REKOD OF ADAPTIVE PRACTISE 2011

POST BASIC ADVANCE EMERGENCY MEDICAL AND TRAUMA CARE

KOLEJ SAINS KESIHATAN BERSEKUTU,
KUCHING, SARAWAK.

RECORD OF ADAPTIVE PRACTICE

NAME : SITI HUSNI BINTI ENTOH

NO I/C : 790210-12-5522
MATRIC NO : PB 1/2011-1407
LOCATION : MATERNITY WARD HOSPITAL BAU SARAWAK
NAME OF PATIENT : ROZALINE AK PETER
REG. NO : 622/11

PROCEDURE/CASE EPISIOTOMY

Rozaline AK Peter /20yrs old /female /Bidayuh

OVERVIEW OF
She is G1 P 0@33/52 + 5/7
CASE/PROCEDURE
Was admitted to maternity ward on March 27,2011 at 10.30am with
complaint of contraction pain with blood show since 8.30 am , no leaking
liquor.
No blood show. No contraction pain
Pmhx/ Obs hx : Nil
On admission :
- B/P 126/84mmhg ,- PR 103/min ,-RR 22/min,- Temp 36.8`c
On palpation :
-Height of fundus is 30/50
- Cephalic, ROA
- Relation to brim is floating at brim of engaged.
- Quality :Strong and Regular
- FHR is 135/min.
Vagina examination :
- OS : closed and membrance intact
- St : high
On March 28,2011@2.00am, mother claimed stronger labour pain.
Mother on CTG Monitoring. FHR is 142 bpm and movement felt.
V/E done and shown OS is fully dilated and ready for delivery.Advice mother
to push actively upon contraction pain.
At 2.20pm head is showing and episiotomy performerced.
Baby come out at 2.22pm .
Baby boy with weight 1.84kg.
Episiotomy done by JM Evelyn and asses by Post basik AEMTC.

RECORD OF ADAPTIVE PRACTISE Page 1

 REKOD OF ADAPTIVE PRACTISE 2011

Explained to mother regading the procedure.

An episiotomy involves incision of the fourchette, the superficial muscle and
skin of the perineum and the posterior vaginal wall.
INTENDED ACTION
It can therefore successfully speed the birth only when the presenting part is
directly applied to these tissues.
If the episiotomy is performed too early it will fail to release the presenting
part and haemorrhage from cut vessels may ensue. In addition, the levator any
muscles will not have had time to be displaced laterally and may be incised as
well. If performed too late there will not be enough time to infiltrate with local
anaesthetic.There is also little reason for superimposing an episiotomy if a
tear has already begun.
To prevent a perineal tear or excessive stretching of the muscle. A tear is less
RATIONALE OF controllable and may involve the anal sphincter and overstretching will

ACTION predispose to prolapsed in later year.

To protect the fetus if it is premature or is being forced repeatedly against an
unyielding perineum which is obstructing delivery.
To prevent damage from an abnormal presenting part occipito posterior
position. Face presentation, after coming head in breech deliveries, all
instrumental deliveries. In such cases it may be done before the perineum is
distended. The obstetrician must himself put the tissue on stretch before
cutting.

PROBABLE Episiotomy can be associated with extension or tears into the muscle of the
OUTCOME rectum or even the rectum itself. Other complication can include :
Bleeding
Infection
Swelling
Defect in wound closure
Local pain
A short term possibility of sexual dysfunction

RECORD OF ADAPTIVE PRACTISE Page 2

 REKOD OF ADAPTIVE PRACTISE 2011

INTERVENTION

BEFORE AFTER

Infiltration of perineum. The perineum should be adequately anaesthetised

prior to the incision.

RECORD OF ADAPTIVE PRACTISE Page 3

 REKOD OF ADAPTIVE PRACTISE 2011

Injection lignocaine 2% is commonly used. The advantage of the more

concentrated solution is that a smaller volume is needed. It take 3-4 minutes
to have an effect and if possible, two or three contraction should be allowed to
occur between infiltration and incision.
The timing is not always easy to calculate but it is better to infiltrate and not
perform an episiotomy than to incise the perineum without an effective
lignocaine anaesthetic.
Cleansed with antiseptic solution.
Two finger are inserted into vagina along the line of the proposed incision in
order to protect fetal head.

Needle is inserted beneath to skin for 4-5cm following the same line.
The piston of the syringe should be withdrawn prior to injection to check
whether the needle is in a blood vessel.
If the blood aspirated, the needle should be repositioned and the procedure
repeatedly until no blood withdrawn.
Lignocaine anaesthetic is continuously injected as the needle is slow
withdrawn. More effective if about one – third of the amount is used at first
and two further injection are made. One either side of the incision line.
The incision type is mediolateral this begin at the midpoint of the fourchette
and is directed at 45o angle to the midline towards a point midway between
the ischial tuberosity and the anus.
A straight bladed, blunt – ended pair of mayo scissor is usually used. The
blades should be sharp to ensure a clean incision.
Two finger are inserted to vagina as before and the open blades are positioned.
The incision is best made during contraction when the tissues are stretched so
that there is clear view of the area and bleeding is less likely to be severe.
A single, deliberate cut 4-5cm long is made at the correct angle. Birth of the
head should follow immediately and its advance must be controlled in order to
avoid extension of the episiotomy. If there is any delay before the head
emerges, pressure should be applied to the episiotomy site between
contraction in order to minimise bleeding contraction in order to minimise
bleeding postpartum haemorrhage can occur from an episiotomy site unless

RECORD OF ADAPTIVE PRACTISE Page 4

 REKOD OF ADAPTIVE PRACTISE 2011

bleeding points are complicated.

The repair is done in 3 layers using absorbable material :
 vaginal canal muscle – continuous suture starting at the apex and
ending at the hymen, bringing together.
 muscle – interrupted suture , burying the knots in the muscle layer.
 perineal skin – continuous or interrupted suture burying the knot
under the suture.

Comment by Local Name of Local Preceptor / Signature by Local Preceptor /

Preceptor/Specialist Specialist Specialist

RECORD OF ADAPTIVE PRACTISE Page 5