Episiotomy.pptx Shweta singh M.sc nursing

Obstetrics and gynecological nursing
Shweta singh M.sc nursing

1. Episiotomy Presented by – ms . Shweta singh m.Sc nursing I year

2. Although episiotomy was a routine part of normal childbirth in the early days, with the advancement in knowledge, it is now recommended only for certain cases.  The episiotomy rate in India is difficult to ascertain, although some studies have shown that it may range between 53-77%, but can be as high as 92% in case of deliveries at private hospitals.

3. Episiotomy, also known as peritectomy , is a surgical procedure in which an incision is made in the vaginal tissue and the muscle between the vagina and anus, called the perineum.  Its is the most common obstetric operation performed.

4. 1 . To enlarge the vaginal introitus so as to facilitate easy and safe delivery of the foetus: spontaneous or manipulative.   2.To minimize overstretching and rupture of the perineal muscles and fascia; to reduce the stress and strain on the foetal head.

5. Episiotomy is recommended in selective cases rather than as a routine. A constant care during the second stage reduces the incidence of episiotomy and perineal trauma.   In elastic (rigid) perineum- causing arrest or delay in descent of the presenting part as elderly primigravidae

6. Anticipating perineal tear - Big baby Face to face pubis delivery Breech delivery and Shoulder dystocia   Operative delivery – Forceps delivery, ventouse delivery   Previous perineal surgery – Pelvic floor repair, perineal reconstructive surgery.

7. Common indications are-   Threatened perineal injury in primigravidae Rigid perineum and Forceps, breech , occipito posterior or face delivery

8. Timing of episiotomy –   The timing of performing the episiotomy requires judgment. If done early, the blood loss will be more. If done late, it fails to prevent the invisible lacerations of the perineal body and thereby fails to protect the pelvic floor- the very purpose of the episiotomy is those defeated. Bulging thinned perineum during contraction just prior to crowing (when 3-4 cm of head is visible is the ideal time)

9. Advantages of an Episiotomy Maternal: The delivery process becomes much easier. Less effort is required by the mother to push the baby out during delivery. Delivery can be hastened, especially when the baby is distressed. Less chance of injury to the tissues. Fewer complications during delivery. Shortening the duration of second stage of labour .

10. Foetal: It minimizes intracranial injuries, especially in premature babies or aftercoming head of breech.

11. Classification s

12. Episiotomy can be classified into four types: Mediolateral: The incision is made downwards and outwards from the midpoint of the fourchette either to the right or to the left. (a thin fold of skin at the back of the vulva). It runs diagonally in a straight line about 2.5 cm away from the anus (Midpoint between anus and ischial tuberosity).   Median: The incision begins in the center of the fourchette (a thin fold of skin at the back of the vulva) and extends for 2.5 cm on the posterior side along the midline.

13. Lateral: The incision begins about 1 cm away from the center of the fourchette (a thin fold of skin at the back of the vulva) and extends laterally. Because of the risk of injury to the Bartholin's duct (secretes fluid that helps lubricate the vagina), some practitioners strongly advise against lateral incisions.   J-shaped: The incision begins in the center of the fourchette (a thin fold of skin at the back of the vulva) and is directed posteriorly along the midline for about 1.5 cm before being directed downward and outward along the 5 or 7 o'clock position to avoid the internal and external anal sphincters. This procedure is not widely used.  

14. Episiotomy procedure

15. Episiotomy Procedure Episiotomy should be performed at the time of maximum uterine contraction and only when the presenting part distends the vaginal opening to about 3 to 4 cm. If forceps are to be applied, episiotomy should be done just prior to its application. Step 1) Preliminaries- The perineum is thoroughly swabbed with antiseptic (povidone-iodine) lotion and draped properly. Local anaesthesia: - the perineum, in the line of proposed incision s infiltrated with 10ml of 1% solution of lignocaine.

16. Step 2) incision-   By inserting two fingers in the vagina, the perineal skin is held away from the presenting part of the foetus (head, buttocks, face, or shoulder). The area to be cut is infiltrated with local anaesthesia if epidural anaesthesia is not given. Still keeping the fingers within the vaginal opening, the tissue is cut by a pair of rounded episiotomy scissors. The incision given is approximately 3 to 5 cm in length, either in the midline or mediolaterally.

17. Deliberate cut should be made starting from the center of the fourchette extending laterally either to the right or to the left. The cut enlarges the vaginal opening and helps in easy delivery of the baby. If a forceps or vacuum delivery is contemplated, a larger incision may be necessary. After delivery of the baby and placenta, the episiotomy incision is repaired in layers by means of absorbable suture materials which will not need to be removed later.

18. Step 3)- repair- Timing of repair- the repair is done soon after expulsion of placenta. if repair is done prior to that, disruption of the wound is evitable, 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 patients prolonged apprehension of “stiches”.

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 clot are removed from the vagina and wound area. The patient is dripped properly and repair should be done under strict aseptic precautions. If the repair field is obstructed 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. Aftercare and Healing The episiotomy wound normally heals by 4 to 6 weeks. The length of the incision as well as the suture material used will determine the healing time. Proper care of the episiotomy wound is necessary for quick healing and early recovery. Pain relief during the first 24 hours can be obtained by using ice packs. Pain relievers should be taken only on doctor’s advice. Keeping the incision area clean with warm water and soap. Sitting in a Sitz bath (a tub full of warm water) for 20 minutes several times a day can help to relieve pain. Application of local anaesthetic ointments for pain relief. Avoiding constipation, which can put pressure on the stitches.  

21. Risks & Complications

22. Risks & Complications of Episiotomy As with any surgical procedure, episiotomy is not without risk. Complications can arise due to penetration of the episiotomy incision into deeper structures, as well as due to various other reasons. The major complications are briefly highlighted below: Excessive Blood Loss:   This can occur either at the time of the episiotomy or after the repair.

23. Extension of the wound:   The wound may extend beyond its intended limits. It may also include the anal region resulting in faecal incontinence Perineal Infections:   Infections are very rare, but can nevertheless occur. Necrotizing fasciitis is a rare but potentially fatal complication of episiotomy. Moreover, methicillin-resistant  Staphylococcus aureus  infection arising from the episiotomy site has also been reported. Postpartum Perineal Pain:  Excessive perineal pain after childbirth can be a sign of the formation of a hematoma, a blood clot in the wound.

24. Health Tips Be cautious about sex after an episiotomy:  Be careful about infections after an episiotomy:  Be aware of the early signs of infection following an episiotomy. Be careful of the following signs: intense pain, swelling and redness at the wound site; pus or liquid oozing from the wound; unusual or putrid smell from the wound; and fever or chills. If experience any of these signs should consult doctor immediately . Seek doctor’s advice about medications for relieving constipation:  If suffer from constipation, there is a greater chance of rupturing y stitches due to the pressure during bowel movements. Ask doctor for suitable medications that can alleviate constipation.

25.   Episiotomy is an incision in the perineum carried out during the second stage of labour to facilitate the birth of an infant. It is an important surgical procedure with physiological, psychological and socio-economic effect on women. While episiotomy may be beneficial for a subgroup of women and their infants. In choosing to perform an episiotomy , it is important to acknowledge the risks of lacerations, excessive blood loss, dyspareunia, postpartum perineal pain, and infection and to take steps to minimize these risks. Episiotomy should only be performed when the expected benefits outweigh the potential risks.

26.     Episiotomy is an incision in the perineum carried out during the second stage of labour to facilitate the birth of an infant. I prepared lesson plan on episiotomy. In this topic I discussed about introduction, definition, list out the objectives of episiotomy, Enlist the indications of episiotomy, List down the timing of episiotomy, explain about advantages of episiotomy, Classify the Types of episiotomy, Classify the episiotomy based on extent of the tear, Explain procedure of episiotomy, List out the aftercare and healing of episiotomy, Explain recovery after episiotomy, Enlist the risks & complication, Enlist health tips.

27. Bibliography Dutta’s DC, textbook of obstetrics, nineth edition, Jaypee publishers, page no. 528-531. Carrolli G, M. L. (2009). “Episiotomy for vaginal birth: the Cochrane collaboration; 1-50. Episiotomy - Types, Risks & Complications (medindia.net)