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.
To minimize severe spontaneous maternal trauma.
Delay 2nd stage – Tear in imminent
Disproportion, - Rigid perineum. Contracted outlet, abnormal positions e.g.
OPP, face to pubes delivery.
Fetal distress – e.g. prolapse cord.To hasten the
delivery of the head.
To facilitate vaginal
and intrauterine manipulation e.g.
forceps delivery, ventouse extraction, breech delivery.
Preterm babies – to avoid intracranial damage.
Previous complete perineal tear
Primipara with big baby.
This is a midline incision which follows the line of insertion of the perineal
muscle. It begins in the centre of the fourchette and directed posteriorly for
Causes less bleeding, because it does cut through
any big blood vessels.
It is easy to repair and it heals better.
It is more convenient for the woman.
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.
incision begins in the centre of thefourchetter and directed to the right or
left of the lateral margin of
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.
lead to 30C tear-recommended for midwives. Use more in U.K.
It is more difficult to repair.
Bilateral mediolateral episiotomy are not
recommended, because it can cause excessive bleeding.
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.
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
Causes profused bleeding
Difficult to repair
Causes a lot of discomfort to the woman
It has been abandoned.
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. The levator
ani muscle would not have displaced laterally and may be incised. 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.
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. Clean the perineum
with antiseptic solution. Insert two fingers along the proposed incision, to
protect the fetal head.
the needle beneath the skin for 4-5cm in a straight line, withdraw to ensure it
has not puncture a blood vessel.
the lignocaine as the needle is being withdraw slowly, reinsert into the other
direction just before the tip is of the needle is withdrawn.
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.
The length is better judged when the perineum is stretched. A single deliberate
incision is better than small nips which result in ragged edge and difficult to
unit. A 4-5cm long incision is made at the correct angle. Delivery of the head
should follow immediately. If there is any delay pressure should be applied on
the wound to minimize bleeding.
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.
Inhalational analgesic such as Trilene could be used to relief pains. She
should be in dorsal position or Lithotomy position with legs well apart and
thighs abducted buttocks at the edge of the bed or table. The vagina is packed to
prevent obstruction by the uterine bleeding. Sterility must be maintained. An
episiotomy is equivalent to 20 tear so it is repaired in 2 layers.
the vaginal wound
the pelvic floor muscles and perineal body
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
or 3-0 chronic catgut is preferable because it is flexible, strong and last
long enough for healing to occur. 0-1 may also be considered in the absence of
non. 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 light 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 vaginal. 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 tds (three times
daily) or as necessary. She should repord a week later for inspection of the
wound. Requirement for Perineal suturing
toothed dressing forceps
I majo’s needle holder
spencer well’s artery for ceps
10 gause swabs
20 wool mops
Haped vaginal tampon.
Gown, mask, cap, hand towel angl gloves.
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 3rd degree tear.
Does not extend to involve the anus-mediolateral
Easier to suture
Care in the Puerperium
Analgesia in the first 48-72hrs.
Perineal toilet with saulon 1:100, 4hrly.
Empty bladder and bowel regularly.
Keep wound surface dry.
Sitz bath – Hibitane for 5 mins or radiant heat lam
p for 5 minute 2-3 times a day.
Inspect for signs of infection.
If wound breaks down, resuture with non-absorbable
suture after thorough cleaning.
Temporary loss of Libido
The scar may necessitate episiotomy in subsequent
An unnecessary injury if given without good cause.