EPISIOTOMY CUTTING AND REPAIR EDITED VK.ppt

episiotomy procedure

1. Episiotomy
KHONJE V

2. Learning Outcomes
•Define an episiotomy
•Describe the types of episiotomy
•Explain the advantages
•Explain the disadvantages
•Discuss the indications for performing an
episiotomy
•Explain the cutting of an episiotomy

3. Definition
•An episiotomy is a surgical incision through the
perineum made to enlarge the vagina and assist
childbirth.
•An artificial incision of the fourchette, the
superficial muscles, the skin of the perineum
and the posterior vaginal wall designed to
enlarge the vulval outlet during birth.
•Perineostomy is a surgical incision made into the
perineum to enlarge the vulval orifice during the
second stage of labour

4. Types of episiotomy
•The median incision:
•It follows the natural lie of the insertion of the
perineal muscles
•Associated with reduced blood loss
•Has a high incidence of damage to the anal
sphincter
–Most comfortable
–Heals quicker
–Easier to repair, less pain and dyspareunia
•Dangers:
–Incision can tear further
–Extend to third degree tear

5. Types of episiotomy cont’d
•Mediolateral incision:
•Begins at the mid-point of the fourchette directed at
a 45
o
angle to the midline towards a point midway
between the ischial tuberosity and the anus
• Avoids danger of damage to both the anal
sphincter and Bartholin’s gland
•More difficult to repair
–safest incision
–most effective
–most common

6. Types of episiotomy cont’d
•J-shaped incision:
–protects the anal sphincter
–difficult to perform & suture
–out dated

7. Types of episiotomy cont’d
•Lateral incision:
–ineffective
–difficult to repair
–can result in damage to other structures
–danger of cutting the Bartholin’s duct or gland
–danger of cutting large blood vessels if
undertaken before stretching of the perineum

8. Justifiable indications
•To speed the delivery in case of fetal
distress
•Minimize risk of intracranial trauma during:
–Preterm delivery
–Breech delivery
•Difficult or assisted deliveries:
–Vacuum extraction
–Breech extraction
–Shoulder dystocia

9. Indications for performing an
episiotomy cont’d
•Fetal:
•Fetal distress
•Prolapse of the cord
•Malpresentations
•Large baby
•Preterm infant

10. Indications for performing an
episiotomy
•Maternal:

11. Advantages of an episiotomy
•The advantages are:
–reduces length of second stage of labour
–prevents occurrence of third degree tears
–allows for manipulation in difficult and assisted
deliveries

12. Advantages of an episiotomy
cont’d
•reduces the effort & stress of bearing down in
patients with hypertension, cardiac & respiratory
diseases
•protects the urethra and clitoris from extensive
trauma
•prevents excessive trauma to the pelvic floor
muscles

13. Advantages of an episiotomy cont’d
•reduces chances of intracranial injury in the preterm
infant
•facilitates rapid delivery of a distressed infant
NOTE :
Routine episiotomy is discouraged sue to HIV infection,

•

14. Disadvantages of an episiotomy
•Causes unnecessary pain in the puerperium
requiring analgesics
• Insomnia due to perineal discomfort
•Not able to sit or walk properly
•Difficulty in passing urine
•Haemorrhage
•Extension of the incision if the delivery is not
controlled or if it is an inadequate incision

15. Disadvantages of an episiotomy
cont’d
•Oedema & bruising causing delay in healing
process
•Risk of infection
•Dyspareunia
•Psychological trauma
•Unsatisfactory anatomical results
–narrowing of introitus
–occlusion of rectum
–Incontinence of flatus in the long term

16. Making an episiotomy
ALWAYS INFILTRATE THE PERINEUM BEFORE
CUTTING
•Explain the indication for the intervention and
the procedure to the woman.
•Obtain verbal consent.
•Respond to any questions or concerns that she
may have
•Ensure the woman has no allergies to lignocaine
or related drugs.

17. Making an episiotomy Cont’d
•Using the syringe and 19 gauge needle draw up
10ml of 1% Lignocaine.
•Check the medication and dosage with an
assistant.
•Insert two fingers into the vagina between the
presenting part and the skin
•For a medio-lateral episiotomy, direct the needle
at an angle of approximately 45° for 4 to 5 cm at
the same skin depth.

18. Infiltrating the perineum

19. Making an episiotomy Cont’d
•Aspirate the syringe
•While withdrawing the syringe, continuously
inject approximately 3 ml of local anaesthetic
into the area.
•Leave the tip of the needle still inserted in the
perineal area.
•Repeat this step twice by redirecting the needle
either side of the initial injection so that a fan
shaped area is anaesthetised.

20. Making an episiotomy Cont’d
•Withdraw the needle and apply pressure over
the injection site.
•Allow time for the Lignocaine to work – if
circumstances allow, wait for 2-3 contractions to
pass.
•The episiotomy can be performed when:
–Perineum thins out
–Crowning is about to take place
–During a contraction

21. Making an episiotomy Cont’d
•Insert the index and middle finger between the
presenting part and the perineum, pointing
downwards.
•Use a straight-bladed, blunt-ended pair of Mayo
scissors
•The blades should be sharp to ensure clean incision
•Take the open scissors and position between the
fingers, over the area intended for incision.
•Ensure there is good vision of the perineum and the
incision is away from the anus and Bartholin’s
gland.

22. Cutting an Episiotomy

23. Making an episiotomy Cont’d
•Make a single, deliberate cut 4 to 5cm into the
perineum at the height of the contraction when the
tissues are stretched and birth is imminent.
•Withdraw the scissors carefully.
•Apply pressure to the episiotomy with a sterile pad
between contractions if there is delay in the delivery
of the dead.
•Control the delivery of the presenting part and the
shoulders to avoid extension of the episiotomy.

24. Making an episiotomy Cont’d
•Dispose of equipment and wash hands
thoroughly
•Proceed to Repair the Episiotomy
immediately once baby is successfully
delivered, and mother is stable
•Prolonged bleeding from an episiotomy
which is not repaired can end up in post
partum haemorrhage

25. References
Fraser, D.M., Cooper, M.A. & Nolte, A.G.W.
(2010). Myles textbook for midwives (African
Edition, 2
nd
Edition). Edinburgh: Churchill
Livingstone
•World Health Organization. (2010).Integrated
management of pregnancy and childbirth:
Essential newborn care course.
•Sellers, P.M. (2001). Midwifery, Volume I. Cape
Town: Creela Diess.