EPISIOTOMY (perineotomy)

An episiotomy is plan incision through the vaginal wall and the perineum (the area between the
thighs, extending from the vaginal opening to the anus) to enlarge the vaginal opening and
facilitate childbirth.

Episiotomy is usually performed during second stage of labor to quickly enlarge the opening for
the baby to pass through. The incision, which can be done at a 90 degree angle from
the vulva towards the anus or at an angle from the posterior end of the vulva (medio-lateral
episiotomy), is performed under local anesthetic (pudendal anesthesia), and is sutured after
delivery.

In some cases, the vaginal opening does not stretch enough to accommodate the fetus. In this
case, an episiotomy may be done to help enlarge the opening and deliver the fetus. The
episiotomy is usually done when the fetal head has stretched the vaginal opening to several
centimeters during a contraction.

Objectives Of Episiotomy

1-To enlarge the vaginal introitus – Facilitate easy and safe delivery of the fetus (spontaneous or
manipulative. )

2-To minimize overstretching and rupture of the perineal muscles and fascia – to reduce the
stress and strain on the fetal head.

Types Of Episiotomy

There are four main types of episiotomy

 Medio-lateral: The incision is made downward and outward from the midpoint of
the fourchette either to the right or left. It is directed diagonally in a straight line which
runs about 2.5 cm (1 in) away from the anus (midpoint between the anus and the ischial
tuberosity).  This type of episiotomy does not tend to tear or extend, but is associated
with greater blood loss and may not heal as well.
 Median: The incision commences from the centre of the fourchette and extends on the
posterior side along the midline for 2.5 cm (1 in). Associated with a higher risk of injury
 to the anal sphincter and the rectum. Damage to the anal sphincter caused by episiotomy
can result in fecal incontinence (loss of control over defecation). This type of episiotomy
usually heals well but may be more likely to tear and extend into the rectal area, called a
third or fourth degree laceration
 Lateral: The incision starts from about 1 cm (0.4 in) away from the centre of the
fourchette and extends laterally. Drawbacks include the chance of injury to
the Bartholin's duct, therefore some practitioners have strongly discouraged lateral
incisions.o
 J-shaped: The incision begins in the centre 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. This procedure is also not widely practised.
After the delivery of the baby, the mother may be asked to continue to push during the next few
uterine contractions to deliver the placenta. Once the placenta is delivered, the episiotomy
incision is sutured. If a mother does not have regional anesthesia such as an epidural, a local
anesthesia may be injected in the perineum to numb the area for repair of a tear or episiotomy
after delivery.
 Indications For Episiotomy

Not all women will require an episiotomy, and assisting the tissues to stretch naturally may help
reduce the need for this procedure. If an episiotomy is not done, tearing of the perineal tissues
may or may not occur. An episiotomy may be used to assist in the treatment of the following
conditions:

 Fetal distress

 Complicated birth such as a breech presentation (bottom or feet first) or shoulder dystocia (when
the fetal head has been delivered but the shoulders are trapped)

 Prolonged second stage (pushing stage of labor)

 Operative delivery (Forceps or vacuum delivery)

 Large baby

 Preterm baby

 Elastic (rigid) perineum

 Anticipating perineal tear

 Previous perineal surgery

 Threatened perineal injury in primigravidae

Timing Of Episiotomy

1-Bulging thinned perineum during contraction just prior to crowning (when 3–4 cm of head is
visible)

2-During forceps delivery, it is made after the application of blades.

If done early, – the blood loss will be more.

If done late, – it fails to prevent the invisible lacerations of the perineal body
Advantages Of Episiotomy

Maternal: (a) a clear and controlled incision is easy to repair and heals better

(b) reduction in the duration of second stage

(c) Reduce the trauma to muscles

Fetal: – It minimizes intracranial injuries

Steps Of Mediolateral Episiotomy

1-The perineum is thoroughly swabbed with antiseptic (povidone-iodine) lotion and draped
properly.

2-The perineum, in the line of proposed incision is infiltrated with 10 mL of 1% solution of

3-Two fingers are placed in the vagina between the presenting part and the posterior vaginal
wall.

4- The incision is made by a curved or straight blunt pointed sharp scissors (scalpel may also be
used)

5-One blade of which is placed inside, in between the fingers and the posterior vaginal wall and
the other on the skin.

6- The incision should be made at the height of an uterine contraction when an accurate idea of
the extent of incision can be better judged from the stretched perineum.

7. Deliberate cut should be made starting from the center of the fourchette extending laterally
either to the right or to the left.

8-It is directed diagonally in a straight line which runs about 2.5 cm away from the anus.

9. The incision ought to be adequate to serve the purpose for which it is needed,
10- The bleeding is usually not sufficient to use artery forceps unless the operation is done too
early or the perineum is thick.

STRUCTURES CUT ARE

1 Posterior vaginal wall

2 Superficial and deep transverse perineal muscles, bulbospongiosus and part of levator ani

3 Fascia covering those muscles

4 Transverse perineal branches of pudendal vessels and nerves

Timing of repair

1. The repair is done soon after expulsion of placenta.

2. If repair is done prior to that, disruption of the wound is inevitable, if subsequent manual
removal or exploration of the genital tract is needed.

3. Oozing during this period should be controlled by pressure with a sterile gauze swab and
bleeding by the artery forceps.

4. Early repair prevents sepsis and eliminates the patient’s prolonged apprehension of “stitches”.
 Steps In Repair

1-Lithotomy position.

2-A good light source

3-Cleansed with antiseptic solution.

4-Blood clots are removed from the vagina and the wound area.

5-The patient is draped properly and repair should be done under strict aseptic precautions.

6-If the repair field is obscured by oozing of blood from above, a vaginal pack may be inserted
and is placed high up.

7- The principles to be followed are:

(1) Perfect hemostasis

(2)To obliterate the dead space and

(3) Suture without tension.

8-The repair is to be done in the following ordered layer:

(1) Vaginal mucosa and submucosal tissues

(2) Perineal muscles

(3) Skin and subcutaneous

9-The vaginal mucosa is sutured first; the first suture is placed at or just above the apex of the
tear.

10-Thereafter, the vaginal walls are opposed by interrupted sutures with No. “0” chromic catgut,
from above downwards till the fourchette is reached.

11-The suture should include the deep tissues to obliterate the dead space.

12-A continuous suture may cause puckering and shortening of the posterior vaginal wall.
13-Care should be taken not to injure the rectum.

Postoperative Care

• Dressing

• Comfort

– Sitz bath

– Ice pack

– Analgesic (ibuprofen)

• Ambulance

• Removal of stitches – Non-absorbable (6th day)

(1) Extension of the incision to involve the rectum.

(2) Vulval hematoma

(3) Infection: signs of infection are

(A) Throbbing pain on the perineum

(B) Rise in temperature

(C) The wound area looks moist, red and swollen and

(D) Offensive discharge

Treatment of Immediate complications

(a) To facilitate drainage of pus

(b) Local dressing with antiseptic powder or ointment

(c) MgSO4 compression or application of infrared heat to the area to reduce edema and pain

(d) Systemic antibiotic (IV).

(4) Wound dehiscence

(5) Injury to anal sphincter causing incontinence of flatus or feces.

(6) Rectovaginal fistula and rarely.

(7) Necroti`zing fasciitis (rare) in a woman who is diabetic or immunocompromised

(8) Dyspareunia

(9) Chance of perineal lacerations in subsequent labor

(10) Scar endometriosis (rare).

(11) Perineal pain

1-An ice pack may be applied immediately after birth to help reduce swelling and pain.

2-Sitz baths (warm or cold shallow baths) may relieve soreness and speed healing.

3-Medicated creams or local anesthetic sprays applied the perineum may also be helpful.

4-Pain reliever for soreness as recommended

5-The incision cite should be kept clean and dry,

6-If bowel movements are painful, stool softeners are recommended

7-Avoid douching, use tampons, or have intercourse until the time instructed by the
physician/midwife.

8-Other restrictions on activity, including strenuous activity or heavy lifting.

9-Normal diet to be resumed immediately, unless otherwise indicated

10-Follow up care

11-Report any of the following signs

 Bleeding from the episiotomy site

PERINEAL TEAR

A perineal tear is a laceration of the skin and other soft tissue structures which, in women,
separate the vagina from the anus. Perineal tears mainly occur in women as a result of
vaginal childbirth, which strains the perineum. It the most common form of obstetric
injury. Tears vary widely in severity. The majority are superficial and may require no treatment,
but severe tears can cause significant bleeding, long-term pain or dysfunction. A perineal tear is
distinct from an episiotomy, in which the perineum is intentionally incised to facilitate
delivery. Episiotomy, a very rapid birth, or large fetal size can lead to more severe tears which
may require surgical intervention.

 Lacerations of perineum are the result of overstretching or too rapid stretching of the tissues,
especially if they are poorly extensile and rigid. Perineal injuries are more common in
primigravida than multigravida.

CAUSES:

1)Obstetrical causes

2)Non Obstetrical causes

1-Obstetric Causes: Malpresentations such as breech

Contracted pelvic outlet

Prolonged labour

Operative vaginal deliveries (forceps or vacuum)

Microsomal babies
 Occipitoposterior delivery

Precipitate labour

Epidural analgesia

Induction of labour

Rigid perineum

2-Non-obstetric causes: Rape

Molestation

Fall

Accidental injuries like RTA, bull horn injuries etc.

CLASSIFICATION OF PERINEAL TEARS

1-First degree: Injury to perineal skin only.

2-Second degree: Injury to perineum involving perineal muscles but not involving the anal
sphincter.

3-Third degree: Injury to perineum involving the anal sphincter complex:

3a: Less than 50% of EAS thickness torn.

3b: More than 50% of EAS thickness torn.

3c: Both EAS and IAS torn.

4-Fourth degree: Injury to perineum involving the anal sphincter complex (EAS and IAS) and
anal epithelium.
How to Recognize a Perineal Tear

• Put the patient in extended lithotomy position.

• Arrange proper spotless bright light.

• Vulva should be examined stepwise right from clitoris to the anus downwards, laterally
paraclitoral, paraurethral, paravaginal and pararectal skin and muscles in every case after
delivery.

• Perineal tears may be associated with high vaginal circular tears and tears in the fornix and
cervix.

• One should suspect traumatic PPH due to perineal tears when continuous bleeding p/v
persisting even after delivery of placenta when uterus is contracted and retracted.
PERINEAL TEARS REPAIR:

Should be repaired immediately after delivery of the placenta (if not possible, within 24 hours of
delivery.)

1-First step is to define the limits of the lacerations, which includes vagina as well as perineum.

2-Prerequisites:

-Proper light with good exposure

-Good analgesia

-Good assistance

-Prefer blunt needle

-Chromic catgut 2-0

-Polyglactin 910

-2-0 Polydiaxone sulfate (PDS)

TECHNIQUE

• All tears that are bleeding should be identified and ligated separately.

• The stitching starts from the apex of vaginal mucosa using polyglactin or chromic stitch with
continuous or interrupted sutures.

• The muscles are stitched using the same stitch taking full thickness of the muscle and achieving
hemostasis.

• The skin is stitched with interrupted sutures.

NB; third and fourth degree perineal tear which involve the anal sphincter (OASIS-
obstretic anal spincter injury) is repair in an operating theatre
POSTOPERATIVE MANAGEMENT:

• Use of broad spectrum antibiotics is recommended following repair of OASIS to reduce the
risk of postoperative infection and wound dehiscence, ampicillin,-500mg tds, and metronidazole
400mg tds

• Postoperative laxatives

• Seitz bath BD.

• Analgesics (ibuprofen)

• Physiotherapy and pelvic floor exercises 6-12 weeks after repair.

Follow-up

• History of symptoms of anal incontinence.

• Inspection of the perineum

• Vaginal and rectal palpation

• Information about a possibly long latency onset/worsening of the symptoms of anal

• Discussion regarding subsequent pregnancies and births

• If patient is experiencing incontinence or pain on follow up refer to a special gynecologists or

Recommendations for subsequent deliveries

• Should be counseled about the risk of developing anal incontinence or worsening symptoms
with subsequent vaginal delivery.

• No evidence to support the role of prophylactic episiotomy in subsequent pregnancies

• An elective Caesarean section should be offered to all women who have previously suffered
from 3rd/4th degree perineal tears, and especially to those patients with – persisting fecal
incontinence, – reduced sphincter function or – suspected fetal macrosomia.
Sequel of obstetric perineal laceration

• Chronic perineal pain

• Dyspareunia

• Urinary & fecal incontinence

PREVENTION

• Liberal use of episiotomy

• Proper conduct of labour during 2nd stage

• Perineal support during 2nd stage