GOVT COLLEGE OF NURSING

MBS HOSPITAL ,KOTA

PROCEDURE
ON
EPISIOTOMY

SUB-OBSTETRICS & GYNECOLOGY

SUBMITTED TO SUBMITTED BY-

MRS SANTOSH MEGHWAL SAMIKSHA

LECTURER MSC NSG FINAL2019-20

GCON,MBS HOSPITAL ,KOTA GCON ,MBS HOSPITAL,KOTA

EPISIOTOMY
DEFINITION
A surgically planned incision on the perineum & the posterior vaginal wall during the second stage of labour
with a view to facilitate the passage of foetal head & prevent uncontrolled tear of the perineal tissue is called
episiotomy (perineotomy).
OBJECTIVES
To enlarge the vaginal introitus so as to facilitate easy & safe delivery of the fetus.
To minimise overstretching & rupture of the perineal muscles & fascia; to reduce the stress & strain
on the fetal head.
INDICATIONS
Rigid perineum
Shoulder dystocia
Anticipating perineal tear
Operative delivery i.e. forceps, ventouse
Previous perineal surgery
Previous caesarean section
Breech delivery
Occipito-posterior position
Foetal distress in 2nd stage of labour
TIMING OF EPISIOTOMY
The episiotomy should be performed when presenting part is bulging in the perineum & is about to
crown or at least 3-4cm of diameter of head is visible during contraction.
In case of instrumental delivery, the episiotomy should be given after the application & locking of
blade of forceps or after application of vacuum cup.
ADVANTAGES
A clear & controlled incision is easy to repair & heals better than a lacerated wound that might occur
otherwise.
Reduction in the duration of second stage.
Reduction of trauma to the pelvic floor muscles.
It minimise intracranial injuries especially in premature babies or after-coming head of breech.
TYPES
The following are the various types of episiotomy:-
a. Medio-lateral:
The incision is made downwards & outwards from the midpoint of the fourchette either to the right
or left.
It is directed diagonally in a straight line which runs about 2.5cm away from the anus (midpoint
between anus & ischial tuberosity)
b. Median:
The incision commences from the centre of the fourchette & extends posteriorly along the midline
for about 2.5cm.
In this repair is simple, bleeding is less but disadvantage is that any extension by tearing will involve
the anal canal.
c. Lateral:
The incision starts from about 1cm away from the centre of the fourchette & extends laterally.
It has got many drawbacks including chances of injury to the Bartholin’s duct, excessive bleeding &
accurate alignment of divided structure is difficult.
It is totally condemned.
d. J shaped:
The incision begins in the centre of the fourchette & is directed posteriorly along the midline for
about 1.5cm & then directed downwards & outwards along 5 or 7 o ’clock position to avoid the anal
sphincter.

ANALGESIA FOR EPISIOTOMY

Episiotomy is always be given & repaired under analgesic.
1% lignocaine is infiltrated in line of proposed cut unless the patient has been already under epidural
anaesthesia.
One should always remember that local anaesthetic takes some time to be effective.
Woman may choose to combine Entonox &local or regional anaesthesia.

STEPS OF MEDIOLATERAL EPISIOTOMY

Articles:
10ml syringe
1% solution of sodium lignocaine
Sharp episiotomy scissor
Draping sheets
Sterile gloves
Suturing material
Preliminaries:
The perineum is thoroughly swabbed with antiseptic solution and draped properly. Local anesthesia is given
with 10ml of 1% lignocaine.
Incision:
Two fingers are placed in vagina between presenting part and posterior vaginal wall. The incision is made
by curved or straight blunt pointed sharp scissor, one blade of which is placed inside, in between the fingers
and posterior vaginal wall and other on the skin. The incision should be made at the height of uterine
contraction when an accurate idea of extent of incision can be better judged from the stretched perineum.
Deliberate cut should be made starting from center of fourchette extending laterally either to the right or to
the left. It is directed diagonally in the straight line which runs about 2.5cms away from the anus. The
incision ought to be adequate to be served the purpose for which it is needed.
Structures cut are –
 Posterior vaginal wall
 Superficial and deep transverse perineal muscles, bulbospongiosus and part of levator ani
 Fascia covering the muscles
 Transverse perineal branches of pudendal vessels and nerves
 Subcutaneous tissue and skin
Repair:
Timing of repair
The repair is done soon after expulsion of placenta. If repair is done prior to that, disruption of wound is
inevitable, if subsequent manual removal or exploration of genital tract is needed. Oozing during this period
should be controlled by pressure with sterile gauze swab and bleeding by artery forcep. Early repair prevents
sepsis and eliminates patient’s prolonged apprehension of stitches.
Preliminaries
Patient is placed in Lithotomy position. A good light source from behind is needed. Perineum including
wound area is cleaned with antiseptic solution. Blood clots are removed from vagina and wound area.
Patient is draped properly and repair should be done under strict aseptic precautions. Ifrepair field is
obscured by oozing of blood from above, vaginal pack may be inserted and placed high up. Donot forget to
remove the pack after repair is completed.
Repair is done in 3 layers:
Principles to be followed are-
 Perfect homeostasis
 To obletrate the dead space
 Suture without tension
Repair is to be done in following order:
 Vaginal mucosa and submucosal tissue
 Perineal muscles
 Skin and subcutaneous tissue
A continuous suture used to repair the vaginal wall. Three or four interrupted sutures to repair the fascia and
muscles of perineum and Integrated sutures to the skin.

For perineal tear:-

Step-I
Dissection is not required as in a complete perineal tear. Rectal and anal mucosa is first sutured from
above downwards. No.’00’ vicryl, a traumatic needle, interrupted stitches with knots inside the
lumen is used.
Rectal mucosa, including the para rectal fascia, is sutured by interrupted sutures using same suture
material.
The torn ends of sphincter ani externus are then exposed by Allis tissue forcep. The sphincter is then
reconstructed with a figure of eight stitch and is supported by another layer of interrupted sutures.
Step-II
Repair of perineal muscle is done by interrupted suture using no. 0 or dexon or polyglactin vicryl.
Step-III
Vaginal wall and perineal skin are apposed by interrupted sutures.
AFTER CARE OF EPISIOTOMY
Dressing: The wound is to be dressed each time following urination & defecation to keep the area
clean & dry. The dressing is done by swabbing with cotton swabs soaked in antiseptic solution
followed by application of antiseptic cream.
Comfort: To relieve pain in the area, magnesium sulphate compress or application of infra-red heat
may be used. Analgesic may be given as & when required to relieve pain.If there is persistent &
severe pain, vaginal haematoma should be ruled out.
Ambulance: The patient is allowed to move out of the bed after 24 hours. Prior to that, she is
allowed to roll over on to her side or even to sit but only with thighs apposed.
Antibiotics:Postoperative antibiotic, for 5-7 days which helps in prevention of infection.
Stool softener:A stool softener can be given to allay discomfort during defecation.
Removal of stitches: Catgut sutures need not be removed. Non-absorbable sutures like silk or nylon
are to best cut on 6th day.
COMPLICATIONS OF EPISIOTOMY
1. Immediate:
Extension of the incision to involve the rectum.
Vulval haematoma
Infection
Wound dehiscence due to infection, haematoma or faulty repaired.
Injury to anal sphincter
Recto-vaginal fistula
Rarely necrotizing fasciitis in women who are diabetic or immune-compromised.
2. Remote:
Dyspareunia due to a narrow vaginal introitus which may result from faulty technique of repair.
Chance of perineal laceration in next labor.
Rarely scar endometriosis, implantation dermoid.

BIBLIOGRAPHY-
 Hiralalkonar, D.C DUTTA’S Textbook of obstetrics, japee publications,8 th edition.

 Annamma Jacob, A comprehensive textbook of midwifery and gynaecological nursing, japee publication,
4th edition.

 www.wikipedia.org.