2. WHAT IS AN EPISIOTOMY?
• A surgical procedure
where an incision into
the perineum ( the
area of skin between
the vagina and anus )
is made to enlarge the
space at the outlet
3. INDICATION
• In anticipation of
difficult delivery e.g.
big baby, instrumental
delivery, vaginal
breech delivery
• Women with previous
perineal surgery e.g.
Fenton operation
5. • Substitutes a straight, neat surgical incision
instead of the ragged laceration that
otherwise frequently results. It is easier to
repair and heals better than a tear.
•
Cunningham, MacDonald and Gant (1989):
6. • Avoid extended tear of the perineum e.g.
third and fourth degree tears
7. • It reduces the incidence of cystocoele,
rectocoele, uterine prolapse and stress
incontinence resulting from pelvic floor
relaxation due to overstretching of
perineum during delivery
•
Pritchard, MacDonald and Gant (1985):
8. • To avert ‘brain damage’ by lessening the
pounding of the head on the perineum
•
De Lee (1920):
11. Protect against brain damage?
• A woman’s perineum is soft, elastic tissue,
not concrete. No one has ever shown that an
episiotomy protects fetal neurologic wellbeing, not even in the tiniest, most
vulnerable preterm infants, let alone a
healthy, term newborn.
•
(Lobb, Duthie and Cooke, 1986)
12. Reduces perineal trauma, - a nice
clean cut is better than a jagged
tear?
• Episiotomies are not easier to repair, do not
heal better than tears
13. Episiotomies avoid extended
tears?
• Episiotomies do not prevent tears into or
through the anal sphincter.
• Episiotomy correlates strongly with deep
tears (p<0.003)
14. Prevent pelvic floor relaxation?
• Episiotomy is not done until the head is
almost ready to be born. By then, the pelvic
floor muscles are already fully
distended/stretched. How is cutting a
muscle and stitching it back together
preserves its strength?
15. Cont.
• No evidence that routine episiotomy
reduces the risk of severe perineal trauma,
improves perineal healing, prevents fetal
trauma or reduces the risk of urinary stress
incontinence.
•
Sleep, Roberts and Chalmers 1989
17. • If a woman does not have an episiotomy,
she is likely to have a small tear, but with
rare exceptions the tear will be, at worst, no
worse than an episiotomy.
19. • Episiotomies are not less painful than tears.
They may cause prolonged problems with
pain, especially pain during intercourse.
20. • As with any other surgical procedures,
episiotomies may lead to infection,
including fatal infections e.g. necrotizing
fasciitis and clostridial myonecrosis.
• 9 cases, 7 dies, two had extensive surgeries
and prolonged hospitalizations.
•
Soper 1986; Sutton et. Al. 1985; Ewing, Small and Elliot 1979; Golde and
Ledger 1977
21. • Epidurals increase the need for episiotomy,
They also increase the probability of
instrumental delivery. Instrumental delivery
increases both the odds of episiotomy and
deep tears.
22. • The lithotomy position increases the need
for episiotomy, probably because the
perineum is tightly stretched.
23. • The birth attendant’s
philosophy, technique,
skill and experience
are the major
determinants of
perineal outcome.
24. • Some techniques for reducing perineal
trauma that have been evaluated and found
to be effective are:
Prenatal perineal massage, slow delivery of
the head, supporting the perineum, keeping
the head flexed, delivering the shoulders
one at a time and doing instrumental
deliveries without episiotomy.
25. • A regular exercise
program strengthens
the pelvic floor
26. Restricted versus routine
episiotomy
Relevant morbidities
Relative
Risk
Post. Perineal trauma
0.88
Need for suturing
0.74
Healing cx at 7 days
0.69
Vaginal or perineal trauma 1.11
Dyspareuria
1.02
Urinary incontinence
0.98
•
Carroli and Belizan 2000; Eason et. Al. 2000; WHO 1999.
27. In conclusion…
Episiotomy is a surgical procedure
which carries the usual surgical
complications and should ONLY be
done when indicated
28. Aim of this workshop is NOT
to promote the practise of
episiotomy, but rather to ensure
good perineal outcome after
delivery
