Episiotomy and the Husband Stitch

I've been asked to do a post on episiotomy. I don't have time to do a detailed review, but let me briefly address the topic.

Tears (lacerations) of the vagina/perineum are classified as 1st (superficial, skin and mucous membrane), 2nd (fascia and muscles of perineal body), 3rd (anal sphincter involvement), and 4th degree (through the rectal mucosa, to the lumen of the rectum; often accompanied by periurethral tears). Think of an episiotomy as a controlled laceration of the pudenda. [Ignore the anatomical terms; we'll look at some very good drawings in a moment.]

There are two types of episiotomies: midline, and mediolateral. Except for the important issue of third- and fourth-degree extensions, midline episiotomy is superior.

Characteristic... Midline... Mediolateral

Surgical repair... Easy... More difficult

Faulty healing... Rare... More common

Postop pain... Minimal... Common

Anatomical results... Excellent... Occasionally faulty

Blood loss... Less... More

Painful intercourse... Rare... Occasional

Extensions... Common... Uncommon

With this oh-so-brief overview out of the way, first, a comment about the recent JAMA study: reporters are clueless when it comes to reporting health news.

One of the most common surgical procedures performed in the United States - an incision many pregnant women receive to make childbirth less damaging - has no benefits and causes more complications, according to the most comprehensive analysis to evaluate the practice.

Contradicting the long-accepted rationale for the operation, called an episiotomy, the analysis found that it increases the risk of tissue tears during delivery, leading to more pain, more stitches and a longer recovery after childbirth. In addition, it increases the risk of sexual difficulties later and does not reduce the risk of incontinence, the federally sponsored study found.

As a result, the researchers concluded, routine use of the procedure undergone by more than 1 million U.S. women each year should be discontinued, and the incision should only be considered to speed delivery when the health of the baby is at risk.

No, no, and no. The study didn't look at the benefits of episiotomy. It reviewed the best evidence available about maternal outcomes of routine vs restrictive use of episiotomy. The findings on tears, pain, and risk of incontinence:

Fair to good evidence from clinical trials suggests that immediate maternal outcomes of routine episiotomy, including severity of perineal laceration, pain, and pain medication use, are not better than those with restrictive use. Evidence is insufficient to provide guidance on choice of midline vs mediolateral episiotomy. Evidence regarding long-term sequelae is fair to poor. Incontinence and pelvic floor outcomes have not been followed up into the age range in which women are most likely to have sequelae.

The study concluded that: Evidence does not support maternal benefits traditionally ascribed to routine episiotomy. [Here's another review study of restrictive vs. routine episiotomy use.] In other words, when compared to restrictive episiotomy, doing routine episiotomy for certain maternal indications (to prevent severe perineal tears, or pain) is not supported by the available evidence.

An aside: As a rule, a laceration is harder to repair vs. an episiotomy. The problem isn't the 3rd/4th degree perineal lacerations--the ones affecting the rectum. Those are relatively easy to repair: you have good exposure, nice planes, and minimal to little bleeding. The big problem is the vaginal tears, in particular those deep inside the vagina. The space is difficult to expose, the tissue is engorged with blood, and tends to be quite friable [imagine having to suture tissue the consistency of a soaked marshmallow].

Last, but not least, just because this procedure is [o]ne of the most common surgical procedures performed in the United States, does not mean that it is routine.

While still a common obstetrical procedure, the use of episiotomy has decreased remarkably over the past 20 years. Through the 1970s, it was common practice to cut an episiotomy for almost all women having their first delivery.

The percentage of episiotomy with vaginal deliveries ranged from 65.3% in 1979 to 38.6% in 1997. ... [The national] rate is 39 per 100 vaginal deliveries (depending on the hospital, ranging from approximately 20% to 73%).

Moreover, an episiotomy is not recommended as a routine procedure:

The procedure should be applied selectively for appropriate indications, including fetal indications [stuck shoulder, feet first]; instrumental delivery [using a vacuum, forceps]; and in instances where it is obvious that failure to perform an episiotomy will result in perineal rupture. The final rule is that there is no substitute for surgical judgment and common sense.

Just to be clear: surgical judgment and common sense do not equal delusions of grandeur, hating your patient, performing unnecessary, or unconsented surgery on your patient, or concern over enhancing the sexual pleasure of your patient's partner. Which brings us to the so called "husband stitch".

This is how an episiotomy repair* looks like [WARNING, graphic drawing]. Basically, it's a two stage repair: first [A] you suture the vagina (think a ~horizontal axis, from back, inside the vagina, to front--towards the outside), then [B, C, D, or E] you suture the perineum (think ~vertical axis, from top, at the vaginal opening, to bottom, towards the anus, and back up).

[*If the link doesn't work for you: go here; click "Search inside this book"; enter "repair of median episiotomy" in Search box and click "GO"; click on "Page 327". I know, a bit cumbersome, but I assure you, the drawing is worth it.]

As you can deduce from the drawing, when you reapproximate the cut margins of the hymenal ring [A], with a final stitch, you bring the edges together, and up. This last throw is the famed, yet quite misunderstood "husband stitch". To be clear: you do not add extra stitches, and you do not alter the anatomy:

There are many ways to close an episiotomy incision, but hemostasis [control of bleeding] and anatomical restoration without excessive suturing are essential for success with any method.

I think a lot of misinformation stems from confusing episiotomy repair with other types of area procedures (e.g., repair of a torn, virginal hymen, repair of a poorly healed perineal laceration [a lot of medspeak, but look at pics 4, and 5 to get an idea; WARNING, graphic OR pictures]).

Bottom line: An episiotomy is not a cosmetic procedure, done to enhance the patient's, or her partner's sex life. It is also not indicated as a routine procedure. To insure the best possible outcome, discuss episiotomy with your doctor before the time of delivery, and, most importantly, make sure you have confidence in your doctor's clinical judgment. If you don't feel comfortable that he/she is guided by your best interest, pick another doctor.

[Tip: If you've had an episiotomy/laceration repair, keep some Dermoplast spray handy.]


Williams, 21ed p 325-8