Episetomy

KSHYANAPRAVA BEHERA
ASSISTANT PROFESSOR
SUM NURSING COLLEGE
EPISIOTOMY

DEFINITION
• A surgically planned incision
on the perineum and the
posterior vaginal wall during
the second stage of labour is
called episiot

OBJECTIVES
• TO enlarge the vaginal introitus so as
to facilitate easy and safe delivery of
the fetus-spontaneous or
manipulative.
• TO minimise overstretching and
rupture of the perineal muscles and
fascia; to reduce the stress and strain
on the fetal head.

INDICATIONS
• In elastic perineum;- Causing arrested or delay in decent of the
presenting part as in elderly primigravidae.
• Anticipating perineal tear;-
 This is widely indicated specially in primigravidae almost as an
elective procedure.
 Face to pubis or face delivery, big baby, narrow pubis arch.
• Operative delivery;- forceps delivery, ventouse delivery.
• Previous perineal surgery;- pelvic floor repair, perineal
reconstructive surgery.
COMMON INDICATION
 Threatened perineal injury in primigravidae.
 Rigid perineum.
 Forceps, Breech, Occipito-posterior or face delivery.

ADVANTAGES
• Maternal-
A clear and controlled incision is easy to repair
and heals better than a lacerated wound that
might occur.
Reduction in the duration of second stage.
Reduction of trauma to the pelvic floor muscles.
• Fetal-
It minimises intracranial injuries specially in
premature babies or after-coming head of breech.

TYPES
Medio-lateral
Median
Lateral
J-shaped

MEDIO-LATERAL;
 The incision is made downwards and out-wards from the
midpoint of the fourchette either to the right or left.
 It is diagonally in a straight line which runs about 2.5cm away from
anus.
Advantages;-
 The muscles are not cut.
 Blood loss is least.
 Repair is easy.
 Post operative comfort is superior.
 Healing is superior.
 Wound disruption is rare.
Disadvantages;-
 Extension, if occurs may involve the rectum.
 Not suitable for manipulative delivery or in abdominal
presentation.

MEDIAN
The incision commences from the centre of the
fourchette and extends posteriorly along the
midline for about 2.5cm.
Advantages;-
Relative from rectal involvement from extension.
Disadvantages;-
Apposition of the tissues is not so good.
Blood loss is little more.
Post operative discomfort is more.
Relative increased incidence of wound disruption.

LATERAL
The incision starts from about 1cm away from the
centre of the fourchette and extends laterally.
J-SHAPED INCISION
The 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
to 7 O clock poInjury to bartholins ducts has more
chance.
sition to avoid the anal sphincter.
Advantages - On extension of incision anal
sphincter will not be affected.
Disadvantages
Repair and healing is not good.

STEPS OF MEDIO-LATERAL
EPISIOTOMY
There are 3-steps of medio-lateral
episiotomy
I. STEP-I (Preliminaries)
II. STEP-II (Incision)
III.STEP-III (Repair)

STEP-I (Preliminaries)
The perineum is thoroughly swabbed with
antiseptic lotion and draped properly.
Local anaesthesia- The perineum, in the
line of proposed incision is infiltrated
with 10ml of 1% solution of lignocaine.

STEP-II (Incision)
 Two fingers are placed in the vagina between the
presenting part and the posterior vagional wall.
 The incision is made by a curved or straight blunt
pointed sharp scissors, one blade of which is placed
inside, in between the fingers and posterior vagional
wall and other on the skin.
 The incision should be made at the height of an
uterine contraction when an adequate idea of the
extent of incision can be better judged from the
stretched perineum.
 Deliberated cut should be made starting from the
centre of the fourchette extending laterally either to
the right or to the left.
 It is directed diagonally in straight line which runs
about 2.5cm away from the anus.

STRUCTURES CUT ARE
 Posterior vaginal wall.
Superficial and deep transverse perineal
muscle.
Fascia covering those muscles
Transverse perineal branches of pudendal
vessels and nerves.
Subcutaneous tissue and skin.

STEP-III (Repair)
Time of repair- The repair is done soon after
expulsion of placenta. 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. Oozing during this
period should be controlled by pressure with a
sterile gauze swab and bleeding by the artery
forceps. Early repair prevents sepsis and
eliminates the patients prolonged apprehension
of stitches.

Preliminaries – The patient is placed in lithotomy
position. A good light source from behind is needed.
The perineum including the wound area is cleansed
with antiseptic solution. Blood clots are removed
from the vagina and the 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, a vaginal
pack may be inserted and is placed high up. Do not
forget to remove the pack after the repair is
completed.

• Steps of repair of episiotomy –
 Wound on inspection.
Repair of vaginal mucosa and perineal
muscles by interrupted sutures.
Apposition of the skin margins.
Repaired wound on inspection.

The repair is to done in the following order ;--
1. Vaginal mucosa and submucosal tissues.
2. Perioneal muscles.
3. Skin and subcutaneous tissues.
The vaginal mucosa is sutured first. The first suture
is placed at or just above the apex of the tear.
Thereafter, the vaginal wall are apposed by
interrupted sutures with polyglycolic acid suture or
No. O chromic catgut, from above downwards til the
fourchette is reached. The suture should include the
deep tissues to obliterate the dead space. A
continuous suture may cause puckering and
shortening of the posterior vaginal wall.

POST OPERATIVE CARE
 Comfort Of dressing
 Ambulance
 Removal of stitches

COMPLICATION
1. IMMEDIATES - Extension of the incision
- Vulval haematoma
- Infection
2.REMOTE - Dyspareunia
- Chance of perineal
lacerations
- Scar endometriosis

Episetomy

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