[Perineal tears and episiotomy: Surgical procedure - CNGOF perineal prevention and protection in obstetrics guidelines]

To recommend the episiotomy procedure, repair of perineal or vaginal tears and episiotomy.Published Literature was retrieved using PubMed and Cochrane Library computer databases up to May 2018 and recommendations issued from international societies.A midline episiotomy increases the risk of OASIS compared with a mediolateral procedure (LE2). OASIS rates are similar for mediolateral and lateral episiotomies (LE1). A scar angle of at least 45° (measured in relation to the midline after suturing) is associated with a lower risk of OASIS (LE3). To obtain this final angle, the episiotomy must be performed at a 60° angle (LE1). Current data are insufficient to recommend the length, the timing, and the modalities procedure during instrumental delivery for mediolateral episiotomy. Suturing the superficial plane of a perineal tear provides no benefits when the edges touch and do not bleed (LE2). The techniques for suturing perineal lacerations by continuous sutures are associated with a reduction in immediate pain, reduced use of analgesics, and less frequent removal of stitches, compared with interrupted stitches (LE1). Synthetic suture materials with either standard or rapid absorption provide similar results for perineal pain and women's satisfaction: rapid absorption polyglactin has the advantage of a reduced need for later stitch removal, but it increases the risk of scar dehiscence (LE1). There are not enough published studies to recommend the use of biological glues in the repair of first-degree perineal tears or skin in second-degree tears. Delaying repair of OASIS for several hours does not aggravate the subsequent prognosis for anal continence (LE1). Internal sphincter injury lead to significant further anal incontinence (LE3). There is no study comparing methods for internal sphincter repair. To repair the external sphincter, overlap and end-to-end suture techniques yield similar results for anal continence (LE2). Use of polydioxanone 3/0 or polyglactin 2/0 to repair the EAS produces similar results for perineal pain and anal incontinence scores (LE2) CONCLUSIONS: A mediolateral incision is recommended for an episiotomy (Grade B). The angle of incision recommended for a mediolateral episiotomy is 60° (GradeC). It is recommended that continuous running sutures be preferred for the repair of episiotomies and second-degree tears (Grade A). It is recommended that obstetrics professionals optimise surgical conditions to the extent possible for repair of OASIS (professional consensus); a detailed report of the extent of the injuries, the techniques of repair, and the material used is recommended (GradeC). The external anal sphincter can be repaired with either overlap or end-to-end suture techniques (Grade B).