Intrapartum Care: Skills workshop Performing and repairing an episiotomy

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Intrapartum Care was developed for doctors and advanced midwives who care for women who deliver in district hospitals. It contains theory chapters and skills workshops adapted from the labour chapters of Maternal Care. monitoring the mother, fetus, and progress of labour, the second and third stages of labour, managing pain, the puerperium and family planning

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Intrapartum Care: Skills workshop Performing and repairing an episiotomy

  1. 1. 4A Skills workshop: Performing and repairing an episiotomy done without adequate analgesia. Usually 10–15 Objectives ml 1% lignocaine (Xylotox) supplies adequate analgesia for performing an episiotomy. Be very careful that the local anaesthetic is not injected When you have completed this skills into the presenting part of the fetus. workshop you should be able to: • Perform a mediolateral episiotomy. C. Types of episiotomy • Repair an episiotomy. There are two methods of performing an episiotomy:PERFORMING AN 1. Mediolateral or oblique. 2. Midline.EPISIOTOMY The midline episiotomy has the danger that it can extend into the rectum to become a thirdA. The purpose of an episiotomy degree tear while the mediolateral episiotomy often results in more bleeding. This skills1. To aid the delivery of the presenting part workshop will only deal with the mediolateral when the perineum is tight and causing episiotomy because it is used most frequently, poor progress in the second stage of labour. is safe and requires the least experience.2. To prevent third degree perineal tears.3. To allow more space for operative or D. Performing a mediolateral episiotomy manipulative deliveries, e.g. forceps or breech deliveries. The incision should only be started during4. To shorten the second stage of labour, e.g. a contraction when the presenting part is with fetal distress. stretching the perineum. Doing the episiotomy too early may cause severe bleeding andB. Preparation for an episiotomy will not immediately assist the delivery. The incision is started in the midline with theIf you anticipate that an episiotomy may be scissors pointed 45 degrees away from theneeded, you should inject local anaesthetic into anus. It is usually directed to the patient’s leftthe perineum. An episiotomy should not be
  2. 2. THE SECOND STAGE OF LABOUR 85Figure 4A-1: The method of performing a left mediolateral episiotomybut can also be to the right. Two fingers of the Suturing the episiotomy usually stops theleft hand are slipped between the perineum venous bleeding but arterial bleeders need toand the presenting part when performing a be tied off.mediolateral episiotomy.E. Problems with episiotomies REPAIRING AN1. The episiotomy is done too soon: This EPISIOTOMY can result in excessive bleeding as the presenting part is not pressing on the perineum. An episiotomy will not help the F. Preparations for repairing an episiotomy descent of a high head. 1. This is an uncomfortable procedure for the2. Extension of the episiotomy by tearing: patient. Therefore, it is essential to explain This is not only a problem in a midline to her what is going to be done. episiotomy. Mediolateral episiotomies 2. The patient should be put into the may also tear through the anal sphincter lithotomy position if possible. into the rectum. However, extension of 3. It is essential to have a good light that must mediolateral episiotomies is less likely to be able to shine into the vagina. A normal occur than a midline episiotomy. ceiling light usually is not adequate.3. Excessive bleeding may occur: 4. Good analgesia is essential and is usually • When the episiotomy is done too early. provided by local anaesthesia which is • From a mediolateral episiotomy. given before the episiotomy is performed. • After the delivery. As 20 ml of 1% lignocaine may be safelyArterial bleeders may have to be temporarily infiltrated, 5–10 ml usually remains to beclamped, while venous bleeding is easily given in sensitive areas. An episiotomystopped by packing a swab into the wound. should not be sutured until there is good analgesia of the site.
  3. 3. 86 INTRAPAR TUM CAREFigure 4A-2: The method of safely handling a needleFigure 4A-3: An episiotomy wound5. In order to prevent blood which drains needle for the vaginal epithelium and out of the uterus from obscuring the muscles, and one on a cutting needle for episiotomy site, a rolled pad or tampon the skin. With smaller episiotomies one should be carefully inserted into the vagina packet on a round needle and one on a above the episiotomy wound. As this is cutting needle will be sufficient. Non- uncomfortable for the patient, she should absorbable suture material such as nylon be reassured while this is being done. and dermalon are very uncomfortable and6. Absorbable suture material should be used should not be used. Remember that the for the repair. Three packets of chromic patient has to sit on her wound. 0 are required. Two on a round (taper)
  4. 4. THE SECOND STAGE OF LABOUR 87Figure 4A-4: Suturing the vaginal epitheliumG.. The following important principles There are four important steps in the repair ofapply to the suturing of an episiotomy an episiotomy wound.1. The apex of the episiotomy must be Step 1 visualised and a suture put in at the apex. Place a suture (stitch) at the apex (the highest2. Dead space must be closed. point) of the incision in the vaginal epithelium.3. The same opposing tissue must be brought Then insert one or two more continuous together using the skin vaginal epithelium sutures in the vaginal epithelium. Do not juncture as an anatomical landmark. complete suturing the vaginal epithelium when4. Tissues must be brought together but not the episiotomy is large or deeply cut but leave strangulated by excessive tension on the this suture and do not cut it. When placing the sutures. suture at the apex, be very careful not to prick5. Haemostasis must be obtained. your finger with the needle.6. The needles must be handled with a pair of forceps and not by hand, and should be Step 2 removed from the operating field as soon Insert interrupted sutures in the muscles. Start as possible. at the apex of the wound. The aim is to bring the muscles together firmly and to eliminateH. The method of suturing an episiotomy any ‘dead space’, i.e. any spaces between theThree layers have to be repaired: muscles where blood can collect. Remember that the sutures must be inserted at 90 degrees1. The vaginal epithelium. to the line of the wound.2. The muscles.3. The perineal skin. When suturing the muscles, be careful not to put the suture through the rectum. If you
  5. 5. 88 INTRAPAR TUM CAREFigure 4A-5: Suturing the musclesFigure 4A-6: The correct position of the skin and vaginal epithelium
  6. 6. THE SECOND STAGE OF LABOUR 89Figure 4A-7: The repair of the skinmake sure that the point of the needle is seen Step 4when crossing from the one side to the other Use interrupted sutures with an absorbableof the deepest part of the wound, the stitch suture material to repair the perineal skin.will not be too deep. ‘Figure 8’ stitches (double Mattress sutures may be used. Do not pull thestitches) are used to suture the muscle layer. sutures tight as they only need to bring theWhen the muscles have been correctly sutured edges of the skin together. Sutures that are toothe cut edges of the vaginal epithelium and tight become uncomfortable for the patient.the skin should be lying close together. Themarkers for correct alignment are: When the suturing is complete:1. The remains of the hymen. 1. Remove the pad from the vagina. Be gentle2. The junction of the skin and the vaginal as this will be uncomfortable for the patient. epithelium. The skin is recognised by the 2. Put a finger into the rectum and feel if a darker pigmentation. suture has been placed through the rectal wall by mistake.Step 3 3. Make sure that the uterus is wellReturn to the vaginal epithelium and complete contracted.the continuous catgut suture, ending at the 4. Get the patient out of the lithotomyjunction with the skin. Do not pull the sutures position and make sure that she istight as they only need to bring the edges of comfortable.the vaginal epithelium together.

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