Presentation episiotomy

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  • 1. Episiotomy and itsrepair… Lt Kalaivani R
  • 2. Episiotomy Definition Purpose Indications Advantages Types Perineal repair Perineal Care Complication
  • 3. Definition A surgically planned incision on the perineum and the posterior vaginal wall during the second stage of labour is called episiotomy.
  • 4. Purpose To enlarge the vaginal introitus To facilitate easy & safe delivery To minimize rupture of the perineal muscles & facia. To reduce stress on fetal head.
  • 5. Indications In rigid perineum
  • 6.  Anticipating perineal tear: Big baby Face to pubis delivery Breech delivery Shoulder dystocia
  • 7. Common indicationThreatened perineal injuryRigid perineumForceps delivery
  • 8. AdvantagesMaternal Fetal Easy to repair  Minimizes Reduction in intracranial duration of labour injuries esp. in Reduction of premature trauma babies
  • 9. Timing of episiotomyBulging thinned perineumduring contraction just priorto crowning
  • 10. Types of episiotomy Medio lateral Median LateralJ shaped
  • 11. Medio lateral : Begins at the midpoint of the fourchette Directed at a 45 degree angle to the midline Towards a point midway between the ischial tuberosity & the anus.
  • 12. MERITS DEMERITS MEDIAN Safety from  Apposition of rectal tissue not so involvement good Incision can  Discomfort is be extend. more.  Wound disruption is more
  • 13. Median : Midline incision that follows the natural line of insertion of the perineal muscles.
  • 14. Merits Demerits Reduced blood  Extension may loss involve the Easy to repair rectum Lesser pain  Damage to anal sphincter
  • 15. Medio lateral episiotomy Step 1:preliminaries Step 2:Incision Step 3:Repair
  • 16. Equipments : Sterile drape Sterile gown and gloves Gauze swabs and tampon Needle holder Sponge holder Scissors ,10 ml syringe Toothed forceps Suture material 1% lignocaine
  • 17. 1 :Preliminaries:  The perineum is thoroughly swabbed with antiseptic lotion,  Draped properly,  Incision line- Infiltrated with 10 ml of 1% lignocaine solution.
  • 18. 2:Making Episiotomy• Two fingers are placed in the vagina between the presenting part & posterior vaginal wall.
  • 19.  The incision is made by straight or curved blunt pointed sharp scissors The open blades are positioned.
  • 20.  Incision should be made at the height of an contraction. Cut should be made starting from the centre of the forchette extendening laterally either to the left or right.
  • 21.  It is directed diagonally in a straight line which runs about 2.5 cm away from the anus.
  • 22.  If delivery of the head does not follow immediately, apply pressure to the episiotomy site. Control delivery of the head to avoid extension of the episiotomy.
  • 23. Structures involved : Posterior vaginal wall Superficial & deep transverse perineal muscles
  • 24.  Fascia covering the muscles Transverse perineal branches of pudendal vessels& nerves Subcutaneous tissue & skin.
  • 25. 3:Perineal Repair Repair is done soon after the expulsion of the placenta.
  • 26. Purpose of RepairTo control bleeding To prevent infection To assist wound healing byprimary intention.
  • 27. The most common suture type polyglactin 910 suture: Coated Vicryl, Vicryl RAPIDE (> 70%) polyglycolic acid: Safil, Safil Quick, Dexon II (12%) Traditional sutures : catgut, chromic catgut) (10%).
  • 28. Preliminaries : The patient is placed in lithotomy positionA good light source from behind is needed to find the apex first.
  • 29.  The perineum &the wound area is cleaned with antiseptics Blood clots are removed from the vagina & the wound area
  • 30.  The patient is drapped properly &repair should be done under strict aseptic precautionA vaginal pack is inserted & is placed high up.
  • 31. Principles in suturing Close all dead space –ensure haemostasis and prevent infection
  • 32. Cotton balls must not be used. Handle tissue gently using nontoothed forceps.Ensure good anatomical restorationand alignment to facilitate healing.
  • 33. • Use minimal amount of suturematerial, and do not over tighten suturethis may impede healing.• Following the repair a rectal examinationshould be performed to ensure no suturematerial has been inserted through therectal mucosa.
  • 34. Layers of perineal repair Vaginal mucosa & submucosal tissue. Perineal muscles Skin & subcutaneous tissue
  • 35. Step 1 Suturing the vagina• Identify the apex.• Insert the anchoring suture 0.5 cmabove the apex.• Repair the vaginal wall with acontinuous non-locking stitch withapproximately 0.5 cm between eachstitch.
  • 36. Step 2 Suturing the perinealmuscle Check the depth of the trauma. Repair the perineal muscles in one or two layers with the same continuous stitch. Ensure the muscle edges are apposed carefully leaving no dead space.
  • 37.  On completion of the muscle layer, the skin edges should align so that they can be brought together without tension.
  • 38. Step 3 Suturing the skin• Reposition the needle at the inferiorend of the wound commence.• Stitches are placed below the surfaceof the skin,
  • 39. • The point of the needle should be repositioned between each side,• So that it faces the skin edge being sutured.• Continue taking bites of tissue from each side until the superior wound edge is reached.
  • 40. Immediate care• Inspect the repair to check that haemostasis has been achieved• Remove the vaginal tampon, if used,• Account for all instruments, swabs and needles• Discard sharps safely
  • 41. Apply sterile pad following thoroughperineal washWait for minimum one hour to shift thepatient to wardCheck for bleeding & urine output
  • 42. Immediate Remote Vulval hematoma  Dyspareunia Infection  Scar endometriosis Recto vaginal fistula Wound dehiscence complications
  • 43. Health education• Eat a diet high in fibre and fluids to prevent constipation• Ask the women to walk with thighs apposed,• not to use squatting position since the wound is healing.
  • 44. Perineal hygiene Change sanitary pads at least every 4 hours to help prevent infection. squirt warm tap water over the perineum, beginning at the front and moving toward the back .
  • 45. • Sit in a tub of warm water• Always wash hands thoroughly before and after going to the bathroom.• Always keep the wound clean & dry after each urination & defecation.
  • 46. kegal’s exercise• Squeeze the perineal muscles as if you were trying to stop the flow of urine.• Hold for 5 to 10 seconds and then relax. Do this exercise 10 times a day to regain muscle strength.