EPISIOSTOMY

Outline
Definition
Indications
Risks
Types
Procedure
Advantages
Complications
Definition
Episiotomy is defined as a surgical incision
made in the perineum to increase the diameter
of the vulval outlet, to facilitate a vaginal
delivery.

Obstetricians used to do episiotomies routinely
to speed delivery and to prevent the vagina
from tearing, particularly during a first vaginal
delivery.
It was routinly usein primigravid women but
was later recognise that routine episiotomy
confer no benefit and should done in special
indications

INDICATIONS
Shortens the time for which the perineum is
stretched during birth to prevent tear
Fetal malpositioning e.g. occipito-posterior
position of the head because a large diameter
is presenting
Breech delivery, esp. primagravida
Instument delivery (Forcepts or vacuum
extractor)
Completion of the second stage of labor*
Tight perineum mosly seen in
primagravida;where the perineum skin
appears tense without episiotomy may result
in laceration of the introitus



Indications (cont)

Decreases maternal trauma

Ease of repair

Reduction of the risk of shoulder dystocia*
Previous vaginal repair with dense scar tissue
Fetal distress
In neonate it helps to prevent:
asphyxia
cranial trauma
cerebral hemorrhage
Risk
There are some risks to having an episiotomy.
Because of the risks, episiotomies are not as
common as they used to be. The risks include:

The cut may tear and become larger during the
delivery. The tear may reach into the muscle
around the rectum, or even into the rectum itself.

There may be more blood loss.
The cut and the stitches may get infected.
Sex may be painful for the first few months after
birth.

TYPES
There are four types of episiotomy
Medio-lateral
Midline
Lateral
J-shaped
Medio-lateral
Midline Episiostomy

A cut is made vertically (3-4cm) in the midline from
the fourchette((a small fold of membrane
connecting the labia minora in the posterior part of
the vulva) towards the anus.

Midline Advantages

The midline episiotomy involves cutting
through less muscle tissue and following the
natural line of the perineum that a tear would
take if it occurred, therefore :

Less blood loss
Easier to repair
Wound heals quicker
Less pain in the postpartum period
The incidence of dyspareunia is reduced

Midline DISADVANTAGE

Median episiotomy is associated with a greater risk for
extension into the anal sphincter or rectum (third/fourth
degree tear).

In women with midline episiotomy, deep perineal tears
occurred in 14.8%, which is statistically significantly
higher compared to 7% in women who underwent a
medio-lateral episiotomy
ItS more likely for deep perineal tears to occur in cases
with other risk factors
Primiparity
Maternal height <145cm
Fetal birth weigh >3500g
Forceps extraction



Mediolateral
The incision is made downward and outward
from midpoint of fourchette either to right or
left. It is directed diagonally in straight line
which runs about 2.5 cm away from the anus
(midpoint between anus and ischial
tuberosity).
Mediolateral
Extension to the
anal sphincter is
less common
Difficult to perform
and to repair
More blood loss
More pain and
discomfort
More dyspareunia
later
Advantages Disadvantages
Classification
Episiotomies are classified according to the depth of
the incision:
A first-degree episiotomy cuts through skin only
(vaginal).
A second-degree episiotomy involves skin and
muscle and extends midway between the vagina
and the anus.
A third-degree episiotomy cuts through skin,
muscle, and the rectal sphincter.
A fourth-degree episiotomy extends through the
rectum and cuts through skin, muscle, the rectal
sphincter, and anal wall

Preparation
Physician should explain the procedure
Informed consent required
Allergies to any medication (iodine, latex,
anesthetic agents)
Medications anticoagulants, herbal
supplements
History of bleeding disorders
Preparation
Equipment:
Sterile drape
Sterile gown and gloves
Gauze swabs and tampon
Needle holder
Sponge holder
Scissors
10ml syringe
Toothed forceps
Suture material
1% lignocaine
Procedure
Perineum is thoroughly cleaned with antiseptic
agents
Draped properly
Adequate anesthesia is required before the
incision line infiltrated with 10ml of 1%
lignocaine solution
Procedure
The index and middle fingers are placed into the
vagina between the fetal head and the perineum
Incision should be made at maximum height of a
contraction
An incision is begun at the posterior fourchette
and continued downward at an angle of at least
45 relative to the perineal body.
The angle of the incision may approach 90
(perpendicular to the posterior fourchette) if the
perineum is significantly stretched by the fetal
head, so that upon relaxation of the perineum the
angle will approach 45

Procedure
The incision can be performed on either side
and is generally 3-4 cm in length.
Control delivery of head to avoid extension of
the incision
The anatomic structures involved in a
mediolateral episiotomy include the vaginal
epithelium, transverse perineal muscle,
bulbocavernosus muscle, and perineal skin.
Management
Perineal Repair
Repair is done soon after the expulsion of the placenta
Evaluate the extent of the laceration after
delivery- is it 3
rd
or 4
th
degree etc
Evaluate the type of suture
Either 2-0 or 3-0 sutures of chromic catgut or
polyglycolic acid (vicryl)
The wound is cleaned and blood clots
removed
Patient draped properly
With 2 fingers placed in the vagina for retraction,
the apex of the episiotomy site is identified, and a
suture is secured approximately 1 cm proximally
The submucosal tissue and vaginal mucosa are
reapproximated in a continuous fashion (either
nonlocked or locked)
A deep episiotomy or laceration may require
additional submucosal sutures for appropriate
tissue reapproximation and closure of dead
space.
Sutures should be placed perpendicular to the
angle of the incision to prevent anatomic distortion
of the perineum and vaginal opening.
Inspect the repair to check that haemostasis
has been achieved
Account for all instruments swabs and
needles
Complete a rectal examination to ensure
Discard sharps safely
Apply sterile pad following thorough perineal
wash
Check for bleeding in recovery room
Complications
Vulval/ perineal
hematoma
Infection
Recto vaginal fistula
Wound dehiscence
Dyspareunia
Scar endometriosis
Immediate Late
After Care
Aid in Healing Process
Use sitz bath a few times a day, change your
pads frequently, and try a hair dryer after you
bathe to keep the area around the stitches
clean and dry.
Take stool softeners, eat lots of fiber, and drink
lots of water to prevent constipation.
Perform Kegel exercises. Squeeze the
muscles that you use to hold in urine for five
minutes, 10 times a day, during your regular
activities

Relief of Pain and Discomfort
Take a warm bath, but not before 24 hours postpartum.
Apply ice packs in the first 24 hours to decrease the swelling,
then put anesthetic ointments on witch hazel pads and apply
over the affected area.
Take medications like ibuprofen, a non-steroidal anti-
inflammatory, to help relieve pain

Stitches do not need to be removed since your body will absorb
them.
Normal activities, such as light office work or housecleaning,
can be resumed within a week after giving birth.
Tampon use, intercourse, or any activity that might rupture the
stitches, can be resumed in about a six weeks

Reference
Chamberlain, Geoffrey. Obstetrics by Ten Teachers 16
th
ed. Arnold
Publishing,London. 1997.
Owen J, Hauth, JC. Episiotomy infection and dehiscence. In: Gilstrap LC III, Faro S,
eds. Infections in Pregnancy. New York: Alan R Liss; 1990.
Aasheim V, Nilsen AB, Lukasse M, Reinar LM. Perineal techniques during the
second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev.
Dec 7 2011;12:CD006672. [Medline].
Ramin SM, Gilstrap LC 3rd. Episiotomy and early repair of dehiscence. Clin Obstet
Gynecol. 1994;37:816.
Hale RW, Ling FW. Episiotomy: Procedure and Repair Techniques. Washington, DC:
American College of Obstetricians and Gynecologists; 2007
Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst Rev.
2009;(1):CD000081.
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