14.

12: Performing and Suturing an EpisiotomyDEFINITIONEpisiotomy is a surgically planned incision on

the perineum and posterior vaginal wall performed during the second

stage of labor to facilitate delivery.PURPOSES1. To substitute a straight surgical incision for the
laceration that may otherwise occur.

2 To facilitate repair of incised area and promote healing.

3 To spare the newborn's head from prolonged pressure and to avoid pushing against rigid perineum.

4. To shorten the second stage of labor.

5. To speed delivery if there is fetal distress.

6. Prior to an assisted delivery such as forceps or ventouse extraction.

7. To minimize the risk of intracranial damage during preterm and breech delivery.

8. To prevent overstretching of the perineal muscles.TYPES OF EPISIOTOMIES1. Median or midline:

Incision is made in the middle of the perineum and directed toward the anus.

2 Mediolateral: Incision begins at the midline and is directed laterally,

INDICATIONS1. Inelastic rigid perineum.

2. Primigravida.

3. Anticipated perineal tear..

4. Operative delivery.5. Previous perineal surgery.ARTICLESA sterile tray containing:

1. Sterile syringe with needle.

2. Needle holder-1.3. Episiotomy scissors-1.

4. Suture cutting scissors-1.

5. Cutting needle-1 for skin.

Round body needle-1 for muscles.

6. Thumb forceps.7. Suture material-2-0 chromic catgut-1.

8. Kidney tray.

9. Plain lignocaine 2%.

10. Antiseptic solution.

11. Sterile gloves.

12. 4x 4 gauze pieces.

13. Tampons.

GENERAL INSTRUCTIONS1. Ensure that:he presenting part is directly applied to the perineal tissues,
which will be evidenced as bulging perineum.

b. Vaginal orifice is distended by approximately 3 cm diameter of presenting part between

contractions.a.

2. The presenting part of the fetus should be protected from injury.

3. A single cut in any direction is preferable to repeated snipping, as the latter will have jagged ends.

The episiotomy should be large enough to meet the purpose.

The timing of the cut should be such that lacerations are prevented and unnecessary blood loss
avoide4.5.

PROCEDURENursing actionPlace the patient on the delivery table in dorsal

1.recumbent position when the fetal head is distending th-perineum.2. Infilterate the perineum using 10
mL of local anesthetic.

Wait for 3-5 minites for the anesthetic to act [Figure

14.12(a)].Figure 14.12(a): Infiltrating the perineum withanesthetic3 Place your index and middle fingers
in the vagina withpalmar side down and facing you.

Separate them slightly and exert outward pressure on thhe

perineal body.

4. Place the blades of the scissors in a straight up and down

position, so that one blade is against the posterior vaginal

wall and the other blade is against the skin of the perineal
body with the point where the blades cross at the middle

of the posterior fourchette [Figure 14.12(b).AAdjust the length of the blades of the scissors on the

perineal body and predict the length of the incision

accordingly.5.6. a. A mediolateral episiotomy is cut at a slant, starting at

the midline of the fourchette with the points of the

scissors directed toward the ischial tuberosity on the6same side as the incision.b. A midline episiotomy
is cut in the middle of the central

tendinous points of the perineum from the posterior

fourchette down to the external anal sphincter. (The

ideal timing of episiotomy is a bulging thin perineum

at the peak of a contraction just prior to crowning).

If a midline episiotomy was cut, palpate for the external

1.anal sphincter.Cut again if needed, avoid snipping. Two cuts should

accomplish the incision.8.9.Extend the vaginal side of the incision if needed byincising the vaginal band.
For this, the scissors must comefrom above the backside of the hand to slide down thefingers and make
the cut.10. Apply pressure with 4"x 4" sponges11.After completion of delivery assist for suturing
ofepisiotomy incision.12. Wipe the wound area with sterile antiseptic cotton swabs13. Focus light on the
perineal area14. Diagnose the degree of perineal tear if any.15Pack the vagina with vaginal plug or
tamponVisualize the apex of the mucosa, start suturing little

16above the apex. Appose the vaginal tear by continuousSuture using a round body needle [Figure
14.12(c)]

Nursing actionRepair the perineal muscles by interrupted sutures,

include the deeper tissue to enclose dead space.17.18.Perineal skin is apposed by mattresS suture.19
Remove the vaginal pack which was inserted duringsuturing.20. Clean the perineum and apply perineal
pads.Straighten patient's legs and assist her to supine position

with legs crossed.21.22. Wash and dry the instruments used for episiotomy along

with those used for conduct of delivery and suturing.22.23. Record in the labor record, the time
episiotomy wasperformed, type of episiotomy, suturing carried out, and
patient's reaction.

AFTER CARE1. Check for any bleeding from inner areas or hematoma formation.

2. Check vital signs.

3. Check for any other tear or laceration.COMPLICATIONS1. Hematoma.2. Infection.3. Wound

dehiscence.4. Perineal laceration.5. Dyspareunia.

6. Scar endometriosis.

SPECIAL CONSIDERATIONS1. Repair of the skin edges should begin at the fourchette so that vaginal
opening is properly aligned.

2. Arectal examination is made when suturing is completed in order to ensure that no sutures have
penetrated the rectal

mucosa to prevent fistula formation.

3. The thread should not be pulled too tightly to prevent edema formation.