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Extracted from Survival Guide to Midwifery, 2nd Edition (2012) Diane M. Fraser and Margaret A. Cooper, Oxford; Churchill Livingstone: 2012. Courtesy Elsevier

Episiotomy is an incision through the perineal tissues to enlarge the vulval outlet during the birth. The rationale for its use depends on the need to minimise the risk of severe. Spontaneous, maternal trauma and to expedite the birth when there is evidence of fetal compromise. The woman needs to give consent prior to the procedure.


  • The perineum should be adequately anaesthetised prior to the incision (lidocaine 0.5% 10ml or 1% 5ml)
  • The incision is made during a contraction when the tissues are stretched so that there is a clear view of the area, and bleeding is less likely to be severe
  • Birth of the head should follow immediately and its advance should be controlled to avoid extension of the episiotomy.


A. Infiltrating the perineum. B. Performing an episiotomy. C. Innervation of the vulval area and perineum


There are two types of incision:

  • Mediolateral: begins at the midpoint of the fourchette and is directed at a 45° angle to the midline towards a point midway between the ischial tuberosity and the anus
  • Median: a midline incision that follows the natural line of insertion of the perineal muscles. It is associated with reduced blood loss but a higher incidence of damage to the anal sphincter.

Further reading

Royal College of Midwives (2012). Evidence Based Guidelines for Midwifery-Led Care in Labour. Available at:


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