EPISIOTOMY.pptx

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1. EPISIOTOMY MRS RAMESHWORI TH ASSOCIATE PROFESSOR

2. EPISIOTOMY AND SUTURING Introduction: Episiotomy is a surgical enlargement of the vaginal orifice by an incision to the perineum. It is clear that much evidence exists supporting a restricted policy for episiotomy and do not intend to suggest that episiotomy should be routinely performed. Episiotomy is necessary, to achieve optimum outcomes for mother and infant, without any adverse risk of perineal or anal sphincter injury.

3. Defin i tion : A surgically planned incision on the perineum and posterior vaginal wall during the second stage of labour to quickly enlarge the opening for the baby is called episiotomy or Perineotomy.

4. Purposes : To prevent the perineum from tearing. To allow more space for manipulative vaginal deliveries, e.g. forceps To shorten the second stage of labour e.g. with fetal distress. To enlarge the vaginal introitus To facilitate easy and safe delivery To minimize out stretching and rupture of the perinealmuscles and fascia To reduce the stress and strain on the fetal head To reduce prolonged maternal pushing efforts

5. Indication: Anticipating perineal tear: Primi as an elective procedure Face to pubis delivery, Big baby Narrow pubic arch Inelastic perineum: Perineal rigidity in elderly primi Old perineal scar of episiotomy Perineorrhaphy Manipulative delivery: Needed to get more space Forceps Bre e ch Internal version To cut the second stage: Heart disease S evere pre eclampsia or eclampsia P ost caesarean cases P ost maturity Fetal interest: F etal distress P remature baby B reech delivery – to minimize compression of the after coming head

6. Risks of the procedure: Bleeding Tearing the rectal tissues and anal sphincter Perineal pain Infection Perineal hematoma (Collection of blood in the perineal tissues) Pain during sexual intercourse

7. Timing of the episiotomy: The timing of performing the episiotomy requires judgement. If done early the blood loss will be more and if done late, it fails to prevent the invisible lacerations of the perineal body and thereby fails to protect the pelvic floor. Bulging thinned perineum during contraction just prior to crowning is the ideal time

8. Types: Median Lateral Medio-Lateral J-Shaped

9. Mediolateral: Down wards and out wards from the mid point of the fourchette Either to the right or left. Runs about 2.5 cm away from the anus Median: Centre of the fourchette and extends posteriorly along the midline for about 2.5 cm

10. Lateral: 1 cm away from the centre of the fourchette Extends laterally Might injure the bartholin’s duct J shaped: Begins in the centre of the fourchette Directed posteriorly along the midline about 1.5 cm Directed downwards and outwards along 5 or 7 o’ clock position .

11. Merits & demerits of Median: Merits: The muscles are not cut Blood loss is least Repair is easy Post op. comfort is better Healing is superior Wound disruption is rare Dyspareunia is rare Demerits: Extension if occurs may involve the rectum Not suitable for manipulative delivery or in abnormal presentation or position Its use is selective

12. Mediolateral: Merits Safety from rectal involvement Incision can be extended Demerits: Apposition is not so good Blood loss is more • Post op. discomfort is more • Increased incidence of wound disruption • Dyspareunia

13. Classification of episiotomy: Classified by degrees that are based on the severity or extent of the tear: First degree: A first-degree episiotomy consists of a small tear that only extends through the lining of the vagina. It doesn’t involve the underlying tissues. Second degree: This is the most common type of episiotomy. It extends through the vaginal lining as well as the vaginal tissue. However, it doesn’t involve the rectal lining or anal sphincter.

14. Third degree: It involves the vaginal lining, the vaginal tissues, and part of the anal sphincter Fourth degree: The most severe type of episiotomy includes the vaginal lining, vaginal tissues, anal sphincter, and rectal lining

15. Preparation : Explain the procedure to the mother Provide privacy and drape the mother Advice the mother to empty her bladder / catheterize the bladder. Monitor the uterine contractions (duration, frequency and intensity) Monitor FHR every 15 mins Do per vaginal examination Observe the color of amniotic fluid

16. Preparation of equipment: A sterile delivery packs containing:- Episiotomy scissor - 1. Artery forceps - 2. Sponge holding forceps - 1 Syringe loaded with 2% of xylocaine(5 to10ml-) Cord cutting Scissors- 1 Bowl for cleaning solution- 1 4 x4 gauze pieces – 5 Cotton balls -7 Gauze pad for supporting the perineum -2 Center hole towel Cord clamp Bulb / mucous sucker

17. INTERVENTION RATIONALE 1 Admit the woman in the labour room Nil 2 Explain the procedure and change her clothing as per the hospital policy To preve N t anxiety 3 Obtain verbal consent Nil 4 Place the mother in the lithotomy position For clear view of the perineum and to assess the progress 5 Arrange the necessary articles near to the mother For convenience and smooth workmanship 6 Wash hands and wear sterile apron and gloves To prevent infectiom 7 Look for the signs of crowning(perineal bulging, vulval stretching, anal pouting, hair line seen and head does not recede back in between the contractions) To prevent bleeding by giving timely episiotomy

18. 8 Swab the perineum with antiseptic solution. To prevent the contamination 9 Drape the perineum. To obtain the sterile area for delivery. 10 Rupture the membrane if it’s still intact. To speed up the delivery 11 Place two fingers in the vagina along the proposed line of incision To protect the fetal head Insert and direct the needle beneath the skin at an angle of approximately 45° for about 4-5 cm in the same line and withdraw the piston of the syringe prior to the injection. Aspiration ensures the needle has not entered a blood vessel Infiltrate the perineum continuously as the needle is slowly withdrawn To ensure adequate analgesia. 12 Withdraw the needle and apply pressure over the injection site Minimise blood loss, and prevents haematoma formation

19. 13 Place two fingers in the vagina between the presenting part and the posterior vaginal wall pointing downwards. In order to protect the fetal head. 14 Take a straight-bladed, blunt pointed sharp scissors over the area intended for incision. Nil 15 Give an episiotomy( a single deliberate cut from the centre of the fourchette extending laterally for about 3 to 4 either to the right or to the left) during the peak of uterine contraction when the birth is imminent A straight cut minimises perineal damage and facilitates optimal anatomical realignment. 16 Withdraw the scissors carefully Nil

20. 17 Encourage the mother to bear down when there is a good uterine contraction. Nil 18 Give perineal support with right hand and urethral support with left and exert pressure over the occiput. Helps for the delivery of the fetal head. (The forehead, mouth and chin are thus born successfully by extension). 19 Apply pressure to the episiotomy between contractions with a sterile pad if there is a delay in the birth. Controls bleeding from the wound

21. STRUCTURES CUT DURING EPISIOTOMY Structures cut during episiotomy Posterior vaginal wall Superficial and deep transverse perineal muscles, Bulbospongiosus and part of levator ani Fascia covering those muscles. Transverse perineal branches of pudental vessels and nerves. Subcutaneous tissue and skin.

22. Complications: Extension of the incision in to rectal tissues and anal sphincter Vulval haematoma Infection Pain and swelling Offensive discharge