EPISIOTOMY AND SUTURING

Definition

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

Purpose

 To enlarge the vaginal introitus

 To facilitate easy & safe delivery

 To minimize rupture of the perineal muscles & facia.

 To reduce stress on fetal head.

Indications
In rigid perineum
 Anticipating perineal tear
 Big baby
 Face to pubis delivery
 Breech delivery
 Shoulder dystocia
Common indication
Threatened perineal injury
Rigid perineum
Forceps delivery
Advantages
 Easy to repair
 Minimizes duration of labor and discomfort
 Reduction in intracranial injuries
 Reduction of premature trauma babies
Complications
 Vulval hematoma
 Dyspareunia
 Infection
  Scar endometriosis
 Recto vaginal fistula
 Wound dehiscence
 Timing of episiotomyBulging thinned perineum during contraction just prior to
crowning
 Types of episiotomy  Medio lateral Median LateralJ shape
Equipments :
 Sterile drape
 Sterile gown and gloves
 Gauze swabs and tampon
 Needle holder
 Sponge holder
 Scissors ,10 ml syringe
 Toothed forceps
 Suture material
 1% lignocaine
Preliminaries:
 The perineum is thoroughly swabbed with antiseptic lotion
 Draped properly
 Incision line- Infiltrated with 10 ml of 1% lignocaine solution.
Making Episiotomy• Two fingers are placed in the vagina between the presenting part &
posterior vaginal wall.
 The incision is made by straight or curved blunt pointed sharp scissors
 The open blades are positioned.
 Incision should be made at the height of an contraction
. Cut should be made starting from the centre of the forchette extendening laterally either to
the left or right.
 It is directed diagonally in a straight line which runs about 2.5 cm away 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 the episiotomy.
Structures involved : Posterior vaginal wall Superficial & deep transverse perineal muscles
 Fascia covering the muscles
 Transverse perineal branches of pudendal vessels& nerves
 Subcutaneous tissue & skin.
Perineal Repair
 Repair is done soon after the expulsion of the placenta.
Purpose of Repair
To control bleeding
 To prevent infection
 To assist wound healing byprimary intention.
The most common suture type
 polyglactin 910 suture: Coated Vicryl, Vicryl RAPIDE (> 70%)
 polyglycolic acid: Safil, Safil Quick, Dexon II (12%)
 Traditional sutures : catgut, chromic catgut) (10%).
Principles in suturing
 Close all dead space –ensure haemostasis and prevent infection
Cotton balls must not be used.
 Handle tissue gently using nontoothed forceps.
Ensure good anatomical restoration and alignment to facilitate healing.
• 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 the rectal mucosa.
Layers of perineal repair Vaginal mucosa & submucosal tissue. Perineal
muscles Skin & subcutaneous tissue

steps
The patient is placed in lithotomy
position
Provide privacy to patient
Perform handwashing
Wear gloves aseptically
A good light source from behind is
needed to find the apex first.
The patient is drapped properly &repair
should be done under strict aseptic
rationale
To ease the procedure
To ensure safe and secure feel to patient
To prevent cross infection
To prevent cross infection
For better visualization
To maintain privacy and prevent
infection
 precaution

The perineum &the wound area is

cleaned with antiseptics
Blood clots are removed from the vagina
& the wound area

steps rationale
Step 1 Suturing the vagina• Identify the To ensure adequate hemostasis
apex.• Insert the anchoring suture 0.5 cm
above the apex.• Repair the vaginal wall
with a continuous non-locking stitch with
approximately 0.5 cm between each stitch.
Step 2 Suturing the perineal muscle Check To ensure adequate hemostasis
the depth of the trauma. Repair the
perineal muscles in one or two layers with
the same continuous stitch.
 Ensure the muscle edges are apposed
carefully leaving no dead space
Step 3 Suturing the skin• Reposition the For better approximation
needle at the inferior end of the wound
commence
.• Stitches are placed below the surface of
the skin,

The point of the needle should be

repositioned between each side.
Continue taking bites of tissue from each
side until the superior wound edge is
reached.

Provide episiotomy care and tie sanitary
pads with T bandage
Make patient comfortable
Replace all articles
Do recording and reporting
Prevents infection and sanitary pads for
blood soakage
To relax patient
As per basic principle of goodworkmanship
To ensure SMART documentation

Immediate care
  Inspect the repair to check that haemostasis has been achieved
 Remove the vaginal tampon, if used,
 Account for all instruments, swabs and needles
 Discard sharps safely
 Apply sterile pad following thorough perineal wash
 Wait for minimum one hour to shift the patient to ward
 Check for bleeding & urine output
Perineal hygiene
 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 thoroughly before and after going to the bathroom.
 Always keep the wound clean & dry after each urination & defecation.
kegal’s exercise
 Squeeze the perineal muscles as if you were trying to stop the flow of urine.
 Hold for 5 to 10 seconds and then relax.
 Do this exercise 10 times a day to regain muscle strength.