Episiotomy

Prepared by:

1. Nour el-din ahmad maklad.

2. Manar loutfy muhammad.
3. Yasser el-said eid.
4. Manal shehata abdallah.
5. El-zahraa muhammad abdelaziz.
• Outlines:

 Definition of episiotomy.
 Indications
 Timing of episiotomy
 Types of episiotomy
 Infiltration to the perineum
 Methods of infiltration
 The incision
 Complications
 Laceration of perineum and genital tract
 Nursing interventions
 Health teaching
Episiotomy:
A surgical procedure for widening the outlet of the birth canal to
facilitate delivery of the baby and to avoid a jagged rip of the area
between the anus and the vulva (perineum).

Objectives
Maternal:
 To enlarge the vaginal introitus so as to facilitate easy and safe
delivery of the fetus.
 To minimize overstretching and rupture of the perineal muscles
and fascia.
 To shorten the second stage of labour.
Fetal:
 To reduce the stress and strain on the fetal head.
INDICATIONS:
Maternal:
 When perineal muscles are excessively rigid.
 Threatened perineal injury in primigravida.
 Labor is going too quickly.
Fetal:
 Baby is large.
 Shoulder dystocia.
 An instrumental or breech delivery.
TIMING OF
EPISIOTOMY:
• It was recommended to perform episiotomy before
crowning, i.e. when the fetal head recedes into the pelvis
in between the contractions and the delivery of the fetus
is expected within the next three to four contractions, or
once 3–4 cm in diameter of the fetal head is visible
during a contraction
 TYPES:
There are four main types of episiotomy:

1. Medio-lateral 2. Median -the most common 2 types-

3. Lateral 4. J-shaped
Mediolateral:
• The 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°.
The incision can be performed on either side and is
generally 3-4 cm in length.
• The anatomic structures involved in a mediolateral
episiotomy include the vaginal epithelium, transverse
perineal muscle, bulbocavernosus muscle, and perineal
skin. A deep or large mediolateral episiotomy may expose
the ischiorectal fossa.
Median
• A midline episiotomy may be performed after adequate
anesthesia has been confirmed.
• Generally, the index and middle fingers are inserted into
the vagina between the fetal head and the perineum,This
maneuver provides space for making the incision.
• A vertical incision is made in the midline of the perineum
from the posterior fourchette toward the anus.
• Most commonly, the incision is made just before delivery
of the fetal head, at the time when the perineum is
thinned and stretched..
 Median Mediolateral
Advantages  The muscles are not  Relative safety from
cut. rectal involvement
 Blood lost is less. from extension
 Repair is easy.  If necessary, the
 Post operative incision can be
comfort is maximum. extended.
 Wound disruption is
rare.
 Dyspareunia is rare.
Disadvantages  Extension, if occurs  Apposition of the
may involve the tissues is not so good.
rectum  Blood loss is little
 Not suitable for more.
manipulative delivery  Post operative
or in abnormal discomfort is more.
presentation or  Relative increased
position incidence of wound
disruption.
 Dyspareunia is more.
 Lateral: The incision starts from about 1 cm (0.4 in) away
from the center of the fourchette and extends laterally. It has
got many drawbacks include the chance of injury to the
Bartholin’s duct, therefore some practitioners have strongly
discouraged lateral incisions.

 ‘J’ Shaped: The incision begins in the center of the fourchette

and is directed posteriorly along the midline for about 1.5
centimetres (0.59 in) and then directed downwards and
outwards along the 5 or 7 o’clock position to avoid the internal
and external anal sphincter.
Infiltration to the
perineum
What is perineal infiltration?

local infiltration of the perineum is a simple and

commonly used technique for providing pain relief for
episiotomy. ... Because of the short time interval between
local infiltration and delivery, very little anesthetic was
thought to reach the fetus.
Methods of infiltration
• Perineal infiltration (ropivacaine 75 mg or placebo) will
be administrated just after vaginal birth and before
episiotomy repair.
• The primary outcome will be the analgesic efficacy at
day 7 postpartum (midterm), defined by the Numeric
Pain Rating Scale (NPRS) strictly superior to 3/10 on the
perineal repair area
• Secondary outcomes will be the analgesic efficacy
(NPRS) and the impact of pain on daily behavior, on the
quality of life (36-item Short Form Health Survey), on
the occurrence of symptoms of postpartum depression
(Edinburgh Postnatal Depression Scale), and on sexual
health (Female Sexual Function Index) at 3 and 6 months
(long-term) using validated online questionnaires.
• This study will have 90% power to show approximately
30% relative risk reduction in the incidence of perineal
pain at day 7, from 70.0% to 50.0%.
The incision
Steps:
• Place the patient in lithotomy/dorsal position
• Perineal area is thoroughly swabbed with antiseptic lotion
• Drape the area
• The perineum, in line of proposed incision is infilterated
with 10 ml. of 1% solution of lignocaine.
Incision:
• Two fingers are placed in the vagina between the
presenting part and the posterior vaginal wall.
• The incision is made by the episiotomy scissors, one
blade of which is placed inside in between the fingers and
the posterior vaginal wall and other on the skin.
• The incision should be made at the height of uterine
contraction.
• Deliberate cut is made starting from the centre of the
fourchette extending laterally either to the right or to the
left (medio lateral).
complications
• bleeding
• prolonged wound healing
• dyspareunia
• pelvic floor dysfunction
• urinary fistulas
• Inappropriate wound scarring.
Laceration of perineum
and gential tract
• Episiotomy should not routinely be performed at the time
of a normal vaginal delivery, as there is no clear evidence
that this reduces the incidence of third- or fourth-degree
tears. Midline episiotomy in particular does not protect
the perineum or sphincters during childbirth and may
impair anal continence. If an episiotomy is to be
performed, a right (or less commonly left) posterolateral
episiotomy is preferred.
• Spontaneous tears are categorized into four degrees An
episiotomy is an iatrogenic second-degree tear. Anterior
perineal trauma is classified as any injury to the labia,
anterior vagina, urethra or clitoris, and is described as
such.

Tear involves
First degree Injury to the vaginal epithelium and vulval
skin only
Second degree Injury to the perineal muscles, but not the anal
sphincter
Third degree Injury to the perineum involving the anal
sphincter complex
Fourth degree Injury to the perineum involving the anal
sphincter complex and anal/rectal mucosa
 Nursing
interventions

Before the procedure:

• Ensure that the woman consents to the procedure

• Ensure good lighting
• Assess the perineum and decide about the type of episiotomy
• Ensure adequate anesthesia
• Check the equipment before starting the procedure
• Count swabs before and after performing the episiotomy repair
• Use a loose, continuous non-locking method for vaginal mucosa and
perineal muscles and a continuous subcuticular technique for perineal skin
During the procedure:

• Pour warm water to washout the discharge

• Clean the perineum with sterile wet swab starting at the pubis
downwards, using one swab once only
• Clean labia majora, labia minora, adjacent area, inner aspects of labia
minora and clitoris using separate swabs.
• Turn the patient on one side. Clean and dry buttocks after removing the
bed pan.
• Apply dry heat for 15 minutes.
• Apply sterile pad and secure it with a bandage or string.
• Make the patient comfortable.
• Remove screens and other articles.
• Wash and dry articles used and replace these in their appropriate places.
• Inspect the perineal stitches for any sign of infection, assess healing of
the wound..
After the procedure:
• The nurse assess vital signs, symptoms and signs of wound
infection, any abnormal discharge, Patient ambulation and level of
activity
• the nurse will often apply a dressing.
• the nurse will monitor the patient for pain and urinary incontinence
• If there is swelling, the nurse will apply ice packs which also
decrease the pain.
• Patients receive training on how to take sitz baths and clean the
perineum.
• The sutures used to close an episiotomy do not require removal,
and will reabsorb in the tissues within 6 to 8 weeks.
• Finally, patients must learn how to perform Kegel exercises to help
tighten up the pelvic floor muscles.
Health education
Incisional care
• It is important to keep the incision clean and dry, taking
sponge baths or showers.
• Drip plain or soapy water over the incision and dry gently
with a clean towel.
• The incision may itch as it heals. So be careful not to
scratch it.
• If staples are present, they are normally removed around
day 3-6. Tiny papers called steri-strips, are often applied
after the staples are removed. These will begin to come off
or can be peeled off by day 5-14. Your physician may give
you more information about the care of steri-strips.
• Your internal stitches will dissolve on their own
Avoid infection:
Lower the risk of infection by keeping her stitches clean:
• Gently wipe from front to back after having a bowel
movement.
• After wiping, spray warm water on the stitches. Pat dry.
• After urination, it's OK not to wipe. Just spray with warm
water and then pat dry.
• Don’t use soap or any solution except water unless
healthcare provider recommends it.
• Change sanitary pads at least every 2 to 4 hours.
Avoid constipation:
Follow these suggestions:
• Eat fresh fruits and vegetables, whole grains, and bran
cereals.
• Drink 6 to 8 glasses of water every day, unless directed
otherwise.
• Don’t strain to have a bowel movement.
• Ask healthcare provider about using a stool softener.
• If the woman is breastfeeding, she must ask healthcare
provider before taking any medicine.
Ease pain:
Try to make herself more comfortable by:
• Sitting in a warm bath (sitz bath).
• Placing cold packs or heat packs on her stitches. Keep a
thin towel between the pack and her skin.
• Sitting on a firm seat so that the stitches pull less.
• Using medicated spray as ordered by her healthcare
provider.
• Talking to her healthcare provider about using an anti-
inflammatory medicine like ibuprofen to ease the pain.
Nutrition
• Drink plenty of liquids as body needs lot of fluid (about
6-10 glasses a day) especially if she is breastfeeding her
baby.
• Eating foods that have protein such as milk, cheese,
yogurt, meat, fish and beans. Protein rich foods are
important to help in recovery from childbirth and
episiotomy.
• Eating fruits and vegetables as they have vitamins and
minerals that keep her body healthy, They also have fiber,
which helps prevent constipation.
• Limit junk foods: Soda pop, cookies, donuts and potato
chips
Any questions?
 Thanks
for your attention.