PERFORMING AND SUTURING AN EPISIOTOMY

DEFINITION
Episiotomy is a surgically planned incision on the perineum and posterior vaginal wall performed
during the second stage of labor to facilitate delivery.
PURPOSES
1. To. substitute a straight surgical incision for the laceration that may otherwise occur.
2. To facilitate repair of incised area and promote healing.
3. To spare the newborn's head from prolonged pressure and to avoid pushing against rigid
perineum.
4. To shorten the second stage of labor.
5. To speed if there is fetal distress.
6. Prior to an assisted delivery such as forceps or ventouse extraction.
7. To minimize the risk of intracranial damage during preterm and breech delivery.
8. To prevent overstretching of the perineal muscles.
TYPES OF EPISIOTOMIES
Median or midline: Incision is made in the middle of the perineum and directed toward the anus.
* Mediolateral: Incision begins at the midline and is directed laterally.
INDICATIONS
1. Inelastic rigid perineum.
2. Primigravida.
3. Anticipated perineal tear.
4. Operative delivery.
5. Previous perineal surgery.
ARTICLES
A sterile tray containing:
1. Sterile syringe with needle.
2. Needle holder-1.
3. Episiotomy scissors-1.
4. Suture cutting scissors-1.
5. Cutting needle-1 for skin.
Round body needle-1 for muscles.
6. Thumb forceps.
7. Suture material-2-0 chromic catgut-1.
8. Kidney tray.
9. Plain lignocaine 2%.
10. Antiseptic solution.
11. Sterile gloves.
12. 4x 4 gauze pieces.
13. Tampons.
GENERAL INSTRUCTIONS
1. Ensure that:
a. The presenting part is directly applied to the perineal tissues, which will be evidenced as bulging
b. Vaginal orifice is distended by approximately 3 cm diameter of presenting part between
contractions
2. The presenting part of the fetus should be protected from injury.
3. A single cut in any direction is preferable to repeated snipping, as the latter will have jagged ends
4. The episiotomy should be large enough to meet the purpose.
5. The timing of the cut should be such that lacerations are prevented and unnecessary blood  loss
avoided.
PROCEDURE
1. Place the patient on the delivery table in dorsalrecumbent position when the fetal head is
distending the perineum.
2.Infilterate the perineum using 10 ml. of local anesthetic. Wait for 3-5 minites for the anesthetic to
act.
3. Place your index and middle fingers in the vagina with palmar side down and facing you.
Separate them slightly and exert outward pressure on the perineal body.
4. Place the blades of the scissors in a straight up and down position, so that one blade is against the
posterior vaginal wall and the other blade is against the skin of the perineal body with the point
where the blades cross at the middleof the posterior fourchette
5. Adjust the length of the blades of the scissors on the perineal body and predict the length of the
incision accordingly.
6. a. A mediolateral episiotomy is cut at a slant, starting at the midline of the fourchette with the
points of the scissors directed toward the ischial tuberosity on the same side as the incision.
b. A midline episiotomy is cut in the middle of the central tendinous points of the perineum from the
posterior fourchette down to the external anal sphincter. (Theideal timing of episiotomy is bulging
thin perineum at the peak of a contraction just prior to crowning).
7. If a midline episiotomy was cut, palpate for the external anal sphincter.
8.Cut again if needed, avoid snipping. Two cuts should accomplish the incision.
9. Extend the vaginal side of the incision if needed by incising the vaginal band. For this, the scissors
must come from above the backside of the hand to slide down the fingers and make the cut.
10. Apply pressure with 4"× 4" sponges
11 After completion of delivery assist for suturing of episiotomy incision.
12 Wipe the wound area with sterile antiseptic cotton swabs.
13. Focus light on the perineal area
14. Diagnose the degree of perineal tear if any.
15. Pack the vagina with vaginal plug or tampon
16. Visualize the apex of the mucosa, start suturing littleabove the apex. Appose the vaginal tear by
continuous suture using a round body needle.
17. Repair the perineal muscles by interrupted sutures, include the deeper tissue to enclose dead
space.
18.Perineal skin is apposed by mattress suture.
19.Remove the vaginal pack which was inserted during suturing.
20.Clean the perineum and apply perineal pads.
21.Straighten patient's legs and assist her to supine positionwith legs crossed.
22.Wash and dry the instruments used for episiotomy along with those used for conduct of delivery
and suturing.
23. Record in the labor record, the time episiotomy was performed, type of episiotomy, suturing
carried out, and patient's reaction.
AFTER CARE
1. Check for any bleeding from inner areas or hematoma formation.
2. Check vital signs.
3. Check for any other tear or laceration.
COMPLICATIONS
1. Hematoma.
2. Infection.
3. Wound dehiscence.
4. Perineal laceration.
5. Dyspareunia.
6. Scar endometriosis.
SPECIAL CONSIDERATIONS
1. Repair of the skin edges should begin at the fourchette so that vaginal opening is properly
2. Arectal examination is made when suturing is completed in order to ensure that no mucosa to
prevent fistula formation.
3. The thread should not be pulled too tightly to prevent edema formation.
REFERENCE

1. Fraser DM, Cooper MA. Myles Textbook for Midwives. 15th edition. Philadelphia: Churchill
livingstone elsevier; 2009
2. Dutta DC. Textbook of obstetrics. 6th edition. Calcutta: New central book agency;2004
3. Annamma Jacob.Clinical Nursing Procedures: The Art of Nursing Practice. 3rd edition. New
Delhi Jaypee Brothers Medical Publishers; 2015