Episiotomy

An episiotomy, also known as perineotomy, is a planned surgical incision made on the perineum and posterior vaginal wall during the second stage of labour to enlarge the vaginal opening and facilitate childbirth. This procedure is sometimes performed to prevent extensive tearing of the tissues during childbirth.

Purpose

• To enlarge the vaginal introitus.
• To facilitate easier and safer delivery.
• To minimize the rupture of the perineal muscles and fascia.
• To reduce stress on the fetal head.

Indications

Episiotomy should not be performed routinely but rather considered only when required, such as in cases of an inelastic (rigid) perineum, particularly in elderly primigravida; when there’s an anticipation of perineal tear due to factors like a big baby, face-to-pubis delivery, breech delivery, shoulder dystocia, or occipito posterior position; during operative deliveries involving forceps or vacuum assistance; following previous perineal surgeries like pelvic floor repair or perineal reconstructive surgery; to expedite second stage cases such as in pre-eclampsia; and for premature babies.

Types

Medio-lateral: An incision is made downward and outward from the midpoint of the fourchette, extending either to the right or left. This incision is directed diagonally in a straight line located approximately 2.5 cm (1 inch) away from the anus, which corresponds to the midpoint between the anus and the ischial tuberosity

Median: The incision starts at the center of the fourchette and extends along the posterior midline for approximately 2.5 cm (1 inch).

Lateral: The incision begins approximately 1 cm (0.4 inches) away from the center of the fourchette and extends laterally. However, this technique has drawbacks, including the potential for injury to the Bartholin’s duct. As a result, some practitioners strongly discourage the use of lateral incisions.

J-shaped: The incision originates from the center of the fourchette and proceeds posteriorly along the midline for approximately 1.5 cm (0.59 inches). From there, it curves downward and outward, following the 5 or 7 o’clock position to prevent any harm to the internal and external anal sphincters. However, it’s important to note that this procedure is not widely practiced.

Time for episiotomy

The optimal time to perform an episiotomy is when the perineum is bulging and thinned during a contraction, with 3-4 cm of the baby’s head visible. This timing ensures that the procedure is neither too early, which could lead to greater blood loss, nor too late, which might result in inadequate protection of the pelvic floor and the perineal body, thus failing to prevent unseen lacerations.

Procedure

1. Prepare the necessary equipment.
2. Confirm the absence of allergies in the woman to lignocaine or related drugs.
3. Offer emotional support and reassurance.
4. Place the woman in a dorsal position with flexed legs.
5. Wear high-level disinfected or sterile surgical gloves on both hands.
6. Cleanse the perineum using an antiseptic solution, such as betadine solution.
7. Draw a 10 ml syringe with 10 ml of 0.5% lignocaine.
8. Place 2 fingers (index and middle) into the vagina along the intended incision line.
9. Explain the procedure details to the woman.
10. Insert the needle below the skin for a depth of 4-5 cm, following the same line.
11. .Withdraw the syringe plunger to confirm the needle’s is not within  a blood vessel.
12. If blood is drawn into the syringe, withdraw the needle, thoroughly verify the placement, and make a new attempt.
13. If no blood is withdrawn continue with the following steps.
14. Administer lignocaine into the vaginal mucosa, under the perineal skin, and deeply into the perineal muscle.
15. Wait for two minutes, then utilize forceps to grasp the incision site.
16. If the woman perceives the pinch, wait an extra two minutes before retesting.
17. Refrain from conducting the episiotomy until the perineum becomes more thinned out, and approximately 3-4 cm of the baby’s head becomes visible during a contraction.
18. Position two fingers (index and middle) between the baby’s head and the perineum (posterior vaginal wall.
19. Insert the open blade of the scissors between the perineum and the two fingers.
20. Perform a deliberate incision on the perineum, approximately 3-4 cm in a medio-lateral direction. Initiate the cut from the center of the fourchette, extending laterally either to the right or left. This incision should be diagonally directed in a straight line, maintaining about 2.5 cm distance from the anus.
21. Cut upwards 2-3 cm along the midline of the posterior vagina.
22. If the birth of the head does not occurs  immediately, exert pressure on the episiotomy site between contractions, utilizing a piece of gauze to minimize bleeding
23. Manage the baby’s head and shoulders to avoid extending the episiotomy.
24. Following the procedure, carefully inspect the woman for tears in the vagina, perineum, and cervix, and for any extension of the episiotomy incision; subsequently, proceed to repair the episiotomy as required.

Repair  of episiotomy

Types of repairing episiotomy

• Interrupted suturing
• Continuous suturing

Steps repair

• Vaginal mucosa and submucosal tissue
• Perineal muscles
• Skin and subcutaneous tissues

Procedure

1. Instruct the woman to position her buttocks towards the lower end of the bed or table.
2. Request an assistant to direct a strong light onto the woman’s perineum.
3. Adequately drape the perineum using a perineal sheet.
4. Administer antiseptic solution to the area surrounding the episiotomy.
5. If the episiotomy extends through the anal sphincter or rectal mucosa, manage it as a 3rd or 4th degree tear and promptly inform the doctor.
6. Securely clamp and lock the needle holder, placing the needle at a 90-degree angle.
7. Perform the repair of the vaginal mucosa.
8. Utilize 2-0 suture material.
9. Initiate the repair around 1 cm above the apex (top) of the episiotomy. Continue suturing down to the level of the vaginal opening.
10. At the vaginal opening, align the separated edges of the incision.
11. Pass the needle beneath the vaginal opening and out through the incision, then secure with a knot.
12. Trim the unattached suture end to about 1 cm length.
13. Close the perineal muscle with interrupted 2-0 sutures, starting from the upper part of the perineal incision and working downwards.
14. Employ interrupted 2-0 sutures to close the skin, bringing the skin edges together.
15. Apply antiseptic solution to the sutured area.
16. Clean the perineal area with clean water and apply clean perineal pad.
17. Insert your smallest finger inside the rectal sphincter. Feel for the tone or tightness of the sphincter.
18. If it has it must be removed and re-sutured.
19. Remove the wet clothes and change the clean clothes
20. Make the woman comfortable
21. Place instruments in 0.5% chlorine solution for 10 minutes. for decontamination.
22. Clean and disinfect all articles and return them to the proper place.
23. Place needle and syringe in a puncture proof container.
24. Remove gloves in 0.5% chlorine solution for 10 minutes to decontaminate.
25. Wash hand thoroughly with soap and water and dry with clean, dry cloth or air-dry
26. Record the procedure accurately (type of suture, number of suture, date and time of suture, condition of the patient).

Complications

Immediate complications

Extension of the  incision to involve the rectum remote complication

• Vaginal hematoma
• Infection
• Suture non union
• Hemorrhage
• Bruising
• Swelling

Remote complications

• Dyspareunia due to narrow vaginal introitus which may result from faulty technique of repair or due to painful perineal scar
• Urinary incontinence

To download ppt: Click here

For more details Click here