EPISIOTOMY

Definition

A surgically planned incision on the perineum

and the posterior vaginal wall during the second
stage of labour is called episiotomy
 PurposeS

• To enlarge the vaginal introitus

• To facilitate easy and safe delivery
• To minimize rupture of the perineal muscles
& facia
• To reduce stress on fetal head.
 Indications
• In rigid perineum
• Shoulder dystocia
• Breech delivery
• Face to pubis delivery
• Big baby
• Anticipating perineal tear
Common indication
•  Forceps delivery
• Rigid perineum
• Threatened perineal injury
 Advantages
Maternal
• Easy to repair  
• Reduction in duration of labour
• Reduction of trauma
Fetal
• Minimizes intracranial injuries esp. in
premature babies
 Timing of episiotomy

Bulging thinned perineum during contraction

just prior to crowning
 Types of episiotomy
• Medio lateral
• Lateral
• Median
• J shaped
 Medio lateral
• Begins at the midpoint of the fourchette
• Directed at a 45 degree angle to the midline
• Towards a point midway between the ischial
tuberosity and anus
 MERITS
• Safety from rectal involvement
• Incision can be extended

DEMERITS
• Apposition of tissue not so good
• discomfort is more
• Wound disruption is more
 Median
• Midline incision that follows the natural line of
insertion of the perineal muscles.
Merits
• Reduced blood loss
• Easy to repair
• Lesser pain
Demerits
• Extention may involve the rectum
• Damage to anal sphincter
 Medio lateral episiotomy
• Step 1:preliminaries
• Step 2:Incision
• Step 3:Repair
 Equipments
• Sterile drape
• Sterile gown and gloves
• Gauze swabs and tampon
• Needle holder
• Sponge holder
• 10 ml syringe
• Scissors
• Toothed forceps
• Suture material
• 1% lignocaine
 1 :Preliminaries
• The perineum is thoroughly swabbed with
antiseptic lotion
• Draped properly
• Incision line- Infiltrated with 10 ml of 1%
lignocaine solution
 2:Making Episiotomy
• Two fingers are placed in the vagina between the presenting part &
posterior vaginal wall.
• The incision is made by straight or curved blunt pointed sharp scissors
• The open blades are positioned.
• Incision should be made at the height of an contraction
• Cut should be made starting from the centre of the forchette
extendening laterally either to the left or right.
• It is directed diagonally in a straight line which runs about 2.5 cm away
from the anus.
• If delivery of the head does not follow immediately, apply pressure to
the episiotomy site.
• Control delivery of the head to avoid extension of the episiotomy.
 Structures involved
• Posterior vaginal wall  
• Superficial & deep transverse perineal muscles
• Fascia covering the muscles
• Transverse perineal branches of pudendal
vessels& nerves
• Subcutaneous tissue& skin.
 3:Perineal Repair
• Repair is done soon after the expulsion of the
placenta.
Purpose of Repair
• To control bleeding
• To prevent infection
• To assist wound healing by primary intention
Traditional sutures
• catgut, chromic catgut
 Preliminaries :
• The patient is placed in lithotomy position
• A good light source from behind is needed to find the
apex first.
• The perineumand the wound area is cleaned with
antiseptics
• Blood clots are removed from the vagina and the
wound area
• The patient is draped properly &repair should be done
under strict aseptic precaution
• A vaginal pack is inserted & is placed high up.
 Principles in suturing
• Close all dead space
• ensure haemostasis and prevent infection
• Cotton balls must not be used.
• Handle tissue gently using non toothed forceps.
• Ensure good anatomical restoration and alignment to facilitate
healing.
• Use minimal amount of suture material, and do not over
tighten suture this may impede healing.
• Following the repair a rectal examination should be
performed to ensure no suture material has been inserted
through the rectal mucosa
 Layers of perineal repair
• Vaginal mucosa& submucosal tissue
• Perineal muscles
• Skin & subcutaneous tissue
 Step 1 Suturing the vagina
• Identify the apex.
• Insert the anchoring suture 0.5 cm above the
apex.
• Repair the vaginal wall with a continuous non-
locking stitch with approximately 0.5 cm
between each stitch
Step 2 Suturing the perinealmuscle
• Check the depth of the trauma.
• Repair the perineal muscles in one or two layers
with the same continuous stitch.
• Ensure the muscle edges are apposed carefully
leaving no dead space.
• On completion of the muscle layer, the skin
edges should align
• so that they can be brought together without
tension.
 Step 3 Suturing the skin
• Reposition the needle at the inferiorend of the
wound commence.
• Stitches are placed below the surfaceof the skin
• The point of the needle should be repositioned
between each side
• So that it faces the skin edge being sutured.
• Continue taking bites of tissue from each side
until the superior wound edge is reached.
 Immediate care
• Inspect the repair to check that haemostasis has
been achieved
• Remove the vaginal tampon, if used
• Account for all instruments, swabs and needles
• Discard sharps safely
• Apply sterile pad following thorough perineal wash
• Wait for minimum one hour to shift the patient to
ward
• Check for bleeding & urine output
 complications
Immediate  
• Vulval hematoma
• Infection
• Infection
• Wound dehiscence

Remote
• Recto vaginal fistula
• Scar endometriosis
• Dyspareunia
  Health education
Diet
• Eat a diet high in fibre and fluids to prevent constipation
• Ask the women to walk with thighs apposed
• not to use squatting position since the wound is healing.

Perineal hygiene
• Change sanitary pads at least every 4 hours to help prevent infection.
• squirt warm tap water over the perineum, beginning at the front and moving toward the
back .
• Sit in a tub of warm water
• Always wash hands thoroughly before and after going to the bathroom.
• Always keep the wound clean & dry after each urination & defecation.

kegal’s exercise
• Squeeze the perineal muscles as if you were trying to stop the flow of urine
• Hold for 5 to 10 seconds and then relax. Do this exercise 10 times a day to regain muscle
strength