head crowns. Fingers are insinuated between the perineum and head. The incision begins in the midline and is directed toward the ipsilateral ischial tuberosity at an angle 60 degrees of the midline. (Reproduced with permission from Kenton K, Mueller M: Episiotomy and obstetric anal sphincter lacerations. In Yeomans ER, Hoffman BL, Gilstrap LC III, et al (eds): Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hili Education, 2017.)
Even fewer studies compare lateral episiotomy to either mediolateral or midline. One randomized trial compared lateral and mediolateral tpes in nulliparas. Groups did not difer in pain scores, in sexual qulity of life, or in vaginal or perineal trauma, including OASIS (Karbanova, 2014a,b; Necesalova, 2016). The authors also reported that mediolateral episiotomies required less time and suture for the repair. Thus, among the three, mediolateral episiotomy may be the preferred incision to reduce OASIS rates.
In the past, routine episiotomy was practiced to avoid a ragged laceration and to limit postoperative pain and anal sphincter injury rates. But, a Cochrane review of randomized trials showed lower rates of severe perineal/vaginal trauma in women managed with a restrictive, that is, selective use of episiotomy for spontaneous delivery rather than with routine episiotomy Qiang, 2017). Importantly, this review did not discern between midline and mediolateral episiotomies.
The American College of Obstetricians and Gynecologists (20 16b) has concluded that restricted use of episiotomy is preferred to routine use. We are of the view that the procedure should be applied selectively for appropriate indications. Thus, episiotomy can be considered for indications such as shoulder dystocia, breech delivery, fetal macrosomia, operative vaginal deliveries, persistent OP positions, markedly short perineal length, and other instances in which failure to perform an episiotomy will result in signiicant perineal rupture. The final rule is that there is no substitute for surgical judgment and common sense.
FIGURE 27-15 Mediolateral episiotomy repair. A. The vaginal epithelium and deeper tissues are closed with a single, continuous, locking suture. The angle seems less acute now (approximately 45°) since the perineum is no longer distended. B. Ater the vaginal component of the laceration is repaired, deeper perineal tissues are reapproximated by a single, continuous, nonlocking suture. Small episiotomies may not require this deeper layer. C. With a similar continuous, non locking technique, the superficial transverse perineal and bulbospongiosus muscles are reapproximated. D. Last, the perineal skin is closed using a subcuticular stitch. (Reproduced with permission from Kenton K, Mueller M: Episiotomy and obstetric anal sphincter lacerations. In Yeomans ER, Hoffman BL, Gilstrap LC III, et al (eds): Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hili Education, 201•7.)
With this new approach, epIsIotomy rates have dropped.
Oliphant and coworkers (2010) used the National Hospital Discharge Survey to analyze episiotomy rates between 1979 and 2006 in the United States. hey noted a 75-percent decline in the age-adjusted episiotomy rate. In the United States in 2012 episiotomy was performed in approximately 12 percent of vaginal births (Friedman, 2015).