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Normal Labor: Adrian Goenawan, M.D
Normal Labor: Adrian Goenawan, M.D
Normal Labor: Adrian Goenawan, M.D
E. Oral Intake
F. IV Fluids
Management of the 1st Stage of Labor
H. Amniotomy
• Advantage – shorter labor
• Disadvantage – increased incidence of
chorioamnionitis
Perineal skin
Vaginal mucosa
Fascia
Muscles of the
perineal body
Anal sphincter
Rectal mucosa
Episiotomy
• Purposes:
1. Substitution of a straight surgical incision is
easier to repair than a ragged laceration. Post-
op pain is less and healing improved.
2. Prevents pelvic laceration
Episiotomy
• Recommendation is that episiotomy should
not be performed routinely because of
increased risk of 3rd and 4th degree laceration
and fecal and flatus incontinence.
Episiotomy
• Indications:
1. Shoulder dystocia
2. Breech delivery
3. Forceps or vacuum extraction delivery
4. Occiput posterior position
5. Instances when failure to perform an episiotomy
will result in perineal rupture
Episiotomy
• Timing:
– Done when the head is visible during a contraction
to a diameter of 3-4 cm.
– If done in conjunction with forceps delivery,
should be made after application of the blades.
Midline vs. Mediolateral
Episiotomy
Type of Episiotomy
Characteristic Midline Mediolateral
Surgical repair Easy More difficult
Faulty healing Rare More common
Postoperative Minimal Common
pain
Anatomic Excellent Occasionally
results faulty
Blood loss Less More
Dyspareunia Rare Occasional
Extensions Common Uncommon
Episiotomy
• Factors associated with increase risk of 3rd &
4th degree laceration
1. Nulliparity
2. 2nd stage arrest of labor
3. Persistent OP position
4. Mid or low forceps
5. Use of local anesthesia
6. Asian race
Episiotomy
• Complications:
1. Wound disruption
2. Infection alone
3. Infection with dehiscence
• Timing of Repair
1. After placenta is delivered
Episiorrhapy
• Hemostasis and anatomical restoration
without excessive suturing is essential for
success of repair
Episiorrhapy
• 4th degree laceration
– Stool softener necessary
– Avoid enema
– Prophylactic antibiotics
Episiotomy
• Pain after episiotomy and repair maybe due to
a large vulvar, paravaginal or ischiorectal
hematoma or perineal cellulitis
• Examine carefully if pain is severe or persistent
• In the absence of complications oral analgesics
is given
thank you!