Episiotomy /Perineal Laceration

Episiotomy /Perineal Laceration

An episiotomy is a deliberate surgical incision made into the perineum to enlarge the vaginal orifice (intritus) to facilitate the birth of the baby. It is a planned surgery but often, it is performed as an emergency, because the need for it may not be apparent until the second stage.

Indication:

1.           To minimize severe spontaneous maternal trauma.

2.           Delay 2^nd stage – Tear is imminent, Disproportion, Rigid perineum, Contracted outlet, abnormal positions e.g. opp; face to pubes delivery.

3.           Fetal distress – e.g. prolapse cord. To hasten the delivery of the head.

4.           To facilitate vaginal and intrauterine manipulation e.g. foreceps and intrauterine manipulation e.g. forceps delivery, ventouse extraction, breech delivery.

5.           Preterm babies – to avoid intracranial damage.

6.           Previous complete perineal tear

7.           Primipara with big baby.

Types

1. Media: 

This is a midline incision which follows the line ofinsertion of the perineal muscle. It begins in the centre of the fourchette and directed posteriorly for about 2.5cm.

Advantages:

·              Causes less bleeding, because it does cut through any big blood vessels.

·              It is easy to repair and it heals better. It is more convinence for the woman.

Disadvantage

·              It may extend and damage the anus (third degree tear) or to the rectum (fourth degree tear).

·              It does not give enough room as medio-lateral for instrumental delivery and rotation used mainly in USA.

2. Medio-lateral: 

The incision begins in the centre of thefourchetter and directed to the right or left of the lateral margin of the anal-sphincter, diagonally in a straight line, at an angle of 45⁰C between the tuberosity and the anus. It should not be more than 4-5cm long and about 2.5cm away from the anus. This line avoids damage to the anal sphincter and Bartholin’s gland.

Advantage:

·              Can not lead to 3⁰C tear-recommended for midwives. Use more in U.K.

Disadvantage

·              It is more difficult to repair. Bilateral mediolateral episiotomy are not recommended, because it can cause excessive bleeding.

3. J-Shaped or Schuchardt incision

The incision begins in the centre of the fourchette and directed posteriorly in the midline for about 2cm and then directed laterally (at 7.Oclock) to avoid the anus. It helps in difficult deliveries e.g. large head, shoulder dystocia or difficult breech. It is difficult to suture and the wound tend to wrinkle.

4. Lateral Episiotomy

The incision begins about 1-2cm away from the centre of the fourchette. It cut across the labia majora, large blood vessel and Bartholin’s duct may be damaged.

Disadvantage

·              Causes profuse bleeding ,difficult to repair ,causes a lot of discomfort to the woman .It has been abadoned.

Timing of the Incision

Episiotomy must be properly timed to achieve the desired goal. It is given when the presenting part is directly applied to the tissue. If given too early it will fail to release the presenting part and causes profuse bleeding.. If given too late, there will be not enough time to infiltrate with local anaesthesia or the tear might have occurred. The purpose is then defeated. The woman should be in dorsal or lithotomy position.

Give local anaesthecia.

Infiltration

The perineum should be adequately anaesthetized prior to the incision. Xylocaine or lignocaine 0.5% 10mls or 1% 5mls is used. It takes 3-4 minute to take effect and last for about 1 hour. So proper time is very important.

Making the incision

A straight, blunt-ended pair or major’s episiotomy scissors is usually used. The blade must be sharp to ensure a straight clean incision. Insert two fingers as before and position the blades and cut one straight line during a contraction.. Delivery of the head should follow immediately. If thereis any delay pressure should be applied on the wound to minimize bleeding.

Repair of Episiotomy

Early suturing is recommended as this prevents sepsis and poor union. The local anaesthesia should be effective so she may not require another one for repair. She should be in dorsal position or Lithotomy position with legs well apart and thighs abducted buttocks at the edge of the bed or couch. The vagina is packed to prevent obstruction by the uterine bleeding. Sterility must bemaintained. An episiotomy is equivalent to 2⁰c tear so it is repaired in 2 layers.

·              the vaginal wound

·              the pelvic floor muscles and perineal body and the skin, 

Touch the cut area to ensure that the effect of anaesthesia has not worn off. If she feels pains there is need to give more anaesthesia. Adjust the light for clearer view.

Use 2-2 or 3-0 chronic catgut is prefarable because it is flexible, strong and last long enough for healing to occur. 0-1 may also be considered in the absence of none. Generally absorbable catgut is less painful, less tissue reaction. A curved round body needle is used for the tissue. Continuous or uninterrupted stitches are better, starting from the apex of the vaginal wound to the fourchette. This is followed by the pelvic floor muscles and the perineal body. Care must be taken not to suture the anus. Ensure that wound is properly aligned. The sutures should not be too tight which can cause oedema, haematoma and prevent healing. Now close the subcutaneous tissue. The skin may be sutured with chromic 0 or 1 or non-absorbable suture with cutting edge needle. Then remove vaginal pack insert a gloved finger into the anus to feel top of the rectum of suture. If non-absorbable suture is made on the skin, the number should be recorded for removal. Double check to ensure no pack or instrument is left in the woman’s vagina. Clean her with antiseptic lotion and apply sterile pad and make her comfortable. Advise the woman to keep her perineum clean and dry. Use sanitary pad wash the vulva with soap and water as necessary. She should report a week later for inspection of the wound.

Advantages of Episiotomy

·              Prevents over streching of pelvic floor muscles.

·              Reduces maternal exhaustion and incidence of PPH.

·              Reduces the risk of cerebral damage to infant resulting from acidosis and hypoxia. 

·              Heals faster than ragged tear.

·              Prevents damage to the urethra 

·              Prevent 3^rd degree tear.

·              Does not extend to involve the anus-mediolateral episiotomy.

·              Easier to suture

Care in the Puerperium

·              Analgesia in the first 48-72hrs.

·              Perineal toilet with savlon 1:100, 4hrly.

·              Empty bladder and bowel regularly.

·              Keep wound surface dry.

·              Sitz bath – Hibitane for 5 minutes or radiant heat lamp for 5 minutes 2-3 times a day.

·              Inspect  daily for signs of infection and healing.

·              If wound breaks down, re-suture with non-absorbable suture after thorough cleaning.

·              Avoid strain / constipation

·              Good diet – protein and roughages

Complications

1. Haemorrhage,Haematoma ,Infection, Dyspareunia,Temporary loss of Libido.

The scar may necessitate episiotomy in subsequent deliveries.

2. An unnecessary injury if given without good cause.

Perineal Lacerations

Perineal laceration is a tear of the perineum which occurs during the second stage of labour . Incidence of perineal laceration can be reduced by given maximum control of the expulsion of the infants but it is inevitable at times.

Sign that the perineum is liable to tear.

A midwife should anticipate tear in cases of abnormal presentation and position which result in larger diameter to descend the perineum and with an uncooperative mother.

Warning

i.                  Cracking or tearing of the fourchette before the head is crowned.

ii.                  Trickling of blood from the vagina

iii.                  Excessive thinning and stretching of the perineum.

iv.                  Oedematous rigid perineum.

Types

1^st degree tear: Skin and the fourchettee only – midwi fe

2^nd degree tear: skin, fourchettee posterior vaginal wall, pelvic floor muscles .

3^rd degree tear: skin, fourchettee, vaginal wall, pelvic floor muscles, anal sphincter, anal canal. Repair is done by Doctor under G.A, epidural or spinal anesthesia.

4^th Degree tear: when the trauma extends to the rectal mucosa. Management of perineal laceration

Prevention

1.           Obtaining the woman’s cooperation.

2.           Having control of the advancing head.

3.           Getting small diameters to distend the vaginal orifice.

4.           Preventing active extension before crowing.

5.           Keeping hand off the perineum – allow to stretch.

6.           Delivering the head and the end or between contractions.

7.           Allowing the woman to breathe the head out.

8.           Taking care in delivering shoulders and body

9.           Timely Episiotomy

The principle of repair is the same as episiotomy. Active management: Refer to episiotomy above.

Removal of Perineal sutures

1.           Stitches are removed 6-7 days. Alternate ones first.

2.           The number of stitches should be checked with the number of record.