Reducing the risk of severe perineal laceration is an important clinical goal because severe lacerations are associated with significant morbidity. In a study of 390 women who had a fourth-degree perineal laceration, 5% had significant complications that, in most cases, required additional surgery.12 Furthermore, in that study:
- 1.8% of women had a breakdown of the repair
- 2.8% had infection plus breakdown of the repair
- 0.8% had infection only.
In another study, 31% of women who sustained a fourth-degree laceration reported poor bowel control postpartum.7
Given the focus on reducing the rate of severe perineal laceration, I recommend that, in most cases, you reduce the use of median episiotomy and increase the use of mediolateral episiotomy.
Use a mediolateral incision for episiotomy
Make the incision at a 45°-angle; incisions made at >35° angle are associated with less of a risk of severe perineal laceration. Avoid using chromic sutures; rapid-absorption polyglactin 910 suture might offer better healing.
Mediolateral episiotomy: Technique
Begin the mediolateral episiotomy in the midline or slightly lateral to the midline (see the FIGURE). Insert two fingers into the vagina to distend the tissue of the birth outlet; using a pair of sharp, straight scissors, cut an incision 4 or 5 cm long at a 45° angle, directing it toward the ipsilateral ischial tuberosity. In most women, this incision cuts a portion of the bulbospongiosus muscle and, occasionally, reaches the ischioanal fossa.
Proper angle is key. The angle of the mediolateral episiotomy, in relation to the midline, is an important variable that influences the possibility that the patient will have a severe perineal laceration. Most experts recommend that the angle of the incision be at least 45° from the midline. If you use a shallow angle (<35°) from the midline to perform mediolateral episiotomy, you increase the risk of a severe perineal laceration, compared with incisions made at an angle >35° degrees from the midline (again, the FIGURE). In one report, the risk of a third-degree tear was about 10% with a 25°-angle mediolateral episiotomy, but less than 1% when the angle was >35°.13
Repairing the incision. After delivery, begin repair of a mediolateral incision by assessing the extent of vaginal, anal sphincter, rectal, and periurethral lacerations. Then, use two fingers, with or without a retractor, to spread the edges of the incision so that you can fully determine the length and depth of the episiotomy.
Place a 2-0 or 3-0 suture just above the apex of the incision. Use a running suture to close the vaginal mucosa and submucosal tissue. As you approach the introitus, suspend the running mucosal–submucosal suture and turn your attention to approximating the deeper submucosal space.
In mediolateral episiotomy, the upper-lateral edge of the incision contains more tissue than the lower-medial edge. To improve healing of the incision, use diagonal, rather than horizontal, sutures to provide better approximation of the submucosa. The fascia of the bulbocavernosus and superficial transveralis muscles might need to be reapproximated with individual sutures. Then, resume closing the skin and submucosa of the introitus and perineum.14 Perioperative antibiotic prophylaxis might be warranted—before you repair a complex perineal laceration.15
Concern about suture material. Using chromic suture to repair an episiotomy incision is associated with increased postdelivery pain, compared with the use of rapid-absorption polyglactin 910 suture (Vicryl Rapide).16 In fact, most OBs have stopped using chromic suture to repair episiotomy incisions. Rapid-absorption polyglactin 910 suture (average time to absorption, 42 days) might be associated with less of a need to remove suture that migrates through the incision than what is seen with standard-absorption polyglactin 910 sutures (average time to absorption, 63 days).16,17
When an episiotomy is indicated
There is renewed emphasis on reducing the rate of third- and fourth-degree perineal lacerations at delivery, because these adverse outcomes are associated with:
- an increased risk of wound breakdown that requires surgical repair
- incontinence of flatus or stool, or both.
At a time when the use of episiotomy has become limited, continuing to use a median incision will get you more third- and fourth-degree lacerations than if you use a mediolateral episiotomy.
A mediolateral episiotomy might cause more perineal pain immediately postpartum but, within a few months after delivery, patients mostly have recovered from either type of episiotomy.
To recap: If an episiotomy is indicated, use a mediolateral incision. I urge you to stop performing median episiotomy incisions.
For many OBs, episiotomy is one of the most common operative procedures that they will perform during their career. Precisely because the procedure is common, and because it is considered minor surgery, coding for the creation of the incision and subsequent repair is, under Current Procedural Terminology (CPT) rules, considered integral to the services provided during delivery.
Repair of an intentional episiotomy closely compares to the repair required for a first- or second-degree laceration. For that reason, payers will not reimburse separately for this level of repair—even when made necessary by laceration of tissues and not by intentional episiotomy.
On the other hand, most payers do reimburse for repair of third- and fourth-degree lacerations and, at times, for a more complex repair of an extension to an intentional episiotomy.
Coding options for more extensive intentional episiotomies and for third- and fourth-degree lacerations vary by payer. The simplest coding option is to add modifier -22 (increased procedural services) to the delivery or the global OB care code (for example, 59400-22 or 59409-22). To support use of this modifier, your documentation must include:
- the reason for the additional work (increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required)
- description of the significant additional work.
Some payers allow you to bill separately for the repair; do this by reporting the integumentary repair codes by type of repair:
- 12001-12007, for simple repair
- 12041-12047, for intermediate repair
- 13131-13132, for complex repair.
Select a code based on the total length of the repair, which must be documented as part of the description of the repair.
When repair is performed at the same time as the delivery, add modifier -51 to the separate repair code because this is considered a multiple procedure.
When repair is made after delivery with a return to the operating room, append a modifier -78 to the repair code.
Note that the CPT code 59300, Episiotomy or vaginal repair, by other than the attending physician, can never be reported by the attending OB or a physician who is covering for this physician; doing so will always result in a denial of the service.
MELANIE WITT, RN, CPC, COBGC, MA