Episiotomy

 Episiotomy

A surgically planned incision on the perineum and posterior vaginal wall during second stage of labor called episiotomy or periniotomy.

Objectives

1. To enlarge the vaginal introitus (facilitie easy and safe delivery of fetus; spontaneous or manipulative).

2. To minimize overstretching and rupture of the perineal muscles and fascia.

3. To reduce the stress and strain on fetal head.

Indications

1. Rigid perineum or thick perineum (inelastic perineum).

2. Big baby; due to gestational mellitus

3. Breech delivery

4. Shoulder dystocia; anterior shoulder stuck in pelvic area.

5. Pre-term delivery

6. Unable to response to the given instruction, mother not responding.

7. Forcep delivery

8. Previous perineal injury

9. Anticipating perineal tear

10. Threaten perineal injury in primigrivida

Timing

Bulging thinned perineum during contraction just prior to crowning (when 3-4cm of head is visible) is ideal time.

If done early; blood loss will be more.

If done late; fails to preventt invisible laceration of the perineal body.

Types

1. Median or midline

Chance to involve rectum

Blood loss less

2. Medio-lateral

Blood loss more

If necessary extended, safely from rectal involvement 

3. Lateral episiotomy

4. J shaped episiotomy

Advantages

1. Maternal

Reduction in duration of second stage

Reduction in trauma to muscle

Clear and controlled incision is easy to repair and heals better

2. Fetal

To minimize intracranial injury

Disadvantages 

Blood loss

Difficult during suturing

Pain and discomfortable postpartum

Complication

1. Immediate complication

1. Extension of incision (involve rectum)

2. Vulval haematoma

3. Infection

Throbbing pain in the perineum

Rise in temperature

Wound area looks moist, red and swollen

Offensive discharge

Throbbing pain in the perineum

4. Rise in temperature

5. Injury to anal sphincter cause incontinence of flatus or feces

6. Wound dehiscence; wound not fit together properly

7. Recto-vaginal fistula; rarely

8. Necrotizing fasciitis; rare (in diabetic or immunocompromised women; failure of wound healing)

Treatment

1. Facilitie dainage of pus

2. Local dressing with antiseptic solution

3. MgSo4 compression

4. Systemic antibiotics (intravenous)

2. Remote

1. Dyspareunia; painful intercourse

2. Chance of perineal laceration in subsequent labour

3. Scar endometriosis (rare)

Post operative care

1. Dressing

2. Comfort;

MgSo4 compression

Ice pack

Analgesics

Infrared heat

3. Vital signs and laboratory tests

4. Prevent infection

5. Care after stitches

6. REEDA scale;

R; redness

E; edema 

E; ecchymosis 

D; Discharge 

A; approximation of skin

Layers

1. Vaginal mucosa and submucosa tissues

2. Perineal muscles

3. Subcutaneous and skin

The episiotomy repair to done in following ordor.

Steps of Episiotomy

Steps of Episiotomy involved;

Perineal infiltration and, 

Cutting perineal 

Step 1

1. Use local infiltration with lignocaine (10ml) 1% solution.

Make sure not allergic 5o lignocaine

2. Infiltrate beneath the vaginal mucosa, beneath the skin of perineum and deeply into the perineal muscles.

3. Wait to perform episiotomy

Step 2

1. Perineum is thinned out and

2.  3-4cm of baby head is visible during contraction

3. Wearing surgical gloves, place two finger between the baby's head (presenting part) and the perineum (posterior vaginal wall).

4. Use episiotomy suture to cut perineum that 3-4cm in medio-lateral direction when uterine contraction occurs and perineum stretched.

Or 

Use episiotomy scissors to cut 2-3 cm up the middle of the posterior vagina.

Step 3

Timing of repair

1. Repair done soon after expulsion of placenta.

2. Oozing during this period controlled by pressure with sterile gauze swab.

3. Early repair prevent sepsis and infection

Step 4

1. Lithotomy position 

2. Cleaned with antiseptic solution

3. Blood clots removed from vagina and wound area

4. If the repaired fill oozing of blood, vaginal pack inserted and placed thigh up

Repair 5

Vaginal mucosa first sutured

First suture at place at or just above apex of tear.

Vaginal wall sutured done interrupted or continuous sutures with chromic catgut no. "0" downward till the fourchette is reached.

Suture include deep tissues muscle.

Continuous suture may cause shortening of posterior vaginal wall.

Suture with care not to injure rectum.