Episiotomy

Episiotomy & repair of
lacerations
ADEM GEMECHU.(BSC)
Episiotomy & repair of lacerations
2
OBJECTIVE
At the end of this session, the students will able to:
 Define Episiotomy
 Identify indication for episiotomy.
 Identify episiotomy type and laceration degree.
 Complications.
 Post procedure care.
BY Adem Gemechu 06/23/2023

Episiotomy
 It refers to a surgical incision of the female
perineum performed by the accoucheur at the time
of parturition.
 It is usually performed with scissors when the
perineum is stretched and distended, just prior to
crowning of the fetal head.

Episiotomy…..
4
Advantage:
 To reduce the risk of laceration (tear)
 To fasten the second stage of labor as in cases of fetal or
maternal distress.
 To decrease fetal brain damage in cases of preterm or SGA.
 To conduct instrumental deliveries.
 To deliver mal-presentations, mal-position, congenital
malformation and large babies.

Episiotomy….
5
 Disadvantages:
 Increase the risk of infection.
 Cause pain, discomfort and dyspareunia.
 May cause severe hemorrhage and hematoma.
 Cause tissue damage

Indication of episiotomy
6
 Large sized baby.
 Preterm or SGA baby.
 Shoulder dystocia.
 Mal-presentation and mal-position.
 Rigid perineum.
 Instrumental deliveries.
 Fetal/maternal distress.

types of Episiotomy
7
There are three major types:
1.median,
2.mediolateral, and
3.J incisions

Fig 1 Types of episiotomy incisions
8

1.Median
9
 It is the most commonly used types of episiotomy
 A vertical incision is begun at the fourchette and
extended caudally in the midline.

 The goal is to release any restriction imposed
offered by the perineal body,

 which can sometimes be felt as a band of tissue
cephal and posterior to the vaginal orifice.

CONT…
10
 Therefore, the incision should be directed
internally to minimize the amount of perineal
skin incised.
 The anatomical structures involved in the
incision include the vaginal epithelium, perineal
body, and the junction of the perineal body with
the bulbocavernosus muscle in the perineum.

Advantages of Median episiotomy
11
 It is typically easier to repair than a
mediolateral episiotomy or a spontaneous
vaginal/perineal laceration
 yields a better cosmetic result .
 it is associated with less pain postpartum.

disadvantages
12
 The apex of a median episiotomy points
directly towards the maternal anus,

 so if an extension occurs, the anal sphincter is
at high risk of injury.

 The incidence of third and fourth degree
obstetric laceration is higher with a median

episiotomy compared to that with
mediolateral episiotomy or no episiotomy
Mediolateral
13
 It is more commonly employed in Europe and the
Commonwealth countries.
 The incision is initiated at the fourchette and cut at an
angle (usually to the maternal right for right handed

clinicians) that may be almost perpendicular to the
midline;
 however, this angle becomes smaller, approaching 45
degrees, when the perineum is no longer stretched and

distorted by the fetal presenting part.
Cont…
14
 The anatomical structures incised include the vaginal
epithelium, transverse perineal and bulbocavernosus
muscles, and perineal skin.
 If the incision is large, adipose tissue within
ischiorectal fossa may be exposed.

Advantages
15
 The major advantage of the mediolateral episiotomy is that
the surgical incision is directed away from the maternal
anal sphincter,
 The incidence of third and fourth degree lacerations is less.
 It is associated with a two- to four-fold reduction in these
injuries compared to no episiotomy .

disadvantages
16
 It is associated with more blood loss .
 The repair is also more technically
challenging.
 It is associated with more postpartum pain
and dyspareunia than either midline or no
episiotomy
J incision
17
 This technique is favored by some practitioners,
but is not widely used.

 The purpose of the "J" incision is to combine the
advantages of the median and mediolateral

techniques, while avoiding their disadvantages.
The incision starts at the fourchette, is initially
extended caudally in the midline and then curved
laterally at an angle, similar to the letter "J”
Cont…
18
The anatomical structures incised include the
vaginal epithelium, perineal body, and the junction
of the perineal body with the bulbocavernosus
muscle and perineal skin. Ideally, the transverse
perineal muscle is spared because the lateral part of
the incision should be below this muscle; however,
it is difficult to ensure that it is not incised.

PROCEDURES
19
 Analgesia : Adequate analgesia should be available
before performing an episiotomy.

 Provide emotional support and encouragement. Use
local infiltration with lignocaine or a pudendal block.

 Make sure there are no known allergies to lignocaine
or related drugs.

Cont…
20
 Review general care principles and apply antiseptic
solution to the perineal area.
 Infiltrate beneath the vaginal mucosa, beneath the
skin of the perineum and deeply into the perineal
muscle using about 10 mL 0.5% lignocaine solution.

Fig 1 Infiltration of perineal tissue with local
anaesthetic
21

Cont…
22
 Timing: the optimal time for cutting the episiotomy
is unclear.
 Excessive blood loss can result from making the
incision too early,

 but protection of the maternal perineum may be
compromised if it is made too late and the fetal head

has already torn perineal muscle and fascia.
Cont…
23
 A reasonable approach is to perform the procedure
with the expectation of delivering the fetus within
the next three to four contractions

Cont…
24
 Wait to perform episiotomy until:
 The perineum is thinned out; and
 The head crowns i.e. 3–4 cm of the baby’s head is visible
during a contraction
 Performing an episiotomy will cause bleeding.
 It should not, therefore, be done too early

Cont…
25
 Wearing high-level disinfected gloves, place two
fingers between the baby’s head and the perineum .
 Use scissors to cut the perineum about 3–4 cm in
the medio-lateral direction.
 Use scissors to cut 2–3 cm up the middle of the
posterior vagina.
cont…
26
 Control the baby’s head and shoulders as they
deliver, ensuring that the shoulders have rotated to

the midline to prevent an extension of the
episiotomy.
 Carefully examine for extensions and other tears
and repair .
 Making the incision while inserting two fingers to
protect the baby’s head .

FIG.3 Making the incision while inserting two fingers to protect the
baby’s head
27

Rationale for episiotomy
28
 Reduction in third and fourth degree tears
 Ease of repair and improved wound healing
 Preservation of the muscular and fascial support of the
pelvic floor
 Reduction in neonatal trauma, such as with the
premature infant (soft cranium) or macrosomic infant
(shoulder dystocia)
CONT…
29
 Reduction in dystocia by increasing the diameter of
the soft tissue outlet
 Expedited delivery of fetuses with non reassuring
fetal heart rate tracings.

RECOMMENDATIONS
30
 An episiotomy is performed to enlarge the pelvic soft tissue
outlet and thereby prevent severe spontaneous perineal
lacerations, facilitate delivery, and shorten the time to fetal
expulsion
 It is recommended avoiding routine episiotomy (median or
mediolateral), given there is no proven benefit to this
practice .
CONT…
31
 Use of episiotomy be limited to deliveries with a
high risk of severe perineal laceration, significant
soft tissue dystocia, or need to facilitate delivery of
a possibly compromised fetus

CONT…
32
 There is inadequate evidence that episiotomy results in
more postpartum pain than not performing an episiotomy.
 The possibility of sexual dysfunction appears to be greater
when an episiotomy is performed than when it is not;
however, this effect is of a short duration.

CONT…
33
 Episiotomy reduces the rate of anterior perineal
trauma.
 Median episiotomy is associated with less blood loss
and is easier to perform and repair than the

mediolateral procedure.
 However, median episiotomy is also associated with a
higher risk of injury to the maternal anal sphincter and

rectum than mediolateral episiotomies or spontaneous
obstetrical lacerations.
REPAIR OF EPISIOTOMY
34
 It is important that absorbable sutures be used for closure.
 Polyglycolic sutures are preferred over chromic catgut for:
_ their tensile strength

_non-allergenic properties
_ lower probability of infectious complications and
episiotomy breakdown.
 Chromic catgut is an acceptable alternative, but is not ideal.

Cotn…
35
 Clean with guaze the area around the episiotomy.
 If the episiotomy is extended through the anal
sphincter or rectal mucosa, manage as third or
fourth degree tears, respectively (i.e. refer if
consultation not possible)

Cont…
36
 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;
 At the opening of the vagina, bring together the cut edges of the
vaginal opening;
 Bring the needle under the vaginal opening and out through the
incision and tie.

Cont….
37
Close the perineal muscle using interrupted 2-0

sutures.
Close the skin using interrupted (or subcuticular) 2-
0 sutures

Repair of episiotomy
38

COMPLICATIONS:
39
 If a haematoma occurs, open and drain. 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;

40
 If the infection is severe but does not involve
deep tissues, give a combination of antibiotics:
 Ampicillin 500 mg by mouth four times per day for
5 days;
 PLUS metronidazole 400 mg by mouth three times
per day for 5 days.

If the infection is deep, involves muscles and is causing necrosis
(necrotizing fasciitis),
41
 give a combination of antibiotics until necrotic tissue has been removed
and the woman is fever-free for 48 hours:
 Penicillin G 2 million units IV every 6 hours;
PLUS gentamicin 5 mg/kg body weight IV every 24 hours;
PLUS metronidazole 500 mg IV every 8 hours;
 Once the woman is fever-free for 48 hours, give:
 Ampicillin 500 mg by mouth four times per day for 5 days;
BY PLUS 5 days;
metronidazole 400 mg by mouth three times per day for06/23/2023
Adem Gemechu
42
 Note: Necrotizing fasciitis requires wide surgical
debridement.
 Perform secondary closure in 2–4 weeks (depending
on resolution of the infection).

repair of genital tears
43
repair of cervical tears:
 Review general care principles and apply antiseptic
solution to the vagina and cervix.
 Provide emotional support and encouragement.
Anaesthesia is not required for most cervical tears.
 For tears that are high and extensive, give pethidine and
diazepam IV slowly (do not mix in the same syringe).

44
 Ask an assistant to massage the uterus and provide fundal pressure.
 Gently grasp the cervix with ring or sponge forceps.
 Apply the forceps on both sides of the tear and gently pull in various
directions to see the entire cervix.
 There may be several tears.
 Close the cervical tears with continuous 0 chromic catgut (or polyglycolic)
suture starting at the apex (upper edge of tear), which is often the source of
bleeding.
45
 If a long section of the rim of the cervix is
tattered, under-run it with continuous 0 chromic

catgut (or polyglycolic) suture.
 If the apex is difficult to reach and ligate, it may
be possible to grasp it with artery or ring forceps.

 Leave the forceps in place for 4 hours.
 Do not persist in attempts to ligate the bleeding points
as such attempts may increase the bleeding.

46
 Then:
 After 4 hours, open the forceps partially but do not remove;
 After another 4 hours, remove the forceps completely.
 If the apex of the cervical tear is not visible, the tear may have involved the
uterus.
 A laparotomy may be required to repair a cervical tear that has extended
deep beyond the vaginal vault. Hence, in such condition, refer urgently or
consult as appropriate.

Figure :- Repair of a cervical tear
47

repair of vaginal and perineal tears
48
 There are four degrees of tears that can occur during delivery:
 First degree tears involve the vaginal mucosa and connective
tissue.
 Second degree tears involve the vaginal mucosa, connective
tissue and underlying muscles.

 Third degree tears involve complete transection of the anal
sphincter.
 Fourth degree tears involve the rectal mucosa.

49
 Note: It is important that absorbable sutures be used for
closure.
 Polyglycolic sutures are preferred over chromic catgut for
their tensile strength, non-allergenic properties and lower
probability of infectious complications.
 Chromic catgut is an acceptable alternative, but is not ideal.

repair of first and second degree tears:
50
 Most first degree tears close spontaneously without sutures.
 Review general care principles.
 Provide emotional support and encouragement.
 Use local infiltration with lignocaine.
 If necessary, use a pudendal block.
 Ask an assistant to massage the uterus and provide fundal
pressure.
 Carefully examine the vagina, perineum and cervix.

51
 If the tear is long and deep through the
perineum, inspect to be sure there is no third or

fourth degree tear:
 Place a gloved finger in the anus;
 Gently lift the finger and identify the sphincter;
 Feel for the tone or tightness of the sphincter.
 Change to clean, high-level disinfected gloves.
 If the sphincter is not injured, proceed with repair

Figure 4-21:- Exposing a perineal tear
52

53
 Clean the area around the tear.
 • Make sure there are no known allergies to lignocaine
or related drugs.
 Note: If more than 40 mL of lignocaine solution will
be needed for the repair, add adrenaline to the solution.

 Infiltrate beneath the vaginal mucosa, beneath the skin of
the perineum and deeply into the perineal muscle using

about 10 mL 0.5% lignocaine solution.

54
 Note: Aspirate (pull back on the plunger) to be sure that no
vessel has been penetrated. If blood is returned in the

syringe with aspiration, remove the needle. Recheck the
position carefully and try again. Never inject if blood is
aspirated.
 • At the conclusion of the set of injections, wait 2 minutes
and then pinch the area with forceps. If the woman feels
the pinch, wait 2 more minutes and then retest.

55
 Anaesthetize early to provide sufficient time for
effect.
 • Repair the vaginal mucosa using a continuous 2-0
suture:
 - Start the repair about 1 cm above the apex (top) of
the vaginal tear.

 Continue the suture to the level of the vaginal
opening;
56
 At the opening of the vagina, bring together the cut
edges of the vaginal opening;
 Bring the needle under the vaginal opening and out
through the perineal tear and tie.
 Repair the perineal muscles using interrupted 2-0
suture. If the tear is deep, place a second layer of
the same stitch to close the space.
 Repair the skin using interrupted (or subcuticular) 2-
0 sutures starting at the vaginal opening.
 If the tear was deep, perform a rectal examination.
Make sure no stitches are in the rectum
Figure 4-22:- Repairing the vaginal
mucosa(A), perineal muscles(B) and the skin(C)
57

third and fourth degree perineal tears
58
 The woman may suffer loss of control over bowel
movements and gas if a torn anal sphincter is not

repaired correctly.
 If a tear in the rectum is not repaired, the
woman can suffer from infection and rectovaginal

fistula (passage of stool through the vagina). Repair
of such tears should be done in the operating room,
therefore refer her immediately.
Repair of a fourth-degree obstetric laceration
59

60

61
 A. 4th degree laceration
 B. The torn anal mucosa is repaired using a running stitch, but
interrupted stitches are also acceptable.

 C. The internal anal sphincter should be properly identified and
repaired as a separate layer.

 D. The external sphincter is then identified and repaired.
 The repair consists of either end-to-end or overlapping plication
of the disrupted external anal sphincter and capsule using

interrupted or figure-of-eight sutures.
Hints on repairing the perineum
62
1. Should be sutured with in one hour after local analgesia given
2. The area is cleansed with savalon solution
3. For any leakage from the uterus, vaginal tampon or pack
should be inserted
4. Good light is essential
. The two extent of the laceration is determined

Controlling methods of bleeding after episiotomy
63
1. Applying gauze swab on the area
2. The pressure exerted by the fetal head
3. If bleeding occurs after delivery – two Spencer
wells forceps should be applied to the bleeding
vessels.

Layers to be repaired
64
1. Vaginal wound
a) Deep and superficial tissue
b) Vaginal mucosa
2. Perineal muscles and fascia
3. Perineal skin and subcutaneous tissue
4. The first stitch inserted at the apex of the incision
The most commonly used suturing material is 2/0 chromic
catgut.
Remember:
65
1. Do not tie the sutures too tightly
2. The last stitches are important for they prevent

excessive scar.
3. Press firmly on suture line with a pad to see if bleeding

has stopped.
4. Remove perineal pad or suture pack from vagina.

Rub up fundus put clean pad on perineum

Cont…
66
5. Put gloved finger in to the rectum – to make

suture that no stitch has one through the rectum
6. Make the women comfortable, clean and dry.

After care of episiotomy
67
1. Hot bath, clean wound care

2. If pus or fouls smelling discharge develop report
to health personnel
3. Advise not to strain and avoid constipation

Episiotomy

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Episiotomy & repair of

 Identify indication for episiotomy.

 Identify episiotomy type and laceration degree.

 Post procedure care.

BY Adem Gemechu 06/23/2023

 It refers to a surgical incision of the female

perineum performed by the accoucheur at the time

 It is usually performed with scissors when the

perineum is stretched and distended, just prior to

crowning of the fetal head.

 To fasten the second stage of labor as in cases of fetal or

 To conduct instrumental deliveries.

 To deliver mal-presentations, mal-position, congenital

malformation and large babies.

BY Adem Gemechu 06/23/2023

 Increase the risk of infection.

 Cause pain, discomfort and dyspareunia.

 May cause severe hemorrhage and hematoma.

 Cause tissue damage

BY Adem Gemechu 06/23/2023

 Preterm or SGA baby.

 Mal-presentation and mal-position.

BY Adem Gemechu 06/23/2023

There are three major types:

BY Adem Gemechu 06/23/2023

BY Adem Gemechu 06/23/2023

 It is the most commonly used types of episiotomy

 A vertical incision is begun at the fourchette and

extended caudally in the midline.

offered by the perineal body,

cephal and posterior to the vaginal orifice.

BY Adem Gemechu 06/23/2023

 Therefore, the incision should be directed

internally to minimize the amount of perineal

 The anatomical structures involved in the

incision include the vaginal epithelium, perineal

body, and the junction of the perineal body with

the bulbocavernosus muscle in the perineum.

 It is typically easier to repair than a

mediolateral episiotomy or a spontaneous

 yields a better cosmetic result .

 it is associated with less pain postpartum.

BY Adem Gemechu 06/23/2023

 The apex of a median episiotomy points

directly towards the maternal anus,

at high risk of injury.

obstetric laceration is higher with a median

angle (usually to the maternal right for right handed

degrees, when the perineum is no longer stretched and

 The anatomical structures incised include the vaginal

epithelium, transverse perineal and bulbocavernosus

muscles, and perineal skin.

 If the incision is large, adipose tissue within

ischiorectal fossa may be exposed.

BY Adem Gemechu 06/23/2023

 The major advantage of the mediolateral episiotomy is that

the surgical incision is directed away from the maternal

 The incidence of third and fourth degree lacerations is less.

 It is associated with a two- to four-fold reduction in these

injuries compared to no episiotomy .

BY Adem Gemechu 06/23/2023

 It is associated with more blood loss .

 The repair is also more technically