, Pudendal nerve block, epidural if available
Protect fetal head with operator hand, and cut along operator hand
Begin incision at posterior fourchette, continue at angle of 45 - 90 degrees relative to perineal body
Incise to generally 3-4 cm in length

Bleeding
Extension to higher-odre lacerations
Infection - routine antibiotic prophylaxis not recommended by ACOG due to lack of evidence
Dehiscence

Examine 360 degrees for other non-hemostatic lacerations that require sutures
Use 2-0 or 3-0 vicryl rapide or similar - the same suture will be used to close all tissue
Start an anchoring stitch at apex within vaginal mucosa
Continuous LOCKing sutures along vaginal mucosa/submucosa
Once at the hymen/perineal muscles, tie suture, but do not cut continuous end
Bury the knot within the perineum, and come out with the needle at the apex of the perineum
Continue suturing perineal muscles up to skin in a NON-locking fashion
At apex of skin, perform dermal approximations down to distal skin edge
Return to apex of skin with a subcuticular stitch (like a monocryl skin closure) and tie knot
Bury knot in superficial perineum/subQ and cut remaining suture from needle

Lappen et al. Episiotomy and Repair Technique. Updated Feb 27, 2014. http://emedicine.medscape.com/article/2047173-technique#showall
American College of Obstetrics and Gynecology. Episiotomy. ACOG Practice Bulletin #71. Obstet Gynecol. 2006. 107:957-62.
American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 120: use of prophylactic antibiotics in labor and delivery. Obstet Gynecol. 2011 Jun. 117(6):1472-83.