REPAIR OF EPISIOTOMY

•Apply antiseptic solution to the area around the episiotomy

•Close the vaginal mucosa using continuous 2-0 suture:
• Start the repair about 1 cm above the apex (top) of the episiotomy.
Continue the suture to the level of the vaginal opening.
• Close the perineal muscle using interrupted 2-0 sutures.
• Close the skin using interrupted 2-0 sutures
Repair of episiotomy
COMPLICATIONS
• If a haematoma occurs, open and drain it. If there are no
signs of infection and bleeding has stopped, reclose the
episiotomy.

• If there are signs of infection, open and drain the wound.

Remove infected sutures and debride the wound:
• If the infection is mild, antibiotics are not required.
• If the infection is severe but does not involve deep
tissues, give a combination of antibiotic:
- ampicillin 500 mg by mouth four times per day for 5
days;
- PLUS metronidazole 400 mg by mouth three times
MANUAL REMOVAL OF
PLACENTA
Review for indications:
• If the placenta has not expelled within 30 minutes after the
birth of the baby, especially in cases of heavy bleeding,
manual removal is recommended.
• In the absence of hemorrhage, the woman can be observed
for another 30 minutes before manual removal of the
placenta is attempted.
• A conservative approach is advised. However, if the woman
is bleeding heavily, manual removal of the placenta should
be attempted.
•Review general care principles and start an IV infusion.
•Ensure that the woman has a companion of her choice with her
while she is being cared for.
•Provide emotional support and encouragement to the woman.
Explain the procedure in simple terms. Obtain her verbal consent
to perform the procedure.
•Give morphine and diazepam IV slowly (do not mix in the same
syringe) or use ketamine
•In cases of hemorrhagic shock, avoid the administration of
medications that could cause mental status changes in the woman
(i.e. narcotic pain medication and sedatives).
•Give a single dose of prophylactic antibiotics:
• ampicillin 2 g IV OR cefazolin 1 g IV.
•Catheterize the bladder or ensure that it is empty.
•Wash and dry hands. Put on sterile gloves (use long gloves if
available).
•Hold the umbilical cord with a clamp. Pull the cord gently with
one hand until it is parallel to the floor.
•Insert the other hand into the vagina and up into the uterus
Introducing one hand into the vagina along cord
Supporting the fundus while detaching the placenta
Withdrawing the hand
from the uterus
Examine the uterine surface of the placenta to ensure that it is
complete. If any placental lobe or tissue is missing, explore the
uterine cavity to remove it.

Examine the woman carefully and repair any tears to the cervix
or vagina, or repair episiotomy.
PROBLEMS
If the placenta is retained due to a constriction ring, or if
hours or days have passed since the woman gave birth, it
might not be possible to get the entire hand into the uterus.
Extract the placenta in fragments using two fingers, ovum
forceps or a wide curette.
POST-PROCEDURE CARE
•Observe the woman closely until the effect of IV sedation
has worn off.
•Monitor vital signs (pulse, blood pressure, respiration)
every
15 minutes for two hours and then every 30 minutes for the
next six hours or until stable.
•Palpate the uterine fundus to ensure that the uterus
remains contracted.
•Check for excessive lochia.
•Continue infusion of IV fluids.
•Transfuse as necessary
•Document procedure and post-procedure care, including
any medications given.
•Counsel the woman and ensure that she understands
what the procedure was and why it was done.
•Provide postnatal care in the facility for at least 24 hours
after childbirth.