episiotomy is a surgical incision on the perineum during normal labor

episiotomy is a surgical incision made on the perineum during labor

1. episiotomy

2. definition Episiotomy is surgically planned incision given on the perineum during second stage of labor to enlarge the vaginal introitus, thereby facilitating safe and easy delivery of the fetus.

3. objectives To enlarge the size of vaginal orifice To prevent perineal tear To reduce stress and strain on fetal head To cut short second stage of labor

4. indications Large fetus >4,000 g Preterm or small for gestational age baby in order to minimize the risk of intracranial hemorrhage Presence of rigid perineum Face to pubis delivery, breech delivery or shoulder dystocia In fetal distress, to make the delivery fast When large lacerations seem inevitable In case of operative delivery like forceps/ventose Previous history of pelvic floor repair, perineal reconstructive surgery

5. Timing of episiotomy Bulging thinned perineum during contraction along with bearing down efforts by the mother just prior to crowning is the ideal time for giving episiotomy.

6. Types of episiotomies Mediolateral : incision is given downward and outward from the midpoint of fourchette. The cut may be given either toward right or left side and about 2.5 cm.

7. Median/midline: The incision is given from the center of fourchette and extends posteriorly. The cut is 2.5 cm in length

8. Lateral: Incision starts from about 1 cm away from the center of fourchette and extends laterally.

9. J shaped: The incision starts from the centre of fourchette and directed posteriorly about 1.5 cm and then points downward and outward along 5 or 7 o’ clock

10. advantages MATERNAL BENEFITS Clear incision is easy to repair Healing is better than lacerated wound Helps cut short the second stage of labor Lessens the chance of trauma to the pelvis floor muscles Tear may be avoided There is less stretching of and less damage to the bladder, anterior vaginal wall and urethra

11. FETAL BENEFITS Episiotomy makes the birth safer and easier It prevents intracranial birth injuries

12. complications IMMEDIATE Extension of episiotomy wound Vulval hematoma Infection Recto-vaginal fistula/vesicovaginal fistula Wound impairment

13. REMOTE Dyspareunia Chances of perineal laceration in subsequent labor Scar endometriosis

14. Repair of episiotomy Requirement Provide lithotomy position A good source of light is needed Instruct the mother to spread the thighs Clean the perineal area with antiseptic solution Drape the patient properly under aseptic precaution Evacuate the uterine cavity for retained clots or placenta Vaginal pack may be inserted and placed high up, if the wound site is obscured by oozing of blood from above, but it must be documented and removed , else it may lead to sepsis

15. Suture material Dexon or number ‘0’ chromic catgut is usually used to repair episiotomy. It is an absorbable suture and is spontaneously sheds off after 7-8 days of repair. Silk or nylon (nonabsorbable) sutures may be used and removed on 6 th day.

16. Episiotomy suturing The sequence of episiotomy suturing is as follows: Vaginal mucosa: it is sutured first. First inspect the apex of tear and first suture is applied just above the apex. Continuous suture is used to repair vaginal mucosa from above downward till the fourchette is reached. Perineal muscles: Interrupted sutures are used to repair perineal muscle same from above downward till the fourchette is reached. Skin : Mattress suture or figure of eight is used to repair skin.

17. Episiotomy care Maintenance of perineal hygiene: instruct to clean episiotomy wound after every urination and defecation. Provide perineal care twice daily and clean the episiotomy wound with antiseptic solution Assess the wound healing status every time with REEDA scale If there is impaired wound healing, provide sitz bath using MgSO4, moist and dry heat therapy or use analgesic drugs/ antibiotic therapy Do not sit with cross legs because stitches may break

18. Instruct the mother to ambulate to avoid stretch on the perineal wound If nonabsorbable sutures are used, stitches are removed on 6 th day. Advise the mother for abstinence for 6 weeks after delivery.