Episiotomy

Episiotomy

Definition: The making of an incision into the prenium to enlarge the vaginal orifice.

Indications for Episiotmy

·                 Delay due to rigid perineum, disproportion between fetus and vaginal orifice.

·                 Fetal distress due to prolapsed cord in second stage.

·                 To facilitate vaginal or intra uterine manipulation Eg. Forceps, breach delivery

·                 Preterm baby in order to avoid intracranial damage

·                 Previous 3^rd degree repaired on the perineum.

Advantages of episiotomy

·                 Fetal acidosis and hypoxia are reduced

·                 Over stretching of the pelvic floor is lessened

·                 Bruising of the urethra is avoided.

·                 In sever pre – eclampsia or cardiac disease to reduce the effort bearing down.

·                 A previous third degree tear which may occur again because of the scar tissue which does not stretch well is prevented.

Types of Episiotomy

·                 Medio- lateral

·                 Median

·                 J- shaped

·                 Lateral

1.  Medio – lateral

The incision is begun in the center of the fourchette and directed posterio laterally, usually to the woman’s right. Not more than 3cm long & directed diagonally in straight line which runs 2.5cm distance from the anus. Advantages - barthlion glands are not affected

Anal sphincters are not injured

2. Median: The incision begun in the center of thefourchette and directed posteriorly for approximately 2.5cm in the midline of the prenium.

Advantage:

·                 Less bleeding

·                 More easily and successfully repaired

·                 Greater subsequent comfort for the women

3. J – shaped : The incision is began in the center or thefourchtte and directed posteriorly in the midline for about 2cm and then directed towards 7 on the clock to avoid the anus. Disadvantage

-   The suturing is difficult

-   Shearing of the tissue occurs

-   The repaired wound tends to be pucked.

4. Lateral: The incision is begun one or more in distant fromthe condomned.

Disadvantages

·                 Bartholins duct may be served

·                 The levatorani muscle is weakened

·                 Bleeding is more profuse

·                 Suturing is more difficult

·                 The woman experiences subsequent discomfort

Local analgesia for Episotomy

Lignocaine /lidocaine/ 0.5 percent of 10ml is safe and efficient.

It takes effect rapidly with in 1 & 2 minutes.

Timing the incision

·                 The head should be well down on the perineum, low enough to keep it stretched and thinned

·                 In breech presentation the posterior buttock would be distending the perineum

·                 It must be made neither too soon nor too late 

Making the incision

·                 Avoid incision on the previous episiotomy scar

·                 Not more than 3 cm from fourchette and 2.5 cm from anus

·                 Position the mother in lithotomy

·                 Wait one or two minutes after injection of local anesthesia

·                 Insert two flingers between the perineum with the fetal scalp

·                 Do the incision during a uterine contraction

·                 It should be deliberate cut

·                 The cut should be adequate to remove any resistance to fetal head

·                 May straight blunt painted scissors 17.5cm commonly used.

·                 Must be sharpened at frequent intervals 

Hints on repairing the perineum

·                 Should be sutured with in one hour after local analgesia given

·                 The area is cleansed with savalon solution

·                 For any leakage from the uterus, vaginal tampon or pack should be inserted

·                 Good light is essential

·                 The two extent of the laceration is determined

Controlling methods of bleeding after episiotomy

·                 Applying gauze swab on the area

·                 The pressure exerted by the fetal head

·                 If bleeding occurs after delivery – two Spencer wells forceps should be applied to the bleeding vessels.

Layers to be repaired

·                 Vaginal wound                     

o       Deep and superficial tissue

o       Vaginal mucosa

·                 Perineal muscles and fascia

·                 Perineal skin and subcutaneous tissue

The first stitch inserted at the apex of the incision The most commonly used suturing material is 2/0 chromic catgut.

Remember:

·                 Do not tie the sutures too tightly

·                 The last stitches are important for they prevent excessive scar.

·                 Press firmly on suture line with a pad to see if bleeding has stopped.

·                 Remove perineal pad or suture pack from vagina. Rub up fundus put clean pad on perineum

·                 Put gloved finger in to the rectum – to make suture that no stitch has one through the rectum

·                 Make the women comfortable, clean and dry.

After care of episiotomy

·                 Hot bath, clean wound care

·                 If pus or fouls smelling discharge develop report to health personnel

·                 Advise not to strain and avoid constipation