At crowning, a mediolateral episiotomy is performed. At what angle from the midline should the incision ideally be directed to minimize the risk of anal sphincter extension?

• A 20 degrees from the midline
• B 45 degrees from the midline
• C 60 degrees from the midline ✓
• D 90 degrees from the midline

Explanation

The incision should be cut at approximately 60 degrees from the midline at the moment of crowning. Because the perineum is stretched and displaced laterally at this time, an incision made at 45 degrees ends up closer to the midline once tension relaxes, increasing the risk of extension into the anal sphincter. This 60 degree recommendation comes from large cohort data on episiotomy technique.

Reference: Williams Obstetrics, 26th ed.

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Written and medically reviewed by the StethoPrep medical team.