Episiotomy n repair

1. Lt Col Sapna Jaggi
Gd Spl (Obs $ Gynae)

2.  Definition
 Purpose
 Indications
 Advantages
 Types
 Perineal repair
 Complications
 Health education
 Perineal care

3.  A surgically planned incision on the perineum
and the posterior vaginal wall during the
second stage of labour

4.  To enlarge the vaginal introitus
 To facilitate easy and safe delivery
 To minimize rupture of the perineal muscles
and fascia
 To reduce stress and strain on fetal head

5.  In rigid perineum(Primigravidas mostly)
 Anticipating perineal tear
 Big baby
 Instrumental delivery
 Breech delivery
 Preterm delivery

6. MATERNAL FETAL
• Easy to repair • Minimises intracranial injuries
esp in premature babies, after
coming head of breech
• Reduction in duration of labour
• Reduction of traumatic injuries
like perineal tears, lacerations

7.  Bulging thinned perineum
during contraction just prior
to crowning(when 3-4 cm of
head is visible) is the ideal
time

8.  Mediolateral ( Most common)
 Median
 Lateral
 J shaped

9.  The incision is made downwards and outwards
from the midpoint of the fourchette either to the
right or to the left.
 It is directed diagonally in a straight line which
runs about 2.5 cm away from the anus (midpoint
between anus and ischial tuberosity).
 MOST COMMONLY USED

10. MEDIAN MEDIOLATERAL
• The muscles are not cut • Relative safety from rectal
involvement from extension
• Blood loss is least • If necessary,incision can be
extended
• Repair is easy
• Postoperative comfort is
maximum
• Healing is superior
• Wound disruption is rare
• Dyspareunia is rare

11. MEDIAN MEDIOLATERAL
• Extension, if occurs, may involve
rectum(MAIN DRAWBACK)
• Apposition of tissues is not so
good
• Not suitable for manipulative
delivery or in malpresentation
• Blood loss is little more
• Postoperative discomfort is
more
• Dyspareunia is comparatively
more
• Relative increased incidence of
wound disruption

12.  Step 1 : Preliminaries
 Step 2 : Incision
 Step 3 : Repair

13. EQUIPMENTS:
 Sterile drape
 Sterile gown and gloves
 Gauze swabs
 Needle holder
 Sponge holder
 Scissors, 10 ml syringe
 Toothed forceps
 Suture material
 1% Lignocaine

14. 1. PRELIMINARIES:
 The perineum is
thoroughly swabbed
with antiseptic solution
 Draped properly
 Empty the bladder
 Incision line –The perineum, in
the line of proposed incision is
infiltrated with 10 mL of
1% solutionof lignocaine
(Fan shaped)
Note: Aspirate( pull back on
plunger) to be sure that no vessel
has been penetrated)

15. 2. MAKING EPISIOTOMY:
 Two fingers are placed in the vagina between
the presenting part and posterior vaginal wall
 The incision is made by
straight/ curved blunt
sharp scissors
 The open blades are
positioned
 Deliberate cut should
be made

16.  Incision should be made at the height of an contraction
 Cut should be made starting from the centre of the
fourchette extending laterally either to the left or right
 It is directed diagonally in a straight line which runs
about 2.5 cm from the anus
 If delivery of the head does
not follow immediately, apply
pressure to the episiotomy
site
 Control delivery of the head
to avoid extension of
episiotomy(PERINEAL SUPPORT0

17.  Posterior vaginal wall
 Superficial and deep transverse perineal
muscles ,bulbospongiosus and part of levator
ani
 Fascia covering those muscles
 Transverse perineal branches of pudendal
vessels and nerves
 Subcutaneous tissue and skin

19. 3. PERINEAL REPAIR
 Repair is done soon after the expulsion of
placenta
 Advantage - Repair is not interrupted or
disrupted by placenta delivery, especially true if
manual removal must be performed
 Disadvantage -Continuing blood loss.Direct
pressure from an applied gauze sponge will help
to limit this volume.

20.  PRINCIPLES OF REPAIR:
(1) Perfect hemostasis
(2) To obliterate the dead space
(3) Suture without tension.

21.  Polyglactin 910 suture:
Coated Vicryl, Vicryl Rapide
 Traditional sutures:
Catgut, chromic catgut

22. PRELIMINARIES:
 Patient placed in lithotomy
position
 A good source of light from
behind is needed to find the APEX first
 The perineum and the wound area is cleaned
with antiseptics
 Blood clots are removed from the vagina and
wound area

23.  Patient is draped properly and repair should
be done under strict aseptic precaution
 A vaginal pack is inserted and is placed high
up (Do not forget to remove the pack after
the repair is completed.)

24. PRINCIPLES IN SUTURING:
 Close all dead space- ensure hemostasis and
prevent infection
 Cotton balls must not be used
 Handle tissue gently using non toothed
forceps
 Ensure good anatomical
restoration and alignment
to facilitate healing

25.  Use minimal amount of suture material and
do not over tighten suture this may impede
healing
 Following the repair a rectal examination
should be performed to ensure no suture
material has been inserted through rectal
mucosa

26. LAYERS OF PERINEAL REPAIR:
 Vaginal mucosa and submucosal tissue
 Perineal muscles
 Skin and subcutaneous tissues

27.  STEPS OF REPAIR OF EPISIOTOMY

28. Step 1 SUTURING THE VAGINA
 Identify apex
 Insert the anchoring suture 0.5 cm above the
apex
 The vaginal epithelium and deeper tissues
are closed with a single, continuous, locking
suture.

29. Step 2: SUTURING THE PERINEAL MUSCLE
 Check the depth of the trauma
 Repair the perineal muscles in one or two
layers
 Ensure the muscle edges are apposed
carefully leaving no dead space
 Deeper perineal tissues are reapproximated
by a nonlocking suture.
 Small episiotomies may not require this
deeper layer.

30. Step 3: SUTURING THE SKIN
 The perineal skin is closed using a
subcuticular stitch/Interrupted mattress
sutures.

31.  Inspect the repair to check that haemostasis has
been achieved
 Remove the vaginal swab
 Account for all instruments, swabs and needles
 Discard sharps safely
 Apply sterile pad following through perineal wash
 Wait for minimum one hour to shift the patient to
ward
 Check for bleeding and urine output
 Always check the fundal height

32. IMMEDIATE RARE
• Extension of hematoma to
involve rectum
• Dyspareunia
• Vulval hematoma • Perineal lacerations
• Infection • Scar endometriosis rare
• Wound dehiscence
• Injury to anal sphincter
• Rarely rectovaginal fistula

33.  Eat a diet high in fibre and fluids to prevent
constipation
 Ask the women to walk with thighs apposed
 Not to use squatting position since the
wound is healing
 Laxatives

34.  Change sanitary pads at least every
4 hours to help prevent infection
 Squirt warm tap water over the perineum,
beginning at the front and moving toward the
back
 Sit in a tub of warm water
 Always wash hands before and after going to
the bathroom
 Always keep the wound clean and dry after
each urination and defecation

35. THANK YOU