Episiotomy Management and Technique

Pre-Procedure Considerations

The American College of Obstetricians and Gynecologists recommends mediolateral episiotomy to minimize the risk of obstetric anal sphincter injuries (OASIS) in patients undergoing vaginal delivery 1
Ensure adequate lighting and proper patient positioning for optimal visualization during episiotomy, as recommended by the American College of Obstetricians and Gynecologists 2
Prepare the surgical site with povidone-iodine or chlorhexidine gluconate (if iodine allergy) before performing episiotomy, as suggested by the American College of Obstetricians and Gynecologists 2, 3

Use continuous non-locking intracutaneous sutures for episiotomy repair, as this technique results in less short-term pain, less dyspareunia, and uses less suture material, according to the American College of Obstetricians and Gynecologists 3
Anchor the suture above the apex of the laceration in the vaginal epithelium, then close the vaginal epithelium using a continuous, non-locking suture, as recommended by the American College of Obstetricians and Gynecologists 3
Consider leaving the skin unsutured or closing with skin adhesive to reduce pain and dyspareunia, as suggested by the American College of Obstetricians and Gynecologists 2, 3
Skin adhesive is associated with shorter procedure time, less pain, and greater satisfaction, according to the American College of Obstetricians and Gynecologists 2

Arrange early follow-up within two weeks, ideally in a specialized postpartum perineal clinic, with clear documentation of repair technique, as recommended by the American College of Obstetricians and Gynecologists 3
Provide prophylactic antibiotics, such as first-generation cephalosporin (cefazolin 2g) or second-generation cephalosporin (cefoxitin 2g), to patients after episiotomy, as suggested by the American College of Obstetricians and Gynecologists 3
Use stool softeners, such as polyethylene glycol 4450 or mineral oil, twice daily for six weeks postpartum to achieve toothpaste consistency stools, according to the American College of Obstetricians and Gynecologists 3
Document the laceration type and repair technique clearly, and provide patient education on degree of injury, as recommended by the American College of Obstetricians and Gynecologists 3

Perform systematic evaluation, including visual inspection, thorough perineal exam, and mandatory digital rectal examination, after all vaginal deliveries, as recommended by the American College of Obstetricians and Gynecologists 1, 2
Digital rectal examination improves detection rate of OASIS and is essential after all vaginal deliveries, according to the American College of Obstetricians and Gynecologists 1, 2
Up to 35% of anal sphincter injuries are missed without rectal examination, as noted by the American College of Obstetricians and Gynecologists 1