EPISIOTOMY & EPISIORRHAPHY

DR. SUMAYYA
 CONTENTS
• DEFINITION
• PURPOSE
• INDICATIONS
• ADVANTAGES
• TYPES
• PREPARATION AND TECHNIQUE
• EPISIORRHAPHY(REPAIR)
• PERINEAL CARE
• COMPLICATIONS
 DEFINITION
• A deliberate surgical incision made on the
perineum to widen or increase the diameter
of the vulva outlet to facilitate vaginal
delivery,it is given during the second stage of
labour,at crowning(when the head is visible at
the introitus and does not recede in between
contractions).
 PURPOSE
• To enlarge the vaginal introitus
• To facilitate easy and safe delivery
• To minimize rupture of the perineal muscles
and fascia(prevent perineal laceration)
• To prevent prolonged and overstretch of the
perineum which predisposes to prolapse and
stress incontinence
• To reduce stress on fetal head
 INDICATIONS
• MATERNAL
• Anticipating perineal tear(in primigravidae)
• Old perineal tear about to rupture
• Prolonged second stage due to rigid perineum
• forceps/vacum
• Vulval edema
• FETAL
• Fetal distress(presenting part already on the
perineum)
• Big baby
• Face to pubis delivery
• Breech delivery
• Shoulder dystocia
• Preterm baby
 CONTRAINDICATIONS
• Bleeding diathesis
• HIV infection
• Rhesus negative women with rhesus positive
fetus
• Face presentation
 ADVANTAGES
MATERNAL FETAL

.Easy to repair Minimizes intracranial injuries esp in

.Reduction in duration of labour premature babies
.Reduction of trauma
 TIMING
• Bulging thinned perineum during contraction
just prior to crowning
 TYPES
• Medio lateral
• Median
• Lateral
• J shaped
• STRUCTURES THAT ARE CUT THROUGH
• Skin
• Vaginal wall
• Bulbospongiosus muscle
• Superficial transverse perineal muscle
• Deep transverse perineal muscle
 EQUIPMENTS
• Episiotomy scissors
• Surgical gloves
• Needle holder
• Stitches
• Surgical drape
• Local anesthetic
• Tissue forceps
• Sims speculum
• Foley catheter
• Syringe,needle
• Scalpel/blade
• Kidney tray
 PREPARATION AND TECHNIQUE
• Valid indication
• Counsel and obtain informed consent
• Clean the area with antiseptic solution
• Infiltrate beneath the vaginal mucosa beneath
the skin and deeply into the perineal muscles
using 10mls of 0.5% xylocaine
• Check at the incision site for effect of local
anesthesia by pinching with the forceps before
giving incision
• Perform episiotomy at crowning
• Place two fingers beneath the babys head and
the perineum and cut 3-4cmin mediolateral
direction starting from the midline
• After delivery of the baby and placenta
carefully examine for extension of tears
 COMPLICATIONS
• Excessive bleeding
• PPP
• Haematoma formation
• Infection
• Breakdown of suture
• Dyspareunia
• Extension of the incision to involve the rectum
• Wound dehiscence
• Injury to anal sphincter causing incontinence
of flatus or faeces
• Rectovaginal fistula(rarely)
• Necrotising fascitis
 EPISIORRHAPHY
• AKA Repair of episiotomy it is a surgical repair of injury to the vulva
by suturing
• Patient is placed in lithotomy position
• Good light source
• Sterilized equipments
• Aseptic procedure
• Drape the area leaving only the operating field
• Infiltrate with 10ml of 1% xylocaine
• Insert a perineal pad into the birth canal to prevent bleeding and
lochia from obscuring the operating field
• Locate the apex of the episiotomy and go 1cm above because of
some blood vessels which might have retracted
• Suture the vagina mucosa by continous interlocking stitches
using vicryl 2 and the muscular layer by simple interrupted
stitches also using vicryl 2 skin is then closed subcuticarly with
vicryl 2,NOTE:Use minimal amount of suture material and
donot overtighten suture because this may impede healing
• Do VE after removing the pads to confirm that the vaginal canal
is not narrowed,also do a RE to be sure the rectal mucosa has
not been accidentaly caught
• Remove pads and place on antibiotics for 7days and analgesics
for 72hours
• Clean up and place in a supine position
 IMMEDIATE CARE
• Inspect the repair to check that hemostasis
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
• Check for bleeding and urine output
 PURPOSE OF REPAIR
• To control bleeding
• To prevent infection
• To assist wound healing by primary intention
 COMPLICATIONS
• Vulval hematoma
• Infection
• Rectovaginal fistula
• Wound dehiscence
• Dyspareunia
• Scar endometriosis
 EDUCATING THE PATIENT

• On eating a diet high in fibre and fluids to

prevent constipation
• To walk with thighs apposed
• Not to use squatting position since the wound
is healing
 PERINEAL CARE
• Changing sanitary pads at least every 4hours to help
prevent infection
• Squirting warm tap water over the perineum
beginning at the front and moving towards the back
• Sitting in a tub of warm water
• Washing hands thoroughly before and after going to
the bathroom
• Keeping the wound clean and dry after each
urination and defecation
 KEGELS EXCERCISE
• Educate the patient on how to do this,it
involves squeezing the perineal muscles as if
she is trying to stop the flow of urine,and then
holding for 5 to 10seconds and relaxing,to do
this as many times as she could everyday to
regain muscle strength
 REFERENCES
• Principles of obstetrics and gynecology
• Labour ward protocol
• A synopsis of obstetrics and gynecology
• Textbook of obstetrics and gynecology by Akin
Agbola
THANK YOU