Procedure on Episiotomy

DEFINITION

A surgically planned incision on the perineum & the posterior vaginal wall during the second stage of labour with a view to facilitate the passage of foetal head & prevent an uncontrolled tear of the perineal tissue is called episiotomy (perineotomy).

OBJECTIVES

• To enlarge the vaginal introitus so as to facilitate easy & safe delivery of the fetus.
• To minimize overstretching & rupture of the perineal muscles & fascia; to reduce the stress & strain on the fetal head.

INDICATIONS

• Rigid perineum
• Shoulder dystocia
• Anticipating perineal tear
• Operative delivery i.e. forceps, ventouse
• Previous perineal surgery
• Previous cesarean section
• Breech delivery
• Occipito-posterior position
• Foetal distress in 2nd stage of labour

TIMING OF EPISIOTOMY

• The episiotomy should be performed when presenting part is bulging in the perineum & is about to crown or at least 3-4cm of a diameter of the head is visible during contraction.
• In case of instrumental delivery, the episiotomy should be given after the application & locking of the blade of forceps or after the application of the vacuum cup.

ADVANTAGES

• A clear & controlled incision is easy to repair & heals better than a lacerated wound that might occur otherwise.
• Reduction in the duration of the second stage.
• Reduction of trauma to the pelvic floor muscles.
• It minimizes intracranial injuries, especially in premature babies or after-coming head of breech.

TYPES

The following are the various types of episiotomy:

A. Medio-lateral

• The incision is made downwards & outwards from the midpoint of the fourchette either to the right or left.
• It is directed diagonally in a straight line that runs about 2.5cm away from the anus (midpoint between anus & ischial tuberosity).

B. Median

• The incision commences from the center of the fourchette & extends posteriorly along the midline for about 2.5cm.
• In this repair is simple, and bleeding is less but the disadvantage is that any extension by tearing will involve the anal canal.

C. Lateral

• The incision starts from about 1cm away from the center of the fourchette & extends laterally.
• It has got many drawbacks including chances of injury to the Bartholin’s duct, excessive bleeding & accurate alignment of divided structure is difficult.
• It is totally condemned.

D. J shaped

• The incision begins in the center of the fourchette & is directed posteriorly along the midline for about 1.5cm & then directed downwards & outwards along 5 or 7 o’clock position to avoid the anal sphincter.

ANALGESIA FOR EPISIOTOMY

1. Episiotomy is always given & repaired under analgesic.
2. 1% lignocaine is infiltrated in line of the proposed cut unless the patient has been already under epidural anaesthesia.
3. One should always remember that local anaesthetic takes some time to be effective.
4. Women may choose to combine Entonox & local or regional anaesthesia.

STEPS OF MEDIOLATERAL EPISIOTOMY

Articles

• 10ml syringe
• 1% solution of sodium lignocaine
• Sharp episiotomy scissor
• Draping sheets
• Sterile gloves
• Suturing material

Preliminaries

The perineum is thoroughly swabbed with an antiseptic solution and draped properly. Local anesthesia is given with 10ml of 1% lignocaine.

Incision

Two fingers are placed in the vagina between presenting part and posterior vaginal wall. The incision is made by curved or straight blunt pointed sharp scissors, one blade of which is placed inside, in between the fingers and posterior vaginal wall and other on the skin. The incision should be made at the height of uterine contraction when an accurate idea of the extent of the incision can be better judged from the stretched perineum. A deliberate cut should be made starting from the center of the fourchette and extending laterally either to the right or to the left. It is directed diagonally in a straight line which runs about 2.5cms away from the anus. The incision ought to be adequate to be served the purpose for which it is needed.

The structures cut are:

• Posterior vaginal wall
• Superficial and deep transverse perineal muscles, bulbospongiosus, and part of the levator ani
• Fascia covering the muscles
• Transverse perineal branches of pudendal vessels and nerves
• Subcutaneous tissue and skin

Repair

Timing of repair

The repair is done soon after the expulsion of the placenta. If repair is done prior to that, disruption of a wound is inevitable, if subsequent manual removal or exploration of the genital tract is needed. Oozing during this period should be controlled by pressure with a sterile gauze swab and bleeding by artery forcep. Early repair prevents sepsis and eliminates patient’s prolonged apprehension of stitches.

Preliminaries

The patient is placed in a Lithotomy position. A good light source from behind is needed. The perineum including the wound area is cleaned with an antiseptic solution. Blood clots are removed from the vagina and wound area. The patient is draped properly and repair should be done under strict aseptic precautions. If the repair field is obscured by oozing of blood from above, vaginal pack may be inserted and placed high up. Do not forget to remove the pack after repair is completed.

Repair is done in 3 layers

The principles to be followed are:

1. Perfect homeostasis
2. To obletrate the dead space
3. Suture without tension

Repair is to be done in the following order:

1. Vaginal mucosa and submucosal tissue
2. Perineal muscles
3. Skin and subcutaneous tissue

A continuous suture used to repair the vaginal wall. Three or four interrupted sutures to repair the fascia and muscles of the perineum and Integrated sutures to the skin.

For perineal tear

Step-I

• Dissection is not required as in a complete perineal tear. Rectal and anal mucosa is first sutured from above downwards. No.’00’ vicryl, a traumatic needle, interrupted stitches with knots inside the lumen is used.
• Rectal mucosa, including the para rectal fascia, is sutured by interrupted sutures using same suture material.
• The torn ends of sphincter ani externus are then exposed by Allis tissue forcep. The sphincter is then reconstructed with a figure of eight stitch and is supported by another layer of interrupted sutures.

Step-II

• Repair of perineal muscle is done by interrupted suture using no. 0 or dexon or polyglactin vicryl.

Step-III

• The vaginal wall and perineal skin are apposed by interrupted sutures.

AFTERCARE OF EPISIOTOMY

Dressing: 

The wound is to be dressed each time following urination & defecation to keep the area clean & dry. The dressing is done by swabbing with cotton swabs soaked in an antiseptic solution followed by the application of antiseptic cream.

Comfort: 

To relieve pain in the area, magnesium sulfate compress or application of infra-red heat may be used. Analgesics may be given as & when required to relieve pain. If there is persistent & severe pain, vaginal haematoma should be ruled out.

Ambulance: 

The patient is allowed to move out of bed after 24 hours. Prior to that, she is allowed to roll over onto her side or even to sit but only with thighs apposed.

Antibiotics: 

Postoperative antibiotic, for 5-7 days which helps in the prevention of infection.

Stool softener: 

A stool softener can be given to allay discomfort during defecation.

Removal of stitches: 

Catgut sutures need not be removed. Non-absorbable sutures like silk or nylon are to best cut on the 6th day.

COMPLICATIONS OF EPISIOTOMY

Immediate

• Extension of the incision to involve the rectum.
• Vulval haematoma
• Infection
• Wound dehiscence due to infection, haematoma or faulty repaired.
• Injury to anal sphincter
• Recto-vaginal fistula
• Rarely necrotizing fasciitis in women who are diabetic or immune-compromised.

Remote

• Dyspareunia due to a narrow vaginal introitus which may result from faulty technique of repair.
• Chance of perineal laceration in next labor.
• Rarely scar endometriosis, implantation dermoid.