Episiotomy

Episiotomy - definition , purpose , indications, anesthesia,timing, Types, Steps of mediolateral episiotomy, precautions, complications and post operative care

1. EPISIOTOMY -DR. SUPRIYA MAHIND

2. EPISISOTOMY A surgically planned incision on the perineum and the posterior vaginal wall during then second stage of labor is called episiotomy (Perineotomy). PERINEUM

3. EPISIOTOMY

4. PURPOSE Prevent irregular perineal tears Effect easy delivery Cut short the second stage of labour Protect the foetal head from compression and intracranial haemorrhage due to tentoreal tears

5. INDICATIONS All primigravidae Rigid perineum , irrespective of parity Breech delivery - to shorten the time for the delivery of the after coming head and thus minimising the period of cord compression Instrumental delivery Premature baby – to protect the soft delicate foetal head from compression during delivery and thus to prevent intracranial haemorrhage

6. 6) Prolonged second stage 7) To cut short the second stage of labour in maternal diseases like heart disease, toxamia in pregnancy , where bearing down may be harmful to the mother Routine episiotomy may increase the risk of vertical transmission of HIV in HIV infected mother

7. ANAESTHESIA Local perineal infilteration to block the perineal branches of posterior cutaneous femoral nerve and dorsal cutaneous branches of pudental nerve .

8. TIMING At the crowning of head Buttocks distending the perineum Before or after introduction of the forcep blades

9. TYPES Median Mediolateral – most commonly practiced today Lateral – not practiced as there is risk of more bleeding and injury to Bartholin’s gland. Its accurate suturing is difficult J shaped

10. TYPES OF EPISIOTOMY

11. Relative merits and demerits of median and mediolateral episiotomy Mediolateral episiotomy Does not lead to third degree perineal tear even if it extends More bleeding and pain Incision can be extended , if required Required skilled approximation Median episiotomy Risk of third degree perineal tear if it extends accidently Bleeding and pain minimum Limitations to extension due to proximity to anus Easy to approximate

12. STEPS OF MEDIOLATERAL EPISIOTOMY STEP—I : Preliminaries— The perineum is thoroughly swabbed with antiseptic (povidone-iodine) lotion and draped properly. Local anesthesia—The perineum, in the line of proposed incision is infiltrated with 10 mL of 1% solution of lignocaine.

13. Steps of mediolateral episiotomy—(A) Perineal infiltration; (B) Cutting the perineum . A B

14. STEP—II: Incision— Two fingers are placed in the vagina between the presenting part and the posterior vaginal wall. The incision is made by a curved or straight blunt pointed sharp scissors ( scalpel may also be used), one blade of which is placed inside, in between the fingers and the posterior vaginal wall and the other on the skin. The incision should be made at the height of an uterine contraction when an accurate idea of the extent of incision can be better judged from the stretched perineum.

15. Deliberate cut should be made starting from the center of the fourchette extending laterally either to the right or to the left. It is directed diagonally in a straight line which runs about 2.5 cm away from the anus. The incision ought to be adequate to serve the purpose for which it is needed, i.e. according to the need of the individual case. The bleeding is usually not sufficient to use artery forceps unless the operation is done too early or the perineum is thick .

16. Structures cut are 1) Posterior vaginal wall (2) Superficial and deep transverse perineal muscles, bulbospongiosus and part of levator ani (3) Fascia covering those muscles (4) Transverse perineal branches of pudendal vessels and nerves (5) Subcutaneous tissue and skin.

17. Diagrammatic representation of the structures to be cut in different types of episiotomy

18. STEP—III: Timing of repair— The repair is done soon after expulsion of placenta. If repair is done prior to that, disruption of the wound is inevitable, if subsequent manual removal or exploration of the genital tract is needed. Oozing during this period should be controlled by pressure with a sterile gauze swab and bleeding by the artery forceps. Early repair prevents sepsis and eliminates the patient’s prolonged apprehension of ‘stitches’.

19. Preliminaries— The patient is placed in lithotomy position. A good light source from behind is needed. The perineum including the wound area is cleansed with antiseptic solution. Blood clots are removed from the vagina and the patient is draped properly and repair should be done under strict aseptic precautions. If the repair field is obscured by oozing of blood from above, a vaginal pack may be inserted and is placed high up. Do not forget to remove the pack after the repair is completed.

20. Repair - The repair is done in three layers. The principles to be followed are— (1) Perfect hemostasis (2) To obliterate the dead space (3) Suture without tension.

21. Steps of repair of episiotomy—(A) Wound on inspection; (B) Repair of vaginal mucosa and perineal muscles by interrupted sutures; (C) Apposition of the skin margins; (D) Repaired wound on inspection A B C D

22. The repair is to be done in the following order: Vaginal mucosa and submucosal tissues Perineal muscles Skin and subcutaneous tissues.

23. SUTURING OF EPISIOTOMY WOUND Episiotomy is sutured in immidietly after the delivery Posterior vaginal wall is sutured by continuous catgut no.1 on atraumatic curved needle The suturing is started from the 0.5 cm above from apex of the vaginal cut . The mucocutaneous junctions on both the edges are approximated by proper alignment The muscles are sutured by interrupted sutures by catgut

24. Skin is Approximated by using non – absorbable suture material on cutting needle

25. PRECAUTIONS Complete haemostasis should be achieved No dead space should be left while suturing the muscles to avoid risk of haematoma formation

26. Complications Immediate – a) Haematoma : Results into swelling and pain b) Infection c) Non union of wound Delayed – Fibrosis and Dyspareunia Implantation dermoid Scar endometriosis

27. Post – Operative Care Perineal care : Perineal wound is prone to infection, hence meticulous care important Cleaning the wound after each bowel and bladder action Application of antiseptic cream Use of sterile pads which are frequently changed Inspection of the wound periodically for redness , purulent discharge or any other sign of infection 2) Removal of the perineal skin stitches after five days

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