L; EPISIOTOMY AND PERINEAL TEARS 2.pptxf

L; EPISIOTOMY AND PERINEAL TEARS 2.pptxf

• 1.
  EPISIOTOMY AND PERINEAL TEAR
• 2.
  OBJECTIVES  Definition  objectives Indication  Types  Post operative care  Complications  Perineal tear.
• 3.
  DEFINITION  Perineotomy; Asurgically planned incision on the perineum and posterior vaginal wall during the second stage of labor .  It is an inflicted second degree perineal injury. OBJECTIVES  To enlarge vaginal opening to facilitate easy and safe delivery of fetus.  To minimize overstretching and rupture of the perineal muscle and fascia.  To reduce stress and strain on fetal head.
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  INDICATIONS  In elastic(rigid) perineum causing arrest or delay in descent of the presenting part as in elderly primigravida  Anticipating perineal tear; big baby, face to pubis delivery, breech delivery, shoulder dystocia.  Operative delivery; forceps delivery, ventous delivery  Previous perineal surgery; pelvic floor repair, perineal reconstructive surgery
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  TIMING TIMING OF EPISIOTOMY Bulging thinned perineum during contraction just prior to crowning (when 3-4cm of fetal head is visible) is ideal time.  If done early blood loss will be more. If done late, it fails to prevent invisible laceration of perineal body fails to protect pelvic floor. ADVANTAGES Maternal  Clear and controlled incision is easy to repair and heals better than lacerated wound.  Reduction in duration of second stage  Reduction of trauma to pelvic floor muscles. Fetal  Minimizes intracranial injury
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  TYPES  Mediolateral ;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 2.5cm away from the anus. (midpoint btw anus and ischial tuberosity)  Median ; incision commences from the center of the fourchette and extends posteriorly along the midline for about 2.5cm  Lateral ; incision starts from about 1cm away from the center of the fourchette and extends laterally. It has got many drawbacks including chance of injury to Bartholin’s duct. It is totally condemned  J shaped; incision begins in center of fourchette and is directed posteriorly along the midline for about 1.5cm and then directed downwards and outwards along 5 or 7 oclock position to avoid anal sphincter. Apposition is not perfect and the repaired wound tends to be puckered. It is not done widely.
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  ADVANTAGE AND DISADVANTAGEOF MEDIAN AND MEDIOLATERAL MEDIAN MEDIOLATERAL ADVANTAGES - Muscles are not cut - Blood loss is least - Repair is easy - Postoperative comfort is maximum - Healing is superior - Wound disruption is rare - Dyspareunia is rare - Relative safety from rectal involvement from extension - If necessary, the incision can be extended DISADVANTAGES - Extension , if it occurs, may involve the rectum - Not suitable for manipulative delivery or in abnormal presentation or position. - Apposition of the tissue is not so good - Blood loss is a little more - Postoperative discomfort is more - Relative increased incidence of wound disruption - Dyspareunia is comparatively more
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   STEPS FORMEDIOLATERAL;  swab perineum thoroughly with antiseptic(povidone iodine), local anesthesia- line of proposed incision incision is infiltrated with 10ml of 1% solution of lignocaine  Incision; place 2 fingers in vagina btwn presenting part and posterior vaginal wall. Incision is made at the height of an uterine contraction. STRUCTURES CUT DURING EPISIOTOMY  Posterior vaginal wall  Superficial and deep perineal muscles, bulbospongiosus and part of levator ani muscles  Transverse perineal branches of pudendal nerve and vessels  Subcutaneous tissue and skin
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  STEPS OF REPAIR It is done soon after expulsion of the placenta. If repair is done prior to that, disruption is inevitable.  Oozing during this period controlled by pressure with a sterile gauze swab and bleeding by artery forceps.  Early repair prevent sepsis and eliminate patient prolonged apprehension of ‘ stiches’ Patient is placed in lithotomy position. Good light source. Perineum and wound area is cleaned with antiseptic solution. Blood clots are removed from the vagina and wound area. If 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 repair is completed.
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   Repair isdone in 3 layers.  The principle to be followed are; perfect homeostasis, to obliterate the dead space, suture without tensions.  Repair should be done in the following order; Vaginal mucosa and submucosa tissues Perineal muscles Skin and subcutaneous tissues
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  POST OPERATIVE CARE DRESSING; wound is dressed each time following urination and defecation to keep area clean and dry  COMFORT; to relieve pain in the area, magnesium sulfate compress  AMBULANCE; move out of bed after 24 hours  REMOVAL OF STITCHES; with vicryl, catgut/ dexon will be absorbed. Non ansorbable like nylus need to be removed on 6th day.
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  COMPLICATIONS  Immediate  Extensionof incision to involve rectum  Vulva hematoma  Infection  Wound dehiscence  Remote  Dyspareunia  Chance of perineal lacerations  Scar endometriosis
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  PERINEAL TEAR  DEFINITION Minor injury is common during first birth  Gross injury( third and fourth degree) is as a result of mismanaged second stage of labor.  Overall risk is 1% of all vaginal deliveries  CAUSES;  results from overstretching and/or rapid stretching of perineum especially when the perineum is inelastic (elderly primigravida, perineal scar)  PREVENTION; proper conduct in the second stage of labor and taking care of the perineum
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  CLASSIFICATION OF PERINEALTEAR  FIRST DEGREE; injury to perineal skin only  SECOND DEGREE; injury to perineum involving perineal body(muscles) but not involving the anal sphincter  THIRD DEGREE; injury to perineum, involving the anal sphincter complex( both external and internal)  FOURTH DEGREE; injury to perineum involving the anal sphincter complex and anal epithelium. RISK FACTORS FOR 3RD DEGREE Big baby(>=3kg), shoulder dystocia, midline episiotomy, nulliparity, outlet contraction with narrow pubic arch, precipitate labor
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  MANAGEMENT  Recent tearshould be repaired immediately following the delivery of the placenta. This reduces chance of infection and minimizes blood loss.  In cases of delay beyond 24hour, the repair is to be withheld. Antibodies should be started to prevent infection. The complete tear should be repaired after 3 months
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  REFERENCE DC DUTTA’S TEXTBOOKOF OBSTETRICS.