EPISIOTOMY

Dr . A . RATHNA ., M.S ( O&G )

1 ST YEAR PG

DEFINITION
A

surgically planned incision on

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

Purpose
To

enlarge the vaginal introitus

To facilitate easy & safe delivery
To minimize rupture of the
perineal muscles & facia. To
reduce stress on fetal head

Indications
In rigid perineum
Anticipating perineal tear:
Big baby
Face to pubis delivery
Breech delivery
Shoulder dystocia
Forceps delivery

ADVANTAGES
MATERNAL

FETAL

EASY TO REPAR

MINIMIZES
INTRACRANIAL INJURIES
ESP. IN PREMATURE
BABIES

REDUCTION IN
DURATION OF
LABOUR
REDUCTION OF
TRAUMA

Timing of episiotomy

Bulging thinned perineum during

contraction just prior to crowning

Types of episiotomy
Medio lateral
Median
Lateral
J shaped

TYPES

TYPES

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 & the anus.

MERITS
Safety from rectal involement
Incision can be extend
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.
Easy to repair.
Lesser pain
Demerits
Extension may involve rectum.
Damage to anal sphincter

Medio lateral episiotomy.

Step 1:preliminaries.
Step 2:Incision.
Step 3:Repair

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.

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 0.5 cm between each
stitch

Step 2 Suturing the perineal muscle.

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 thoroughperineal

wash.Wait for minimum one hour to shift
the patient to ward.
Check for bleeding & urine output

Complications
Immediate
Vulval hematoma
Infection
Recto vaginal fistula
Wound dehiscence.
Remote
Dyspareunia
Scar endometriosis

Health education
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.

kegals 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.