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Procedure and

Repair Techniques
The American Co llege o f
Obstetricians and Gyneco lo gists
Episiotomy is the most common operative procedure that most obste-
tricians will perform in their lifetime. Because it is so common and
considered minor surgery, teaching students or interns the principles
and techniques usually is left to the most junior of residents. As a
result, the Residency Review Committee for Obstetrics and Gynecology
( RRC) asked the American College of Obstetricians and Gynecologists
( ACOG) to prepare a teaching aid for all residents, but especially those
with the least experience. The result is this monograph.
As with most surgical procedures, there are many approaches and
modifications to episiotomy. However, the principle is the same. It
does not matter if your preference is 4-0 chromic catgut suture or 3-0
polyglycolic suture. What matters is how, where, and when you suture.
It is hoped that this monograph will be a guide to your approach to
Many Fellows of ACOG participated in the development of this
monograph, and it would be impossible to name them all. However,
special thanks go to Frank Ling, MD, Howard Blanchette, MD, John
Hauth, MD, and Gary Hankins, MD. A very special thank you goes to
Tamara Tin-May Ho Chao, MD, resident member of the RRC, for her
insightful comments.
Finally, this document would not have been possible without the
support of the ACOG Development Committee. Countless members of
ACOG donate to the Development Fund annually to allow ACOG to
expand its activities and further our educational endeavors. This
monograph is just one example of how those donations can have a
major impact.
Ralph W. Hale, MD
ACOG Executive Vice President
The first use of an episiotomy to facilitate the delivery of an infant is
lost in the past. Whether ancient midwives or birth attendants used
primitive knives has been questioned for years. Perhaps they did or per-
haps they did not. What is known, however, is that intentional incision
of the perineum was not practiced as a routine procedure until the 20th
Treatises on management of the perineum as the fetal head
emerges at the time of delivery focused on protecting against tears
and lacerations. In the 1700s, the usual description of a delivery of
the infants head concentrated on preserving the intact perineum by
allowing a slow, controlled dilation and delivery by exerting pressure
on the perineum ( 1) .
In 1828, Ferdinand von Ritgen described a similar maneuver for
easing the head over an intact perineum ( 2) . His procedure, which he
modified to use extension rather than flexion of the head, also was
designed to prevent trauma to the perineum while facilitating the deliv-
ery ( 3) . This was accomplished by placing the examiners fingers on the
perineal body and gently pushing the head from flexion to extension.
This maneuver is still performed in deliveries today and is known as the
Ritgen maneuver.
Although procedures for increasing the size of the vaginal outlet
may have been used in the United States by Native Americans, immi-
grant midwives, or others, the first reported use was in Virginia in 1852
( 4) . However, there is little evidence that it gained any regional or wide-
spread acceptance as part of a vaginal delivery.
In 1893, Karl August Schuchardt, preparing to perform a vaginal
approach to excision of a large cervical cancer, performed a medio-
lateral incision of the perineum to obtain additional exposure ( 5) . He
reported on this procedure to increase exposure in the same year. In his
report, he described incision in the mediolateral tissue and muscles
with much the same anatomical detail we would use today. Although
he never used the word episiotomy, the procedure would be called
gynecologic episiotomy today.
J. B. Delee usually is credited with popularizing the use of the epi-
siotomy when he became the champion for the use of forceps to pro-
tect the fetal head during delivery ( 6) . He felt strongly that use of the
forceps always should be accompanied by an episiotomy to prevent
damage to the pelvic floor. Because of Delees stature in the field of
obstetrics, his premise rapidly became accepted by U.S. obstetricians.
As more and more women gave birth in hospitals rather than
homes, episiotomy became the rule rather than the exception. The
lithotomy position, especially if extreme, actually accentuated the tight-
ening of the perineal opening and further contributed to the perceived
need for a surgical approach to increase the vaginal opening. This pro-
cedure, which began as a mediolateral approach, slowly evolved in the
United States during the 1950s and 1960s to predominantly a midline
The purpose of the procedure, which was explained to residents
year after year, was to facilitate the second stage of labor. It also was
reported to reduce perianal trauma, pelvic floor dysfunction and pro-
lapse, urinary and fecal incontinence, and sexual dysfunction. Benefits
to the fetus were a shortened second stage and less potential trauma to
the fetal head.
In the 1970s and 1980s, however, obstetricians began to question
the validity of the concept of protecting the perineum and the benefits
related to routine episiotomy. In 1981, the National Childbirth Trust
in London published a study that questioned the use of episiotomy as
a routine procedure ( 7) . This led to further review and questioning of
routine use of episiotomy for vaginal delivery given that there was little
evidence to support the reported benefits.
Today, episiotomy is still the most common surgical procedure
performed by most obstetricians; however, it is much less common
than in the 20th century. In 2003, 716,000 episiotomies were per-
formed in the United States, whereas 11 years earlier, more than 1.6
million episiotomies were performed ( 8, 9) ( see table) . It most often
is used in women who are having their first child and less frequently
used with later children.
2 Episiotomy