Int Urogynecol J

DOI 10.1007/s00192-017-3349-9

ORIGINAL ARTICLE

The optimal angle of the mediolateral episiotomy at crowning

of the head during labor
Shimon Ginath 1,2 & Osnat Elyashiv 1 & Eran Weiner 1 & Ron Sagiv 1 & Jacob Bar 1 &
Joseph Menczer 1 & Michal Kovo 1 & Alexander Condrea 1

Received: 31 January 2017 / Accepted: 17 April 2017

# The International Urogynecological Association 2017

Abstract Conclusions The angle of the mediolateral episiotomy line

Introduction and hypothesis The aim of the mediolateral epi-
siotomy incision is to increase the diameter of the soft tissue of
the vaginal outlet to facilitate birth and to prevent vaginal
tears. Episiotomy angles that are too narrow and close to the
midline increase the risk of obstetric anal sphincter injuries. In
order to determine the optimal angle of the episiotomy, we
assessed the changes in the angles of episiotomy lines marked
during the first stage of labor and measured at the time of
crowning of the head.
Methods Incision lines for mediolateral episiotomy were
marked on the perineal skin at angles of 30°, 45°, and 60°
from the midline during the first stage of labor in women with
a singleton pregnancy. The angles of the marked lines were
measured at crowning of the head. Mediolateral episiotomy
was performed only for obstetric indications.
Results The study included 102 women with a singleton preg-
nancy. Of these women, 50 were primiparous and 52 were
multiparous. All angles marked during the first stage of labor
increased significantly (by more than 30°) at crowning of the
head. Similar changes were observed in primiparous and mul-
tiparous women.
Conference presentation
The findings of this study were presented at the 38th Annual IUGA
Meeting, Dublin, Ireland, 28 May – 1 June 2013.
* Shimon Ginath
ginath@gmail.com
1
Department of Obstetrics and Gynecology, Edith Wolfson Medical
Center, Holon, affiliated to The Sackler Faculty of Medicine, Tel
Aviv University, Tel Aviv, Israel
2
Department of Gynecology and Obstetrics, E. Wolfson Medical
Center, HaLochamim 62, P.O.B 5, 58100 Holon, Israel
was significantly greater at crowning of the head than when
marked during the first stage of labor. To achieve the desired
episiotomy angle, it is important to take into consideration the
changes in mediolateral episiotomy angles that occur during
labor.
Keywords Mediolateral episiotomy . Incision angle .
Crowning
Abbreviations
MLE Mediolateral episiotomy
OASIS Obstetric anal sphincter injuries
Introduction
When crowning of the head occurs during labor, the forces
exerted on the walls of the birth canal by the fetal head stretch
the soft tissue of the perineum and may cause deformation of
the birth canal and its surroundings [1]. The aim of the episi-
otomy incision is to increase the diameter of the soft tissue of
the vaginal outlet to facilitate birth, to prevent vaginal tears,
and most importantly to protect the perineum from uncon-
trolled obstetric anal sphincter injuries (OASIS) [2]. There
are several types of episiotomy. The most common are the
midline episiotomy (commonly used in the US), mediolateral
episiotomy (MLE; commonly used in the US and Europe),
and lateral episiotomy (commonly used in Europe) [3]. A
lower rate of OASIS has been found to be associated with
limited use rather than routine use of episiotomy during labor
[2, 4]. Since many studies have shown an increased risk of
OASIS with midline episiotomy than with MLE, MLE should
be considered in preference to a midline episiotomy [2, 5–14].

However, the question remains as to how to ensure a correct
episiotomy angle so that the episiotomy sufficiently relieves
pressure on the vaginal tissue [12, 15–19].
The recommended MLE angle in obstetric textbooks for
physicians and midwives is no less than 45° [20, 21].
Episiotomy angles that are too narrow and close to the midline
are associated with a higher risk of OASIS. Episiotomies are
performed during perineal distention, but the angle of the su-
ture line changes after delivery. Kalis et al. found that the
angles of MLE performed at crowning of the head are
narrower than after repair [1, 17]. In their first study, an inci-
sion angle of 40° at crowning of the head decreased to 22.5°
immediately after repair of the episiotomy [1]. In their second
study, an incision angle of 60° at crowning of the head de-
creased to 45° immediately after repair of the episiotomy, and
to 48° after 6 months [17]. Bearing in mind that the possible
effect of MLE in protecting against OASIS requires an angle
of at least 40° [15, 16, 18, 19], it is important to carefully plan
the optimal angle of the MLE to be performed at crowning of
the head. To determine the optimal angle of an episiotomy, we
assessed the changes in the angles of episiotomy lines marked
during the first stage of labor and measured at the time of
crowning of the head. The change in the angle would allow
planning of the optimal angle of an episiotomy to be per-
formed at crowning of the head.
Materials and methods
We performed a prospective study in the labor ward of our
institution after obtaining approval from the local Helsinki
committee. Included in the study were women with singleton
term pregnancies (≥37 weeks of gestation) who were admitted
to the delivery ward during the first stage of labor and who
eventually delivered spontaneously. Excluded from the study
were women with multifetal pregnancies, preterm labor or
nonvertex presentation, and women who delivered by cesare-
an or instrumental delivery.
In each recruited woman, three incision lines for a planned
MLE were marked during the first stage of labor on the right
perineal skin at 30°, 45° and 60° as measured from a vertical
line between the fourchette and the center of the anal orifice
(Fig. 1a, c). Measurements were made in the lithotomy posi-
tion using a protractor during the first stage of labor and again
during crowning of the head between contractions. The
changes in the marked angles between these two times points
were recorded. The head crowning stage of labor was defined
as a genital hiatus diameter of at least 40 mm [1]. The
anovaginal distance was defined as the distance between the
fourchette and the anal epithelium located anterior to the cen-
ter of the anal orifice. MLEs were performed for obstetric
indications by trained and registered nurse midwives.
Int Urogynecol J
Fig. 1 Incision lines for mediolateral episiotomy at the beginning of
labor and at crowning of the head in two women (with permission). a, c
Marked angles during the first stage of labor. b, d Appearance of the
premarked angles during crowning of the head
The following data were collected from the computerized
medical database: maternal age, gestational age, gravidity, parity,
prepregnancy body mass index (BMI), neonatal birth weight,
neonatal head circumference, and episiotomy rates in the study
group. The angles of the marked lines were compared between
the first stage and the head crowning stage of labor in primipa-
rous and multiparous women with a singleton pregnancy.
Statistical analysis
Continuous variables are presented as mean ± SD or median and
range, as appropriate. Categorical variables are presented as rate
(percent). The t test was used to compare continuous variables,
and the chi-squared test was used to analyze categorical vari-
ables. Spearman’s rank order correlation test was used for testing
the correlations between the angles and the demographic param-
eters (all tests applied were two-tailed). Statistical significance
was considered at p < 0.05. We estimated that the minimal dif-
ference between the angle at the baseline position and the posi-
tion at crowning would be 12 ± 10° in accordance with Kalis
et al. [17]. Using this assumption, we calculated that a sample
size of 20 subjects in each group would provide 90% power to
detect true differences in the magnitudes of the angles between
the first stage and head crowning regardless of the starting angles
measured. This sample size was based on the t test for paired
samples and assumed a two-sided alpha of 0.017 to preserve an
overall alpha of 0.05, considering that three measurements were
performed in each woman. Since this study was novel in design,
we doubled the sample size, and to preserve the sample size in
the event of instrumental delivery or emergency cesarean
Int Urogynecol J

Table 1 Maternal characteristics

of the whole group and according All (n = 102) Primiparae (n = 50) Multiparae (n = 52) p valuea
to parity
Age (years) 28.7 ± 5.6 26.0 ± 4.7 31.4 ± 5.2 <0.001
Gravidity 2.2 ± 1.5 1.2 ± 0.5 3.1 ± 1.6 <0.001
Parity 0.9 ± 1.2 0.0 ± 0.0 1.7 ± 1.3 <0.001
Gestational week 39.6 ± 1.1 39.5 ± 1.1 39.7 ± 1.1 0.402
Body mass index (kg/m2) 22.5 ± 3.8 22.0 ± 3.6 23.0 ± 4.0 0.261
Birth weight (g) 3351.0 ± 402.2 3335.6 ± 417.4 3365.5 ± 390.9 0.473
Anovaginal distance (cm) 2.9 ± 0.6 2.8 ± 0.5 2.9 ± 0.6 0.212
Neonatal head 345 ± 133 347 ± 158 344 ± 93 0.229
circumference (mm)
Mediolateral episiotomy, n (%) 13 (12.7) 9 (18.0) 4 (7.7) 0.206

The data are presented as means ± SD, except as indicated

a
Primiparae vs. multiparae (t test and chi-squared test)

section, additional women were recruited so that the final target
sample size was 50 in each group. Data were analyzed using the
SPSS statistical software (SPSS, Inc., Chicago, IL).
Results
and multiparous women analyzed separately (Table 2). There
were no correlations between the changes in the marked angles
and the angles measured at the head crowning stage and the
following characteristics: maternal age, gravidity, parity, gesta-
tional week, BMI, anovaginal length, neonatal birth weight and
neonatal head circumference (Table 3).

Included in the study were 102 women with a singleton preg-

nancy. Of these women, 50 were primiparous and 52 were
multiparous. The maternal characteristics of the whole group
and according to parity are presented in Table 1. There were
no differences between primiparous and multiparous women
regarding gestational age at delivery, maternal BMI, birth
weight, anovaginal length and neonatal head circumference.
An episiotomy was performed in nine primiparous women
(18%) and in four multiparous women (7.7%). Most of the
episiotomies were performed at an angle of 60° at the fetal
head crowning stage. There were no OASIS among the 13
women who underwent episiotomy.
All the angles marked during the first stage of labor increased
significantly at the fetal head crowning stage by more than 30°
(p < 0.001; Table 2, Fig. 1b, d). The 60° angle changed to 94.7°,
the 45° angle changed to 78.5°and the 30° angle changed to
62.4° (Fig. 2). Similar results were observed in primiparous
Discussion
The present study demonstrated that the planned MLE inci-
sion angle marked during the first stage of labor becomes
significantly wider (i.e. by more than 30°) at the head
crowning stage of labor, irrespective of maternal parity.
There are conflicting data regarding the role of MLE in
preventing OASIS. However, more recent studies indicate that
a midline episiotomy is associated with an increased risk of
OASIS as compared to MLE [9, 10, 22]. The absence of
consensus on the optimal MLE angle raises the issue of stan-
dardization and optimization of episiotomy in relation to its
role in preventing anal sphincter damage [23]. A subjective
consideration of the anatomy of the external anal sphincter
would suggest that episiotomy at an angle of 30° or less is
likely to behave more as a midline incision [12].

Table 2 Angles at the head crowning stage of labor

Group Angle marked at first stage (°)

30 45 60

Angle at crowning (°) Total study group (n = 102) 62.4 ± 8.2 (p < 0.001a) 78.5 ± 8.7 (p < 0.001a) 94.7 ± 9.3 (p < 0.001a)
Primiparae (n = 50) 62.6 ± 8.0 78.7 ± 8.8 95.5 ± 9.1
Multiparae (n = 52) 62.3 ± 8.5 78.4 ± 8.8 93.9 ± 9.5
p valueb 0.755 0.756 0.383

The data are presented as means ± SD

a
Marked angle vs. angle at crowning (t test)
b
Angle at crowning in primiparae vs. multiparae (t test)
 Int Urogynecol J

Fig. 2 Incision lines for

mediolateral episiotomy at the
beginning of labor and at
crowning of the head. a Angles
marked during the first stage of
labor. b Appearance of the
premarked angles during
crowning of the head

Several studies [15, 16, 18, 19, 24] have investigated the
association between the MLE angle and the development of
OASIS. There is inconsistency in the reported times at which
the MLE angles were measured. Andrews et al. measured the
angles immediately after episiotomy or sphincter repair, and ob-
served that women with OASIS had MLEs that were significant-
ly closer to the midline than a control group of women without
OASIS (26° and 37°, respectively; p = 0.01) [18]. Eogan et al.
measured the MLE angles 3 months after birth and observed that
the mean angle of the MLE scar from the midline was smaller in
women with OASIS than in a control group of women (30° and
38°, respectively; p < 0.001) [15]. They calculated that for every
increase of 6.3° away from the perineal midline of the episioto-
my, the chance of a third-degree anal sphincter tear is reduced by
50% [15]. Stedenfeldt et al. measured the MLE angle 2–3 years
after birth, and found a ‘U-shaped’ association between the epi-
siotomy angle and OASIS, with an increased risk of OASIS
when the episiotomy angle was either smaller than 15° or greater
than 60° (OR 9.00, 95% CI 1.1–71.0), suggesting that an episi-
otomy angle ranging from 30° to 60° is associated with the
lowest risk of OASIS [16]. On the other hand, van Dillen et al.
found no significant difference in episiotomy angle between
women with OASIS (37.2° ± 8.3°) and those without
(40.3° ± 9.9°; p = 0.4) when the angles were measured immedi-
ately after episiotomy repair [19].
In view of the potential effect of MLE in protecting against
OASIS following delivery, it is imperative to determine the
optimal angle of the episiotomy at the head crowning stage of
labor [24]. The protective effect of MLE requires an angle of
at least 40° [9, 15, 16, 18, 19]. Moreover, as already men-
tioned, it has been demonstrated that the angles of MLE per-
formed at the head crowning stage of labor become markedly
narrower when measured after repair [1, 17].
The current study demonstrated the changes in episiotomy
incision angles between the angle marked during the first
stage of labor and the angle measured at the head crowning
stage. The forces exerted on the vaginal walls by the crowning
fetal head cause distortion and distention of the perineal tissue,
leading to differences in the episiotomy incision angle at the
time of crowning, as reflected by the suture angle following its
repair [1]. The perineal tissue is unstretched during the first
stage of labor, and the angle marked at that time may possibly

Table 3 Correlations between the changes in the marked angles and the angles measured at crowning of the head and maternal and neonatal variables
in the 102 women

Variable Marked angle (°)

30 45 60

Spearman’s r p value Spearman’s r p value Spearman’s r p value

Age (years) −0.00946 0.925 0.00410 0.967 −0.0367 0.714

Gravidity 0.0128 0.898 −0.0161 0.873 −0.0249 0.804
Parity 0.0232 0.817 0.0490 0.625 0.0180 0.858
Gestational week −0.100 0.315 0.0234 0.816 −0.0145 0.885
Body mass index (kg/m2) −0.130 0.193 −0.0395 0.693 −0.0693 0.489
Birth weight (g) −0.0501 0.617 −0.0283 0.778 −0.0371 0.711
Anovaginal distance (cm) −0.000912 0.993 −0.103 0.304 −0.0857 0.392
Neonatal head circumference (mm) 0.0547 0.620 0.0232 0.834 0.000381 0.997
Int Urogynecol J
indicate the required angle of the incision after delivery, when
the tissue retracts to normal. This would allow planning of the
optimal angle of the episiotomy to be performed at the head
crowning stage, a technique that could prove especially useful
in training inexperienced obstetricians and midwives.
The strengths of the current study were its prospective nature,
analysis of both primiparous and multiparous deliveries, and
measurements of different angles in each patient that demonstrat-
ed similar and persistent changes. The study was limited by the
relatively small number of patients, even though the power was
sufficient. As stated above, MLE was performed only for obstet-
ric indications by trained registered nurse midwives. Due to the
low rate of episiotomies performed in this cohort and the small
sample size, the number of episiotomy lines measured following
delivery was not sufficient to draw definitive conclusions. In
addition, conclusions cannot be drawn regarding the protective
effect of MLE at the different angles studied. Larger prospective
studies are needed to investigate the correlation between the
MLE angle marked during the first stage of labor and angle at
the time of the head crowning, after repair of the episiotomy or
even 3 or 6 months after birth.
In conclusion, the MLE incision angle becomes signifi-
cantly wider at the head crowning stage. Our study indicates
the importance of carefully planning the optimal angle of the
MLE to be performed at the head crowning stage. In order to
achieve the desired episiotomy angle, it is important to take
into consideration the changes in MLE angles that occur dur-
ing labor. The desired episiotomy angle can be marked on the
perineum during the first stage of labor.
Compliance with ethical standards
Conflicts of interest None.
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