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Episiotomy: By: Charisse Ann G. Gasataya

Episiotomy is an incision made in the perineum during childbirth to prevent tearing of the perineum and facilitate delivery. It is performed when there is risk of significant tearing such as with shoulder dystocia, breech delivery, or large babies. The incision can be midline or mediolateral. Midline episiotomies are easier to repair but risk deeper tearing, while mediolateral have less risk of deep tearing but are harder to repair. Repair involves closing the vaginal mucosa with absorbable sutures followed by the muscles and fascia, then the skin. Complications can include extensions of the tear, dehiscence, infection

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Charisse Ann Gasataya
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63 views

Episiotomy: By: Charisse Ann G. Gasataya

Episiotomy is an incision made in the perineum during childbirth to prevent tearing of the perineum and facilitate delivery. It is performed when there is risk of significant tearing such as with shoulder dystocia, breech delivery, or large babies. The incision can be midline or mediolateral. Midline episiotomies are easier to repair but risk deeper tearing, while mediolateral have less risk of deep tearing but are harder to repair. Repair involves closing the vaginal mucosa with absorbable sutures followed by the muscles and fascia, then the skin. Complications can include extensions of the tear, dehiscence, infection

Uploaded by

Charisse Ann Gasataya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
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EPISIOTOMY

By: Charisse Ann G. Gasataya


What Is Episiotomy?
 Derived from the Greek word episton – PUBIC REGION and tomy – to cut.
 Is the incision of the pudendum – the external genital organs
Indications
 Shoulder dystocia
 Breech delivery
 Macrosomic fetuses
 Operative vaginal deliveries
 Persistent occiput posterior positions
 Other instances in which failure to perform episiotomy will result in significant perineal
rupture
Timing of Episiotomy
 Completed when the head is visible during a contraction to a diameter of 3 to 4 cm ~
crowning
 If performed unnecessarily early, bleeding from the episiotomy may be considerable during
the interim between incision and delivery.
 If it is performed too late, lacerations will not be prevented.
 When used in conjunction with forceps delivery, most perform an episiotomy after
application of the blades
Different Techniques
MIDLINE EPISIOTOMY

 Scissors are positioned at 6 o’clock on the vaginal opening and directed posteriorly
 Incision length: 2 – 3 cm
 Easier to perform and repair and is associated with less postoperative pain, less blood loss,
and better anatomic results
 Major disadvantage: INCREASED RISK OF THIRD AND FOURTH DEGREE
LACERATIONS
Different Techniques
MEDIOLATERAL EPISIOTOMY

 Scissors are positioned at 7 o’clock or at 5 o’ clock


 Incision length: 3 – 4 cm (toward the ipsilateral ischial tuberosity)
 Disadvantages: greater blood loss, more difficult to repair, anatomic results may be faulty;
post-op pain is more common
Repair of Episiotomy
Repair
 Close the vaginal mucosa & submucosa with a continuous locking suture of 2-0 synthetic
delayed absorbable suture or chromic catgut
 Closure of the fascia and muscle of the perineal body with three or four interrupted
sutures of similar suture material.
 the skin of the perineum can then be closed with a continuous subcuticular stitch or by
interrupted sutures of 3-0 or 4-0 synthetic absorbable or chomic suture through the
subcutaneous tissue and skin.
Repair of Midline Episiotomy

Disruption of the hymenal ring and An anchor stitch is placed above the wound apex
bulbocavernosus and superficial transverse perineal to begin a running closure. Absorbable 2–0 or 3–0
muscles are seen within the diamond – shaped suture is used for continuous closure of the vaginal
episiotomy incision mucosa and submucosa with interlocking stitches.
Repair of Midline Episiotomy

After closing the vaginal incision and A continuous closure with absorbable 2–0 or 3–0
reapproximating the cut margins of the hymenal suture is used to close the fascia and muscles of the
ring, the needle and suture are positioned to close incised perineum. This aids restoration of the
the perineal incision. perineal body for long-term support.
Repair of Midline Episiotomy

The continuous suture is then carried upward as a


subcuticular stitch. The final knot is tied proximal to
the hymenal ring.
Repair of Midiolateral Episiotomy
The vaginal mucosa is shown as already closed using 2–0
absorbable suture in a running interlocking stitch similar to that
for midline repair.
perineal reapproximation begins with reunion of
bulbocavernosus and transverse perineal muscles.
These will assist reestablishment of perineal body support.
Distal to these muscles, abundant fat in the ischiorectal fossa is
incorporated in the same running closure.
A second layer atop this first perineal layer may be required to
adequately close dead space.
The skin is then closed with a subcuticular stitch as used for
midline closure.
4th Degree Laceration Repair
End – To – End Technique
During this suturing, the superior extent of the anterior anal laceration is identified,
The sutures are placed through the submucosa of the anorectum approximately 0.5 cm
apart down to the anal verge.
4th Degree Laceration Repair
End – To – End Technique
A second layer is placed through the rectal muscularis using 3–0 Vicryl suture in a running
or interrupted fashion.
This “reinforcing layer” should incorporate the torn ends of the internal anal sphincter,
which is identified as the thickening of the circular smooth muscle layer at the distal 2 to 3
cm of the anal canal.
4th Degree Laceration Repair
End – To – End Technique
In overview, with traditional end- to-end approximation of the EAS, a suture is placed
through the EAS muscle, and four to six simple interrupted 2–0 or 3–0 Vicryl sutures are
placed at the 3, 6, 9, and 12 o’clock positions through the connective tissue capsule of the
sphincter.
Complications
 Extensions and Fistula Formation
 Dehiscence
 Infection
 Hematoma
Extensions & Fistula Formation
Extensions

incontinence of
flatus & stool

rectovaginal fistula

Infection
Dehiscence
 Predisposing factors:  Early repair of dehiscence:
o Infection o Cleaning and debridement of the episiotomy site
o Human papillomavirus o After initial debridement the wound should be
o Cigarette smoking scrubbed and cleaned at least twice daily.
o Hematoma o debridement of granulation tissue and dissection to
o trauma ensure good tissue mobility
o Identify the fibrous capsule and mobilize the muscle
and capsule for reapproximation
Post-Episiotomy Pain
 Pudendal nerve blockade
 Locally applied ice packs
 Analgesics (codeine)
 For those with second-degree or greater lacerations, inter course is usually proscribed until
after the first puerperal visit at 4 to 6 weeks.
 Because pain may be a signal of a large vulvar, paravaginal, or ischiorectal fossa hematoma
or peri- neal cellulitis, these sites should be examined carefully if pain is severe or
persistent.
- Thank You -

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