Episiotomy

Preliminaries:

• The perineum is thoroughly swabbed with antiseptic lotion,
• Draped properly
• Incision line- Infiltrated with 10 ml of 1% lignocaine solution.

EPISOTOMY:

• Two fingers are placed in the vagina between the presenting part & posterior vaginal wall.
• The incision is made by straight or curved blunt pointed sharp scissors
• The open blades are positioned.
•  Incision should be made at height of contraction.
• Cut made from the centre of the forchette extendening laterally either to the left or right.
• Directed diagonally in a straight line which runs about 2.5 cm away from the anus.
• If delivery of head does not follow immediately, apply pressure to the episiotomy site
• Control delivery of the head to avoid extension of the episiotomy.

STRUCTURES INVOLVED:

• Posterior vaginal wall
• Superficial & deep transverse perineal muscles
• Fascia covering the muscles
• Transverse perineal branches of pudendal vessels& nerves
• Subcutaneous tissue & skin.

PERINEAL REPAIR:

• Repair is done soon after the expulsion of the placenta.

Purpose :

• Control bleeding
• Prevent infection
• Assist wound healing by primary intention.

Principles in suturing

• Close all dead space –ensure haemostasis and prevent infection
• Cotton balls must not be used
• Handle tissue gently using nontoothed forceps.
• Ensure good anatomical restorationand alignment to facilitate healing.
• Use minimal amount of suture material, and do not over tighten suturethis may impede healing.
• Rectal examination:To ensure no suturematerial has been inserted through therectal mucosa.

Layers of perineal repair

• Vaginal mucosa & submucosal tissue
• Perineal muscles
• Skin & subcutaneous tissue

STEPS:

Suturing the vagina

• Identify the apex.
• Insert the anchoring suture 0.5 cm above the apex.
• Repair the vaginal wall with continuous non-locking stitch with 0.5 cm between each stitch.

Suturing the perineal muscle

• Check the depth of the trauma
• Repair the perineal muscles in one or two layers with the same continuous stitch
•  Ensure the muscle edges are apposed carefully leaving no dead space.
• On completion of the muscle layer, the skin edges should align

Suturing the skin

• Reposition the needle at the inferiorend of the wound commence
• Stitches are placed below the surface of the skin

Immediate care

• Inspect haemostasis 
• Remove vaginal tampon
•  Discard sharps safely
• Apply sterile pad following thorough perineal wash
• Check for bleeding & urine output

COMPLICATIONS:

•  Immediate
• Vulval hematoma
•  Infection  
• Recto vaginal fistula
• Wound dehiscence 
•  Remote
• Dyspareunia
•  Scar endometriosis

KEGAL’S EXERCISE:

• Squeeze the perineal muscles as if you were trying to stop the flow of urine.
•  Hold for 5 to 10 seconds and then relax.
• Do this exercise 10 times a day to regain muscle strength

Exam Question

• Scar endometriosis can occur following Episiotomy, Hysterotomy or Classical Cesarean Section
• A primipara is in labor and an episiotomy is about to be cut. Compared with a midline episiotomy, an advantage of mediolateral episiotomy is Less extension of the incision
•  Most suitable method of treating 4 inch size episiotomy hematoma is by Evacuation
• The most important step in the treatment of a badly infected episiotomy is  Drainage
• Episiotomy is best done Mediolaterally
• Advantages of median episiotomy over mediolateral episiotomy are Less blood loss, Easy repair & Muscles are not cut

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