EpisiotomyDefinition An episiotomy is a planned incision on the perineum and posterior vaginal wall to enlarge the vaginal orifice during the second stage of labour for obstetrical purpose. This is an incision through the perineal tissues which is designed to enlarge the vulval outlet during birth.Purpose1. To minimize over stretching of perineal muscle as in case of very large baby.2. To enlarge the vaginal orifice so it facilitates easy and safe delivery of the fetus-spontaneous or manipulative.3. To speed up delivery in fetal distress in second stage of labour.4. To an assisted delivery such as forceps or ventouse extraction.5. To prevent a recurrence of previous third or fourth degree tears.6. To decrease the length of second stage for women who are ill with heart disease and eclmpsia etc.

IndicationsEpisiotomy should not be performed routinely. It should be considered only in the following cases:1. Fetal distress in second stage of labour.2. Complicated vaginal delivery such as breech, shoulder dystocia, forceps, vaccum extraction etc.)3. Scarring from female genital cutting or poorly healed third and fourth degree of tears.4. Maternal distress due to exhaustionor heart failure.5. A very tight perineum that prevents delivery.6. Manipulative delivery such as vaccum, forceps, breech extraction, internal version.7. To cut short the second stage of labour especially for woman who is at risk for bearing down efforts, eg. Heart disease, pre-eclampsia, post caeserean cases, post maturity.8. Premature baby to minimize compression of the soft and flexible skull bone there by preventing intracranial damage.9. Cord prolapse in second stage of labour.10. Big baby.

Advantages of episiotomyMaternal A clean and controlled incision is easy to repair and heals better than lacerated wound. Timely episitomy saves perineum from laceration, heamatoma and complete perineal tear. Shortening of second stage of labour and it reduce the bearing down efforts which is beneficial in womans with cardiac disease or severe pre-eclampsia or eclampsia. Prevent postpartum genital prolapse.Fetal Minimizes intracranial injury especially in premature babies. Prevent fetal asphyxia by reducing longer stay in the perineum.

Disadvantage Blood loss 100-200 ml from episiotomy wound. Increased perineal trauma Vulval haematoma and infection Painful wound Dysparuenia due to over stitching.

Timing of episiotomy Judgement is needed for the episiotomy must be made neither too soon nor too late. An episiotomy involves incision of the fourchette, superficial muscle and skin of the perineum and the posterior vaginal wall. If the episiotomy is performed too early it will fail to release the presenting part and bleeding from cut vessels. In addition, the levator ani muscle will not have had time to be displaced laterally and may be incised as well. If performed too late there will not be enough time to infiltrate with local anaesthesia and tear and laceration may occur. It is best to make the episiotomy when bulging thinned perineum during contraction just prior to crowning.Types of EpisiotomyThe following are the types of episiotomy.1. Mediolateral 2. Median3. Lateral4. J shaped1. Mediolateral incisionThe incision is made downwards and outwards 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 away from the anus (midpoint between anus and ischial tubersity). It is commonly used by midwife.Advantages It avoids the danger of damage to both anal sphincter and Bartholins gland. Rectal involvement from episiotomy extension is less. Easy to do repair If needed incision can be extended.

Disadvantages Apposition of the tissue is not so good. Blood loss is little more. Dyspareunia is comparatively more. Post operative discomfort and pain more. Relative increased incidence of wound disruption.2. Median incisionThis is midline incision which follows the natural line at insertion of perineal muscle. Incisions commence from the centre of the fourchette and extend posteriouly along the midlinefor about 2.5cm. This incision reduces blood loss but higher incidence of damage of anal sphincter.Advantages Muscle are not cut Blood loss is least Easy to repair Post-incisional comfort is maximum Wound healling is superior and disruption is rare Dysparenuia is rareDisadvantage If extension occurs, may involve rectum Not suitable for manipulative delivery or in abnormal presentation or position3. Lateral incisionThe incision starts from about 1cm away from the centre of fourchette and extends laterally. It has got many drawbacks including chance of injury to the bartholins duct. It is totally condemned (strong disapproval of something).

4. J shaped incisionThe incision begins in the centre of the fourchette and is directed posteriorly along the midline for about 1.5cm and then directed downwards along 5 or 7 oclock position to avoid anal sphincter. This is also not done widely.Equipment needed for episiotomy1. perineal sheet2. Sponge holder3. Small bowl 14. Episiotomy scissor 15. Suture cutting scissor 1 6. Needle holder 1 7. Tooth dissecting forceps 18. Chromic catgut 2-09. Injection xylocain 2% or 1% or 0.5%10. 5cc or 10cc disposable syringe with needle11. Gauze pieces and cotton balls 5-612. Perineal pads 213. Sterile water or antiseptic solution14. For staff (plastic apron, mask, cap and high level disinfected or sterile gloves).

METHODS OF EPISIOTOMYStep -1 Methods of infiltration1. The perineum is thoroughly swabbed with antiseptic solution and draped properly.2. Draw 10ml of 0.5% lignocaine or xylocaine.3. Two fingers are inserted into the vagina along the line of proposed incision.4. The needle is inserted beneath the skin for 4-5cm following the same line.5. Withdraw the piston to check whetherr the needle is inserted into the blood vessels.6. If blood is aspirated reposition the needle and repeate process until no blood is withdrawn.7. Lignocain is continuously injected as the needle is withdrawn and needle must be redirected towards the either sides of the first injection just before the tip is withdrawn.8. Wait 2 minutes and then pinch the incision site with forcep. If the woman feels the pich, wait 2 more minutes and then retest.Step-2 Method of incision1. Wait to perform the episiotomy until the perineum is thinned out and 3-4 cm of the babys head is visible during contraction.2. Two fingers are inserted into the vagina and the open blades are positioned. The blades should be sharp to ensure clean episiotomy.3. Make an incision during contraction. A single deliberate (planned) cut 4-5cm long is made at the correct angle or at 7 oclock from centre of fourchette extending laterally either left or right diagnolly in a straight line runs about 2.5cm away from the anus (mediolateral).4. Delivery of the head should follow immediately, therefore control the head and support the perineum to prevent or avoid the extension of the episiotomy.5. If there is delay in the delivery of the head pressure should be applied to the episiotomy site to minimize bleeding.Structures cut in episiotomy Posterior vaginal wall Superficial and deep transverse perineal muscle, bulbospongiosus and part of levator ani. Fascia covering the muscles. Transverse perineal branches of pudendal vessels and nerves. Subcutaneous tissue and skin.

Degree of perineal tears1. First degree tears involve the vaginal mucosa and connective tissue.2. Second degree tears invlove the vaginal mucosa, connective tissue and underlying muscles.3. Third degree tears involve complete transection of the anal sphincter.4. Fourth degree tears involve the rectal mucosa.