Episiotomy

Episiotomy, also known as perineotomy, is a

surgical incision of the perineum and the
posterior vaginal wall generally done by a
midwife or obstetrician. Episiotomy is usually
performed during second stage of labor to
quickly enlarge the opening for the baby to pass
through.
Definition :- an episiotomy is a surgical
incision in the perineum to enlarge the vaginal
orifice for obstrical purpose.
Purpose:-
- to minimize over stretching the perineal muscles in the
case of the large baby.
- To enlarge the vaginal introitus.
- To speed up delivery in fetal distress.
In second stage of labor .
- To minimize the risk of intra cranial damage during the
pre term and breech delivery.
- To assist delivery such a forceps or vacuum extraction.
- To prevent third and fourth degree of tear.
- To decrease the second stage of labor in the case of any
chronic disease
• Indication :-
 fetal distress in the second stage of labour.
 Complicated vaginal delivery.( breech , shoulder
dystocia, forceps or vacuum)
 scar from female genital cutting.
 maternal distress.
 very tight perineum.
 premature baby.
 to make short second stage of labour.eg heart disease ,
severe pre eclampsia, eclampsia, previous c\s ,post
maturity.
Big baby, cord prolapse in 2nd stage of labour.
Contd. .
Mediolateral :- the incision made down ward and
outward from the midpoint of the fourchette either to
the right or left. It is directed diagonaslly in a straight
line which runs about 2.5 cm from the anus
Mediolateral
Median
Contd. .
• Median :- this is a midline incision which follows the
natural line at of insertion of the perineal muscles .incision
commence from the centre of the fourchette and extend
posterior along the midline for about 2.5 cm
• Lateral :- the incision start from about 1cm away from the
centre of the fourchette and extends laterally.
• J shaped :- this incision begin in the centre of the fourchette
and is directed posteriorly along the midline for about 1.5
cm and then directed down ward along 5or 7 o’clock
position to avoid internal and external anal sphincter.
Perineal tears
• These are classified into 4 degrees:
- 1st-degree tears are where the fourchette and
vaginal mucosa are damaged and the underlying
muscles are exposed, but not torn.
- 2nd-degree tears are to the posterior vaginal walls
and perenial muscles, but the anal sphincter is
intact.
- 3rd-degree tears extend to the anal sphincter that is
torn, but the rectal mucosa is intact.
- 4th-degree tears are where the anal canal is opened,
and the tear may spread to the rectum.
 Classification of perineal trauma

First degree Injury to perineal skin only

Second degree Injury to perineum involving perineal
muscles but not involving the anal
sphincter
Third degree Injury to perineum involving the anal
sphincter complex:
  3a: Less than 50% of external anal
sphincter (EAS) thickness torn
Repair of perineal trauma
 
Basic principles prior to repairing
perineal trauma
The skills and knowledge of the operator are important factors in
achieving a successful repair. Ideally the repair should be conducted in
a timely manner by the same midwife who afended the woman in
labour. This ensures seamless continuity of care, as the midwife would
have established a good rapport and trust with the woman. The woman
should be referred to a more experienced healthcare professional if
uncertainty exists as to the nature or extent of trauma sustained. Having
fully informed the woman why a detailed examination is required and to
gain her consent, an initial systematic assessment of the perineal
trauma must be performed including a sensitive rectal examination to
exclude any trauma to the IAS/EAS is not missed (NICE 2007).
In order to reduce maternal morbidity, repair of the perineum should be
undertaken as soon as possible to minimize the risk of bleeding and
oedema of the perineum as this makes it more difficult to recognize
tissue structures and planes when the repair eventually takes place.
Perineal trauma should be repaired using aseptic techniques.
Equipment should be checked and swabs and needles counted before
and aher the procedure.
A repair undertaken on a non-cooperative woman, due to pain, is likely to
result in a poor repair. Ensure that the wound is adequately anaesthetized
prior to commencing the repair. It is recommended that 10–20 ml of
lidocaine 1% (maximum dose 3 mg/kg) is injected evenly into the perineal
wound. If the woman has an epidural it may be ‘topped- up’ instead of
injecting local anaesthetic.
The issue of obstetric anal sphincter injuries is addressed in more detail
later in the chapter, but it is worth noting here that repair of such trauma
should be undertaken in theatre, under general or regional anaesthesia. In
addition to providing pain relief, this provides the added advantage of
relaxing the muscles, enabling the operator to retrieve the ends of the torn
sphincter and identify the full length of the anal sphincter prior to repair. An
indwelling catheter should be inserted for at least 12 hours to avoid urinary
retention.
In the case of FGM, if a woman undergoes
a deliberate traumatic deinfibulation in
labour without antenatal preparation she
may ask to be reinfibulated (closed again),
but any repair carried out aher birth,
whether following spontaneous laceration
or deliberate defibulation, should be
sufficient to oppose the raw edges of the
perineal trauma and control bleeding. It
must not result in a vaginal opening that
makes intercourse difficult or impossible,
as this would be in breach of the law. The
WHO (2001, 2008, 2013) recommends
suturing of raw edges to prevent
spontaneous reinfibulation but an individual
assessment should be made.
First-degree tears and labial lacerations
 
Women should be advised that, in the case of first-degree trauma,
the wound should be sutured in order to improve healing, unless
the skin edges are well opposed (NICE 2007). If the tear is leh
unsutured, the midwife or doctor must discuss the implications
with the woman and obtain her informed consent. Details
regarding the discussion and consent must be fully documented
in the woman's case notes.
Labial lacerations are usually very superficial but may be very
painful. Some practitioners do not recommend suturing, but if the
trauma is bilateral the lacerations can sometimes adhere together
over the urethra and the woman may present with voiding
difficulties. It is important to advise the woman to part the labia
daily during bathing to prevent adhesions forming. This is
particularly important when caring for women with type 3 FGM.
Episiotomy and second-degree tears
 
Although the repair of these tears was previously
carried out using the interrupted technique, the
continuous suturing technique for perineal skin
closure has been shown to be associated with less
short-term pain. Moreover, if the continuous
technique is used for all layers (vagina, perineal
muscles and skin), the reduction in pain is even
greater (Kefle et al 2007). The perineal muscles
should be repaired using absorbable polyglactin
material which is available in standard and rapidly
absorbable forms. A recent Cochrane review has
shown that there are few differences in short-term
and long-term pain, between standard and rapidly
absorbing synthetic sutures, but more women need
standard sutures to be removed (Kettle et al 2010).
 
Technique for perineal repair
 
Technique is important, as is the suturing
material used (Kettle and Fenner 2007).
 
 
Suturing the vagina (Fig. 15.7a)
Using 2/0 absorbable polyglactin 910
material (Vicryl rapide®), the first stitch is
inserted above the apex of the vaginal skin
laceration to secure any bleeding points.
The vaginal laceration is closed using a
loose, continuous, non-locking technique
ensuring that each

stitch is inserted not more than 1 cm apart

to avoid vaginal narrowing. Suturing is
continued down to the hymenal remnants
and the needle is inserted through the skin
at the fourchette to emerge in the centre of
the perineal wound.
Continuous suturing technique for mediolateral episiotomy (
Kettle and Fenner 2007): (a) loose continuous non-locking stitch to the
vaginal wall; (b) loose, continuous non-locking stitch to the perineal muscle;
(c) closure of skin using a loose subcutaneous stitch.
Suturing the muscle layer (Fig. 15.7b)
The muscle layer is then approximated aher assessing the depth of the
trauma and the perineal muscles (deep and superficial) are approximated with
continuous non-locking stitches. If the trauma is deep, two layers of
continuous stitches can be inserted through the perineal muscles.
 
 
Suturing the perineal skin (Figure 15.7c)
To suture the perineal skin the needle is brought out at the inferior end of the
wound, just under the skin surface. The skin sutures are placed below the
skin surface in the subcutaneous tissue, thus avoiding the profusion of nerve
endings. Bites of tissue are taken from each side of the wound edges until the
hymenal remnants are reached. A loop or Aberdeen knot is placed in the
vagina behind the hymenal remnants.
A vaginal examination is carried out to ensure that the vagina is not narrowed
and a rectal examination carried out to ensure that sutures have not been
inadvertently placed through the anorectal epithelium.
Obstetric anal sphincter injuries (OASIS)

The quoted rate of OASIS is 1% of all vaginal births (

RCOG 2007), although a more recent analysis reveals the
rate to be 3.2% in consultant-led units (unpublished data).
However, ‘occult’ OASIS (i.e. defects in the anal sphincter
detected only by anal endosonography) has been identified
in 33% of primiparous women following vaginal birth (
Sultan et al 1993). More recent work has shown that these
defects were not really occult but could have been
identified by an adequately trained doctor or midwife (
Andrews et al 2006a). The most plausible explanation for
what was previously believed to be an ‘occult’ OASIS is
either an injury that has been missed, recognized but not
reported, or, wrongly classified as a second-degree tear (
Sultan and Thakar 2007).
 
Technique for OASIS repair (Sultan and Thakar 2007)
In the presence of a fourth-degree tear, the torn anorectal epithelium is sutured
with a continuous 3/0 Vicryl suture. When torn (Grade 3c tear/fourth-degree),
the internal anal sphincter tends to retract and can be identified lateral to the
torn anal epithelium. It should be repaired with mafress sutures using 3-0 PDS
(Polydioxanone) or modern braided sutures such as 2/0 Vicryl (polyglactin –
Vicryl®). To repair a torn external anal sphincter, the ends are grasped using
Allis forceps and the muscle is mobilized. When the EAS is only partially torn
(Grade 3a and some 3b) then an end-to-end repair should be performed using
two or three mafress sutures. Haemostatic ‘figure of eight’ sutures must not be
used to repair the mucosa or sphincter muscle. If there is a full-thickness EAS
tear (some 3b, 3c or fourth-degree), either an overlapping or end-to-end
method can be used with equivalent outcome. The limited data available from
the Cochrane review on the topic showed that compared to immediate primary
end-to-end repair of OASIS, early primary overlap repair appears to be
associated with lower risks of faecal urgency and anal incontinence symptoms
and deterioration of anal incontinence over time. However, as the experience
of the surgeon was addressed in only one of the three studies reviewed, it
would be inappropriate to recommend one type of repair over the other (
Fernando et al 2006). Aher either technique of repairing the external sphincter
the remainder of the tear is closed using the same principles and suture
material outlined in the repair of episiotomy.
Basic principles after repair of perineal tears (NICE 2007; Sultan and Thakar 2007)
 
Aher repair, complete haemostasis should be achieved. A rectal and vaginal
examination should be performed to confirm adequate repair, to ensure that no other
tears have been missed and that a suture is not inadvertently placed through the rectal
mucosa. Confirm that all tampons (if used) or swabs have been removed.
Detailed notes should be made of the findings and repair. Completion of a pre- designed
proforma and a pictorial representation of the tears can prove very useful when notes
are being reviewed following complications, audit or litigation. An accurate detailed
account of the repair should be documented in the woman's case notes

following completion of the procedure, including details of suture method and materials
used.
The woman should be informed regarding the use of appropriate analgesia, hygiene and
the importance of a good diet and daily pelvic floor exercises. It is important that the
woman is given a full explanation of the injury sustained and contact details if she has
any problems during the postnatal period. In presence of OASIS women should be
advised that the prognosis following EAS repair is good, with 60–80% being
asymptomatic at 12 months (RCOG 2007). In the case of FGM, the woman and her
partner must be advised about the legalities regarding reinfibulation and safeguarding
issues if the baby is female.
Postoperative care after OASIS
 
Broad-spectrum antibiotics should be given intraoperatively (intravenously) and continued orally for 3
days. Severe perineal discomfort, particularly following instrumental delivery, is a known cause of
urinary retention, and following regional anaesthesia it can take up to 12 hours before bladder
sensation returns. A Foley catheter should be inserted for at least hours unless medical staff can
ensure that spontaneous voiding occurs at least every 3–4 hours without undue overdistension of the
bladder.
The degree of pain following perineal trauma is related to the extent of the injury and OASIS is
frequently associated with other more extensive injuries, such as paravaginal tears. In a systematic
review, Hedayati et al (2003) found that rectal analgesia such as diclofenac is effective in reducing
pain from perineal trauma within the first 24 hours aher birth and women used less additional
analgesia within the first 48 hours aher birth. Diclofenac is almost completely protein-bound and
therefore excretion in breast milk is negligible. In women who had a repair of a fourth-degree tear
diclofenac should be administered orally as insertion of suppositories may be uncomfortable and there
is a theoretical risk of poor healing associated with local anti-inflammatory agents. Codeine based
preparations are best avoided as they may cause coAnstipation leading to excessive straining and
possible disruption of the repair. It is of utmost importance that constipation is avoided as passage of
constipated stool or indeed faecal impaction may disrupt the repair. Stool soheners (Lactulose) should
be prescribed for the first 10–14 days postpartum and the dose titrated to keep the stools soh. The
addition of isphagula
husk (Fybogel) should be avoided as it has been shown to be non-beneficial (Eogan 2007). It is reco
mmended that women with OASIS be contacted by a healthcare provider

24 or 48 hours aher hospital discharge to ensure bowel evacuation has occurred (Sultan and Thakar
2007).
Follow-up
 
Special designated multidisciplinary clinics should be available for women with perineal
problems to ensure that they receive appropriate, sensitive and effective management. All
women who sustain OASIS should be assessed by a senior obstetrician at 6–12 weeks

aher birth (RCOG 2007). If facilities are available, follow-up of women with OASIS should
be in a dedicated clinic with access to endoanal ultrasonography and anal manometry, as
this can aid decision on future mode of birth ( RCOG 2007; Scheer et al 2009).
In the clinic a genital examination is performed looking specifically for scarring, residual
granulation tissue and tenderness. Where facilities are available, women would undergo
anal manometry and endosonography. The women are assessed by the physiotherapists
and advised to continue pelvic floor exercises while others with minimal sphincter
contractility may need electrical nerve stimulation.
If a perineal clinic is not available, women with OASIS should be given clear instructions,
preferably in writing, before leaving the hospital. In the first six weeks following birth, they
should look for signs of infection or wound dehiscence and call with any increase in pain or
swelling, rectal bleeding, or purulent discharge. Any incontinence of stool or flatus should
also be reported. Under such circumstances referral to a specialist gynaecologist or
colorectal surgeon for endoanal ultrasound and manometry should be considered (RCOG
2007).
 
 
Medicolegal considerations
Although creating a third- or fourth-degree tear is seldom found to be
culpable, missing a tear is considered to be negligent. It is essential that a
rectal examination is performed before and aher any perineal repair and
findings must be carefully documented in the notes. Delay in repairing in
theatre, poor note-keeping, repair by untrained personnel, poor lighting and
inadequate exposure, inadequate anaesthesia, failure to recognize extent of
the tear, use of wrong suture material, forgofen swab in the vagina, deviation
from recommended safe practice, failure to inform and counsel the woman,
failure to inform the general practitioner, inappropriate follow-up and advice
regarding subsequent pregnancy are common issues raised at litigation. In
the UK a recent report by the National Health Service Litigation Authority
(NHSLA 2012) demonstrated that during the review period, from 1 April 2000
to 31 March 2010, the NHSLA received 441 claims in which allegations of
negligence were made arising out of perineal damage (principally third- and
fourth-degree tears) caused during labour. The total value of those claims,
including both damages and legal costs, was estimated to be £31.2 million.
Allegations of negligence included failure to consider a caesarean section or
perform or extend the episiotomy, and failure to diagnose the true extent and
grade of the injury including failure to perform a rectal examination. Failure to
perform the repair and the adequacy of the repair itself were also raised as
allegations in this cohort of claims (NHSLA 2012).
 
Training
 
Throughout the centuries, midwives have received very lifle formal training in
the art of perineal suturing. In June 1967, midwives working in the United
Kingdom were

permifed by their then regulatory body, the Central Midwives Board (CMB), to
perform episiotomies, but they were not allowed to suture perineal trauma. In
June 1970 the Chairman of the CMB issued a statement that midwives who
were working in ‘remote areas overseas’ may be authorized by the doctor
concerned to repair episiotomies, provided they have been taught the
technique and were judged to be competent, but the final responsibility lay with
the doctor. It was not until 1983, however, that perineal repair was included in
the midwifery curriculum in the UK, when the European Community Midwives
Directives came into force and the CMB issued the statement that midwives
may undertake repair of the perineum provided they received the necessary
instruction and are deemed competent to undertake the procedure (Thakar
and Kefle 2010). Tohill and Kefle (2013) have provided evidence-based
guidelines for midwives on how to suture correctly.
However, it has been reported that there is a lack of general knowledge
on the agreed classification of perineal trauma and that midwives feel
inadequately prepared to assess or repair perineal trauma (Mutema
2007). It has also been demonstrated that practitioners require more
focused training relating to performing mediolateral episiotomies.
Andrews et al (2006b) carried out a prospective study over a 12-month
period of women having their first vaginal birth to assess positioning of
mediolateral episiotomies. The depth, length, distance from the midline,
the shortest distance from the midpoint of the anal canal, and the angle
subtended from the sagifal or parasagifal plane were measured following
suturing of the episiotomy. Results of the study demonstrated that no
midwife and only 13 (22%) doctors performed a truly mediolateral
episiotomy and that the majority of the incisions were in fact directed
closer to the midline (Andrews et al 2006b). The current recommendation
is that all relevant healthcare professionals should afend training in
perineal/genital assessment and repair, and ensure that they maintain
these skills (NICE 2007).