Tag: Episiotomy

Episiotomy

Episiotomy


DEFINITION:

  • A surgically planned incision on the perineum and the posterior vaginal wall during the second stage of labour is called episiotomy.

PURPOSE:

  • To enlarge the vaginal introitus
  • To facilitate easy & safe delivery
  • To minimize rupture of the perineal muscles & facia
  • To reduce stress on fetal head.

INDICATION:

In rigid perineum

  • Anticipating perineal tear:
  •  Big baby
  • Face to pubis delivery
  •  Breech delivery
  • Shoulder dystocia

Common indication

  • Threatened perineal injury
  • Rigid perineum
  • Forceps delivery

ADVANTAGES:

Maternal

  • Easy to repair
  • Reduction in duration of labour  
  • Reduction of trauma  

Fetal:

  • Minimizes intracranial  injuries specially in premature babies

TIMIMNG OF EPISITOMY:

  • Bulging thinned perineumduring contraction just priorto crowning

TYPES OF EPISIOTOMY:

MEDIAL LATERAL:

  • Begins at the midpoint of the fourchette
  • Directed at a 45 degree angle to the midline
  • Towards a point midway between the ischial tuberosity & the anus

MERITS :

  • Safety from rectal involvement 
  • Incision can be extend

DEMERITS :

  • Apposition of tissue not so good
  • Discomfort is more
  • Wound disruption is more

MEDIAN:

  • Midline incision that follows the natural line of insertion of the perineal muscles.
  • Merits 
  • Reduced blood loss 
  • Easy to repair 
  • Lesser pain 

DEMERITS :

  • Extension may involve the rectum
  • Damage to anal sphincter

 

 MEDIOLATERAL EPISITOMY:

  • Step 1:preliminaries
  • Step 2:Incision
  • Step 3:Repair

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.
  • 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

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
Don’t Forget to Solve all the previous Year Question asked on Episiotomy

Episiotomy

EPISIOTOMY

Q. 1

Scar endometriosis can occur following :

 A

Classical Cesarean Section

 B

Hysterotomy

 C

Episiotomy

 D

All of the above

Q. 1

Scar endometriosis can occur following :

 A

Classical Cesarean Section

 B

Hysterotomy

 C

Episiotomy

 D

All of the above

Ans. D

Explanation:

Ans. is d i.e. All of the above                   

Endometriosis sometimes occurs in abdominal wall scars following operations on uterus or tubes and is known as Scar endometriosis.

Operations most likely to be followed by scar endometriosis

  • Hysterotomy°                                                                               • Classical cesarean section°
  • Myomectomy°                                                                              • Ventrofixation°
  • Following operations for section of Fallopian tube°                    • Following operations for removal of pelvic
  • Episiotomy°                                                                                     endometriosis°

Q. 2

A primipara is in labor and an episiotomy is about to be cut. Compared with a midline episiotomy, an advantage of mediolateral episiotomy is:

 A

Ease of repair

 B

Fewer breakdowns

 C

Less blood loss

 D

Less extension of the incision

Q. 2

A primipara is in labor and an episiotomy is about to be cut. Compared with a midline episiotomy, an advantage of mediolateral episiotomy is:

 A

Ease of repair

 B

Fewer breakdowns

 C

Less blood loss

 D

Less extension of the incision

Ans. D

Explanation:

Midline episiotomies are easier to fix and have a smaller incidence of surgical breakdown, less pain, and lower blood loss. The incidence of dyspareunia is somewhat less. However, the incidence of extensions of the incision to include the rectum is considerably higher than with mediolateral episiotomies. 

  Type of Episiotomy Type of Episiotomy
Characteristic Midline Mediolateral
Surgical repair Easy More difficult
Faulty healing Rare More common
Postoperative pain Minimal Common
Anatomical results Excellent Occasionally faulty
Blood loss Less More
Dyspareunia Rare Occasional
Extensions Common Uncommon

Ref: Cunningham F.G., Leveno K.J., Bloom S.L., Hauth J.C., Rouse D.J., Spong C.Y. (2010). Chapter 17. Normal Labor and Delivery. In F.G. Cunningham, K.J. Leveno, S.L. Bloom, J.C. Hauth, D.J. Rouse, C.Y. Spong (Eds), Williams Obstetrics, 23e.


Q. 3

Most suitable method of treating 4 inch size episiotomy hematoma is by :

 A

Evacuation

 B

Magsulf compression

 C

Cold compress

 D

Marsupialisation

Q. 3

Most suitable method of treating 4 inch size episiotomy hematoma is by :

 A

Evacuation

 B

Magsulf compression

 C

Cold compress

 D

Marsupialisation

Ans. A

Explanation:

Evacuation


Q. 4

The most important step in the treatment of a badly infected episiotomy is :

 A

Securing cultures

 B

Antibiotics

 C

Hot sitz baths

 D

Drainage

Q. 4

The most important step in the treatment of a badly infected episiotomy is :

 A

Securing cultures

 B

Antibiotics

 C

Hot sitz baths

 D

Drainage

Ans. D

Explanation:

Drainage


Q. 5

Episiotomy is best done :

 A

Medially

 B

Laterally

 C

Mediolaterally

 D

J shaped

Q. 5

Episiotomy is best done :

 A

Medially

 B

Laterally

 C

Mediolaterally

 D

J shaped

Ans. C

Explanation:

Mediolaterally


Q. 6

Advantages of median episiotomy over mediolateral episiotomy are all except:      

March 2005

 A

Less blood loss

 B

Easy repair

 C

Extension of the incision is easy

 D

Muscles are not cut

Q. 6

Advantages of median episiotomy over mediolateral episiotomy are all except:      

March 2005

 A

Less blood loss

 B

Easy repair

 C

Extension of the incision is easy

 D

Muscles are not cut

Ans. C

Explanation:

Ans. C: Extension of the Incision is Easy

Mediolateral episiotomy is performed by making a diagonal incision across the midline between the vagina and anus This method is used much less often.

The disadvantages are:

  • Apposition of the tissues is not so good.
  • May require more healing time than the midline incision.
  • Blood loss is little more
  • Postoperative discomfort is more
  • Relative increased incidence of wound disruption
  • Dyspareunia is comparatively more

The advantages are:

  • If necessary the incision can be extended.
  • Relative safety from rectal involvement from extension.


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