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- was significantly greater at crowning of the head than when
siotomy incision is to increase the diameter of the soft tissue of marked during the first stage of labor. To achieve the desired
the vaginal outlet to facilitate birth and to prevent vaginal episiotomy angle, it is important to take into consideration the
tears. Episiotomy angles that are too narrow and close to the changes in mediolateral episiotomy angles that occur during
midline increase the risk of obstetric anal sphincter injuries. In labor.
order to determine the optimal angle of the episiotomy, we
assessed the changes in the angles of episiotomy lines marked Keywords Mediolateral episiotomy . Incision angle .
during the first stage of labor and measured at the time of Crowning
crowning of the head.
Methods Incision lines for mediolateral episiotomy were
marked on the perineal skin at angles of 30°, 45°, and 60° Abbreviations
from the midline during the first stage of labor in women with MLE Mediolateral episiotomy
a singleton pregnancy. The angles of the marked lines were OASIS Obstetric anal sphincter injuries
measured at crowning of the head. Mediolateral episiotomy
was performed only for obstetric indications.
Results The study included 102 women with a singleton preg- Introduction
nancy. Of these women, 50 were primiparous and 52 were
multiparous. All angles marked during the first stage of labor When crowning of the head occurs during labor, the forces
increased significantly (by more than 30°) at crowning of the exerted on the walls of the birth canal by the fetal head stretch
head. Similar changes were observed in primiparous and mul- the soft tissue of the perineum and may cause deformation of
tiparous women. 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,
Conference presentation
The findings of this study were presented at the 38th Annual IUGA
and most importantly to protect the perineum from uncon-
Meeting, Dublin, Ireland, 28 May – 1 June 2013. trolled obstetric anal sphincter injuries (OASIS) [2]. There
are several types of episiotomy. The most common are the
* Shimon Ginath midline episiotomy (commonly used in the US), mediolateral
[email protected] episiotomy (MLE; commonly used in the US and Europe),
and lateral episiotomy (commonly used in Europe) [3]. A
1
Department of Obstetrics and Gynecology, Edith Wolfson Medical
lower rate of OASIS has been found to be associated with
Center, Holon, affiliated to The Sackler Faculty of Medicine, Tel limited use rather than routine use of episiotomy during labor
Aviv University, Tel Aviv, Israel [2, 4]. Since many studies have shown an increased risk of
2
Department of Gynecology and Obstetrics, E. Wolfson Medical OASIS with midline episiotomy than with MLE, MLE should
Center, HaLochamim 62, P.O.B 5, 58100 Holon, Israel be considered in preference to a midline episiotomy [2, 5–14].
 Int Urogynecol J

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
Fig. 1 Incision lines for mediolateral episiotomy at the beginning of
the head. To determine the optimal angle of an episiotomy, we labor and at crowning of the head in two women (with permission). a, c
assessed the changes in the angles of episiotomy lines marked Marked angles during the first stage of labor. b, d Appearance of the
during the first stage of labor and measured at the time of premarked angles during crowning of the head
crowning of the head. The change in the angle would allow
planning of the optimal angle of an episiotomy to be per- The following data were collected from the computerized
formed at crowning of the head. 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
Materials and methods the first stage and the head crowning stage of labor in primipa-
rous and multiparous women with a singleton pregnancy.
We performed a prospective study in the labor ward of our
institution after obtaining approval from the local Helsinki Statistical analysis
committee. Included in the study were women with singleton
term pregnancies (≥37 weeks of gestation) who were admitted Continuous variables are presented as mean ± SD or median and
to the delivery ward during the first stage of labor and who range, as appropriate. Categorical variables are presented as rate
eventually delivered spontaneously. Excluded from the study (percent). The t test was used to compare continuous variables,
were women with multifetal pregnancies, preterm labor or and the chi-squared test was used to analyze categorical vari-
nonvertex presentation, and women who delivered by cesare- ables. Spearman’s rank order correlation test was used for testing
an or instrumental delivery. the correlations between the angles and the demographic param-
In each recruited woman, three incision lines for a planned eters (all tests applied were two-tailed). Statistical significance
MLE were marked during the first stage of labor on the right was considered at p < 0.05. We estimated that the minimal dif-
perineal skin at 30°, 45° and 60° as measured from a vertical ference between the angle at the baseline position and the posi-
line between the fourchette and the center of the anal orifice tion at crowning would be 12 ± 10° in accordance with Kalis
(Fig. 1a, c). Measurements were made in the lithotomy posi- et al. [17]. Using this assumption, we calculated that a sample
tion using a protractor during the first stage of labor and again size of 20 subjects in each group would provide 90% power to
during crowning of the head between contractions. The detect true differences in the magnitudes of the angles between
changes in the marked angles between these two times points the first stage and head crowning regardless of the starting angles
were recorded. The head crowning stage of labor was defined measured. This sample size was based on the t test for paired
as a genital hiatus diameter of at least 40 mm [1]. The samples and assumed a two-sided alpha of 0.017 to preserve an
anovaginal distance was defined as the distance between the overall alpha of 0.05, considering that three measurements were
fourchette and the anal epithelium located anterior to the cen- performed in each woman. Since this study was novel in design,
ter of the anal orifice. MLEs were performed for obstetric we doubled the sample size, and to preserve the sample size in
indications by trained and registered nurse midwives. 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 and multiparous women analyzed separately (Table 2). There
sample size was 50 in each group. Data were analyzed using the were no correlations between the changes in the marked angles
SPSS statistical software (SPSS, Inc., Chicago, IL). 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
Results 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 Discussion
multiparous. The maternal characteristics of the whole group
and according to parity are presented in Table 1. There were The present study demonstrated that the planned MLE inci-
no differences between primiparous and multiparous women sion angle marked during the first stage of labor becomes
regarding gestational age at delivery, maternal BMI, birth significantly wider (i.e. by more than 30°) at the head
weight, anovaginal length and neonatal head circumference. crowning stage of labor, irrespective of maternal parity.
An episiotomy was performed in nine primiparous women There are conflicting data regarding the role of MLE in
(18%) and in four multiparous women (7.7%). Most of the preventing OASIS. However, more recent studies indicate that
episiotomies were performed at an angle of 60° at the fetal a midline episiotomy is associated with an increased risk of
head crowning stage. There were no OASIS among the 13 OASIS as compared to MLE [9, 10, 22]. The absence of
women who underwent episiotomy. consensus on the optimal MLE angle raises the issue of stan-
All the angles marked during the first stage of labor increased dardization and optimization of episiotomy in relation to its
significantly at the fetal head crowning stage by more than 30° role in preventing anal sphincter damage [23]. A subjective
(p < 0.001; Table 2, Fig. 1b, d). The 60° angle changed to 94.7°, consideration of the anatomy of the external anal sphincter
the 45° angle changed to 78.5°and the 30° angle changed to would suggest that episiotomy at an angle of 30° or less is
62.4° (Fig. 2). Similar results were observed in primiparous 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 found no significant difference in episiotomy angle between
association between the MLE angle and the development of women with OASIS (37.2° ± 8.3°) and those without
OASIS. There is inconsistency in the reported times at which (40.3° ± 9.9°; p = 0.4) when the angles were measured immedi-
the MLE angles were measured. Andrews et al. measured the ately after episiotomy repair [19].
angles immediately after episiotomy or sphincter repair, and ob- In view of the potential effect of MLE in protecting against
served that women with OASIS had MLEs that were significant- OASIS following delivery, it is imperative to determine the
ly closer to the midline than a control group of women without optimal angle of the episiotomy at the head crowning stage of
OASIS (26° and 37°, respectively; p = 0.01) [18]. Eogan et al. labor [24]. The protective effect of MLE requires an angle of
measured the MLE angles 3 months after birth and observed that at least 40° [9, 15, 16, 18, 19]. Moreover, as already men-
the mean angle of the MLE scar from the midline was smaller in tioned, it has been demonstrated that the angles of MLE per-
women with OASIS than in a control group of women (30° and formed at the head crowning stage of labor become markedly
38°, respectively; p < 0.001) [15]. They calculated that for every narrower when measured after repair [1, 17].
increase of 6.3° away from the perineal midline of the episioto- The current study demonstrated the changes in episiotomy
my, the chance of a third-degree anal sphincter tear is reduced by incision angles between the angle marked during the first
50% [15]. Stedenfeldt et al. measured the MLE angle 2–3 years stage of labor and the angle measured at the head crowning
after birth, and found a ‘U-shaped’ association between the epi- stage. The forces exerted on the vaginal walls by the crowning
siotomy angle and OASIS, with an increased risk of OASIS fetal head cause distortion and distention of the perineal tissue,
when the episiotomy angle was either smaller than 15° or greater leading to differences in the episiotomy incision angle at the
than 60° (OR 9.00, 95% CI 1.1–71.0), suggesting that an episi- time of crowning, as reflected by the suture angle following its
otomy angle ranging from 30° to 60° is associated with the repair [1]. The perineal tissue is unstretched during the first
lowest risk of OASIS [16]. On the other hand, van Dillen et al. 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

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Conflicts of interest None.
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