1. EPISIOTOMY
Fahad zakwan

2. Definition:
It is an intrapartum
incision of the perineum
to widen the introitus.

4. Benefits:
•Prevention of perineal lacerations by anatomical incision
and repair of the episiotomy.
•Prevention of prolonged and overstretch of the perineum
which predisposes to prolapse and stress incontinence.
•Minimizing compression and decompression of the head
which causes intracranial haemorrhage.

5. Indications:
Maternal:
• Nearly in all primiparas.
• Old perineal scar about to rupture.
• Prolonged second stage due to rigid perineum.
• Prior to most instrumental vaginal delivery as forceps
and vacuum.
• Vulval oedema.

6. Foetal
• Large sized baby.
• Preterm baby.
• Direct occipito-posterior.
• Breech delivery.

7. TYPES

9. Median episiotomy
• A midline incision down to, but not, including the external
anal sphincter.
Advantages:
• It is the easiest to perform and to repair.
• Less blood loss.
• Less pain and discomfort in the pueperium.
• Less dyspareunia later on.
• Better end-result cosmetic appearance.

10. Disadvantages:
•Its inadvertent extension will injure the
external anal sphincter and rectum.
•This can be prevented by extending the
incision by the scissors in a J-shaped manner
to avoid the external sphincter.

11. Mediolateral episiotomy:
•The incision extends from the midline of the
forchette mediolaterally at 5 or 7 o’clock towards the
direction of the ischial tuberosity.
Advantages:
•Extension to the anal sphincter is less common so it
is more suitable for instrumental delivery and in
short perineum.

12. Disadvantages:
•Difficult to perform and to repair.
•More blood loss.
•More pain and discomfort in the puerperium.
•More dyspareunia later on.
•Less end-result cosmetic appearance.

13. Procedure
•Anaesthesia: Local infiltration, pudendal nerve
block, epidural, spinal or general anaesthesia can be
used.
•Timing: when the introitus is distended by the
presenting part or the cup of the ventouse with a
visible diameter not less than 3-4 cm, and done at the
maximum of a uterine contraction. If forceps will be
used episiotomy is done just before its application.

14. •Incision: The index and middle fingers of one
hand is introduced between the presenting part
and the proposed site of perineal incision to
protect the presenting part and support the
tissues that will be incised. The incision is usually
3-5 cm length. including the posterior vaginal
wall, forchette, perineal muscles and perineal
skin.

15. •Repair: Cut gut O, Dexon or vicryl 2/0 may
be used to close the posterior vaginal wall
by continuous sutures where the first stitch
should be above the apex of the vaginal
incision, then the muscles with interrupted
sutures and lastly the skin with interrupted
or subcuticular sutures.

16. Postnatal care:
•A non- steroidal anti-inflammatory agent
as diclofenac is used as an analgesic for
the first 72 hours.
•Local antiseptic lotion and antibiotic
powder or spray is used for 7 days.