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1. EPISIOTOMY
MRS RAMESHWORI TH
ASSOCIATE PROFESSOR

2. EPISIOTOMY AND SUTURING
Introduction:
• Episiotomy is a surgical enlargement of the vaginal
orifice by an incision to the perineum.
• It is clear that much evidence exists supporting a
restricted policy for episiotomy and do not intend to
suggest that episiotomy should be routinely performed.
• Episiotomy is necessary, to achieve optimum outcomes
for mother and infant, without any adverse risk of perineal
or anal sphincter injury.

3. Definition:
• A surgically planned
incision on the perineum
and posterior vaginal wall
during the second stage
of labour to quickly
enlarge the opening for
the baby is called
episiotomy or
Perineotomy.

4. Purposes:
• To prevent the perineum from tearing.
• To allow more space for manipulative vaginal deliveries, e.g.
forceps
• To shorten the second stage of labour e.g. with fetal distress.
• To enlarge the vaginal introitus
• To facilitate easy and safe delivery
• To minimize out stretching and rupture of the perinealmuscles
and fascia
• To reduce the stress and strain on the fetal head
• To reduce prolonged maternal pushing efforts

5. Indication:
Anticipating perineal tear:
• Primi as an elective procedure
• Face to pubis delivery,
• Big baby
• Narrow pubic arch
Inelastic perineum:
• Perineal rigidity in elderly primi
• Old perineal scar of episiotomy
• Perineorrhaphy
Manipulative delivery:
• Needed to get more space
• Forceps
• Breech
• Internal version
To cut the second stage:
• Heart disease
• Severe pre eclampsia or eclampsia
• Post caesarean cases
• Post maturity
Fetal interest:
• Fetal distress
• Premature baby
• Breech delivery – to minimize
compression of the after coming head

6. Risks of the procedure:
• Bleeding
• Tearing the rectal tissues and anal sphincter
• Perineal pain
• Infection
• Perineal hematoma (Collection of blood in the
perineal tissues)
• Pain during sexual intercourse

7. Timing of the episiotomy:
• The timing of performing the episiotomy requires
judgement.
• If done early the blood loss will be more and if done late, it
fails to prevent the invisible lacerations of the perineal
body and thereby fails to protect the pelvic floor.
• Bulging thinned perineum during contraction just prior to
crowning is the ideal time

8. Types:
• Median
• Lateral
• Medio-Lateral
• J-Shaped

9. Mediolateral:
• Down wards and out wards
from the mid point of the
fourchette
• Either to the right or left.
• Runs about 2.5 cm away from
the anus
Median:
Centre of the fourchette and
extends posteriorly along
the midline for about 2.5 cm

10. Lateral:
• 1 cm away from the centre
of the fourchette
• Extends laterally
• Might injure the bartholin’s
duct
J shaped:
• Begins in the centre of the
fourchette
• Directed posteriorly along
the midline about 1.5 cm
• Directed downwards and
outwards along 5 or 7 o’
clock position .

11. Merits & demerits of Median:
Merits:
• The muscles are not cut
• Blood loss is least
• Repair is easy
• Post op. comfort is better
• Healing is superior
• Wound disruption is rare
• Dyspareunia is rare
Demerits:
• Extension if occurs may
involve the rectum
• Not suitable for
manipulative delivery or
in abnormal presentation
or position
• Its use is selective

12. Mediolateral:
Merits
• Safety from rectal
involvement
• Incision can be extended
• Demerits:
• Apposition is not so good
• Blood loss is more
• • Post op. discomfort is
more
• • Increased incidence of
wound disruption
• • Dyspareunia

13. Classification of episiotomy:
Classified by degrees that are based on the severity or extent of the tear:
First degree:
• A first-degree episiotomy
consists of a small tear that
only extends through the lining
of the vagina.
• It doesn’t involve the
underlying tissues.
Second degree:
• This is the most common
type of episiotomy.
• It extends through the
vaginal lining as well as
the vaginal tissue.
• However, it doesn’t
involve the rectal lining or
anal sphincter.

14. • Third degree:
• It involves the vaginal
lining, the vaginal tissues,
and part of the anal
sphincter
• Fourth degree:
• The most severe type of
episiotomy includes the
vaginal lining, vaginal
tissues, anal sphincter,
and rectal lining

15. Preparation:
• Explain the procedure to
the mother
• Provide privacy and
drape the mother
• Advice the mother to
empty her bladder /
catheterize the bladder.
• Monitor the uterine
contractions (duration,
frequency and intensity)
• Monitor FHR every 15
mins
• Do per vaginal
examination
• Observe the color of
amniotic fluid

16. Preparation of equipment:
• A sterile delivery packs containing:-
• Episiotomy scissor - 1.
• Artery forceps - 2.
• Sponge holding forceps - 1
• Syringe loaded with 2% of xylocaine(5 to10ml-)
• Cord cutting Scissors- 1
• Bowl for cleaning solution- 1
• 4 x4 gauze pieces – 5
• Cotton balls -7
• Gauze pad for supporting the perineum -2
• Center hole towel
• Cord clamp
• Bulb / mucous sucker

17. INTERVENTION RATIONALE
1 Admit the woman in the labour room Nil
2 Explain the procedure and change her clothing as per
the hospital policy
To preveNt anxiety
3 Obtain verbal consent Nil
4 Place the mother in the lithotomy position For clear view of the perineum
and to assess the progress
5 Arrange the necessary articles near to the mother For convenience and smooth
workmanship
6 Wash hands and wear sterile apron and gloves To prevent infectiom
7 Look for the signs of crowning(perineal bulging, vulval
stretching, anal pouting, hair line seen and head does
not recede back in between the contractions)
To prevent bleeding by giving
timely episiotomy

18. 8 Swab the perineum with antiseptic solution. To prevent the contamination
9 Drape the perineum. To obtain the sterile area for delivery.
10 Rupture the membrane if it’s still intact. To speed up the delivery
11 Place two fingers in the vagina along the proposed line
of incision
To protect the fetal head
Insert and direct the needle beneath the skin at an
angle of approximately 45° for about 4-5 cm in the
same line and withdraw the piston of the syringe prior to
the injection.
Aspiration ensures the needle has not
entered a blood vessel
Infiltrate the perineum continuously as the needle is
slowly withdrawn
To ensure adequate analgesia.
12 Withdraw the needle and apply pressure over the
injection site
Minimise blood loss, and prevents
haematoma formation

19. 13 Place two fingers in the vagina between the
presenting part and the posterior vaginal wall pointing
downwards.
In order to protect the fetal head.
14 Take a straight-bladed, blunt pointed sharp scissors
over the area intended for incision.
Nil
15 Give an episiotomy( a single deliberate cut from the
centre of the fourchette extending laterally for about 3
to 4 either to the right or to the left) during the peak of
uterine contraction when the birth is imminent
A straight cut minimises perineal
damage and facilitates optimal
anatomical realignment.
16 Withdraw the scissors carefully Nil

20. 17 Encourage the mother to bear down when there is a
good uterine contraction.
Nil
18 Give perineal support with right hand and urethral
support with left and exert pressure over the occiput.
Helps for the delivery of the fetal head.
(The forehead, mouth and chin are thus
born successfully by extension).
19 Apply pressure to the episiotomy between contractions
with a sterile pad if there is a delay in the birth.
Controls bleeding from the wound

21. STRUCTURES CUT DURING EPISIOTOMY
• Structures cut during episiotomy
• Posterior vaginal wall
• Superficial and deep transverse perineal
muscles,
• Bulbospongiosus and part of levator ani
• Fascia covering those muscles.
• Transverse perineal branches of pudental
vessels and nerves.
• Subcutaneous tissue and skin.

22. Complications:
• Extension of the incision in to
rectal tissues and anal sphincter
• Vulval haematoma
• Infection
• Pain and swelling
• Offensive discharge