Episiotomy pkg

EPISIOTOMY
PRESETED BY
PRAVEEN KUMAR GHANCHI
PRINCIPAL,
ARAVALLI SCHOOL OF NURSING,
JUNA TAKHATPUR

EPISIOTOMY
INTRODUCTION:-
Episiotomy is a surgical incision of the perineum that
is made to prevent tearing of the perineum and to
release pressure on the fetal head with birth.
praveen kumar ghanchi

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

OBJECTIVES
• To enlarge the vaginal introitus so as to facilitate easy and safe
delivery of the fetus – spontaneous or manipulative.
• To minimise overstretching and rupture of the perineal muscles
and fascia; to reduce the stress and strain on the fetal head.

INDICATION
In elastic (rigid ) perineum :-
Causing arrest or delay in descent of the presenting part as in elderly
primigravidae.
Anticipating perineal tear :-
A] big baby
B] face to pubis delivery
C] breech delivery
D] shoulder dystocia
Operative delivery :-
Forceps delivery ,
Ventous delivery .

Conti….
Previous perineal surgery :-
Pelvic floor repair ,
perineal reconstructive surgery.
Fetal interest :-
• 1. fetal distress
• 2. premature baby
• 3. breech delivery
Common indication are :-
• 1. threatened perineal injury in primigravidae
• 2.rigid perineum
• 3. forceps , breech, occipito-posterior or face delivery.

ADVANTAGES
• MATERNAL
• A] a clear and controlled incision is easy to repair and heal
batter than a lacerated wound.
• B] reduction in the duration of second stage
▪ c] reduction of trauma to the pelvic floor muscle – that
reduces the incidence of prolapse and perhaps urinary
incontinence.

Conti..
FETAL ;-
▪ It minimise intracranial injuries specially in premature babies or
after-coming head of breech.

Timing of episiotomy
▪ Bulging thinned perineum during contraction just prior to
crowning is the ideal time.

Types of episiotomy
▪ medio-lateral
▪ Median
• Lateral
• J’ shaped

Conti..
Medio-lateral
• The incision is made dounward and outwards from the
midpoint of the fourchette either to the right or left. It is
directed diagonally in a straight line which runs about 2.5 cm
away from the anus.

Conti..
Median
▪ The incision commences from the centre of the fourchette and
extends posteriorly along the midline for about 2.5cm.
lateral
▪ the incision start from about 1cm away from the centre of the
fourchette and extends laterally.
“J” shaped
▪ The incision begins in the centre of the fourchette and is directed
posteriorly along the midline for about 1.5cm and then directed
dounwards and outwards along 5or 7 O’ clock position to avoid the
anal sphincter.

STEPS OF MEDIOLATERAL
EPISIOTOMY
STEP- 1
▪ preliminaries- the perineum is thoroughly swabbed with
antiseptic (povidone-iodine)lotion and draped properly. Local
anaesthesia – the perineum, in the line of proposed incision is
infiltration with 10 ml of 1% solution of lignocain.

Conti…
STEP- 2
▪ incision :- two fingers are placed in the vagina between the
presenting part and the posterior vaginal wall. The incision is
made by a curved or straight blunt pointed sharp scissors (
scalpel may also be used ), one blade of which is placed inside,
in between the fingers and the posterior vaginal wall and the
other on the skin. The incision should be made at the height of
an uterine contraction when an accurate idea of the extend of
incision can be better judged from the stretched perineum.

Conti..
▪ Delibrate cut should be made starting from the centre of the
fourchette extending laterlly either to the right or to the left. It is
directed diagonally in a straight line which runs about 2.5cm
away from the anus. The incisio ought to be adequate to serve
the purpose of which it is needed. i.e. according to the
individual case. The bleeding is usually not sufficient to use
artery forceps unless the operation is done too early or the
perineum is thick.

Conti…
STRUCTURE CUT ARE
1. posterior vaginal wall
2. superficial and deep transverse perineal muscles
bulbospongiosus and part of levater ani .
3. fascia covering those muscles
4. transverse perineal branches of pudendal vessels and nerves
5.subcutaneous tissue and skin

STEPS -3
Repair ;-
the repair is done soon after expulsion of placenta .

Preliminaries
The patient is in lithotomy position. A good light source from
behind is needed. The perineum including the wound area is
cleaned with antiseptic solution. Blood clots are removed from
the vagina and the wound area. The patient is draped and repair
should be done under strict aseptic precaution.

The repair is done in three layers. The principles
to be followed are
1. Perfect haemostasis
2. To obliterate the dead space
3. Suture withouht tension.
The repair is done in following order :
1.Vaginal mucosa and submucosal tissues
2.Perineal muscles
3.skin and subcutaneous tissues.

POST OPERATIVE CARE
▪ Dressing :-
▪ The wound is to be dressed each time following urination and
defeacation to keepthe area clean and dry . The dressing is done
by swabbing with cotton swabs soaked in antiseptic solution
followed by application of antiseptic powderor ointment .
▪ Comfort :-
Torelieve pain in the area, application of heat and cold, sitz bath
may be used. Analgesic drugs (aspirin} may be given as and
when required.

COMPLICATIONS
1. Immediate
2. Remote
1) Immediate
1. Extension of the incision to involve the rectum
2. Vulval haemetoma
3. Infection
4. Wound dehiscene is often due to infection, haematoma or faulty repair.
2) Remote
1. Dyspareunia
2. Chance of perineal lacerations
3. Scar endometriosis

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