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Maternal Care: Skills workshop Performing and repairing an episiotomy
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Maternal Care: Skills workshop Performing and repairing an episiotomy

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Maternal Care addresses all the common and important problems that occur during pregnancy, labour, delivery and the puerperium. It covers: the antenatal and postnatal care of healthy women with normal …

Maternal Care addresses all the common and important problems that occur during pregnancy, labour, delivery and the puerperium. It covers: the antenatal and postnatal care of healthy women with normal pregnancies, monitoring and managing the progress of labour, specific medical problems during pregnancy, labour and the puerperium, family planning, regionalised perinatal care


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  • 1. 9A Skills workshop: Performing and repairing an episiotomy into the perineum. An episiotomy should Objectives not be done without adequate analgesia. Usually 10–15 ml 1% lignocaine (Xylotox) supplies adequate analgesia for performing When you have completed this skills an episiotomy. Be very careful that the local workshop you should be able to: anaesthetic is not injected into the presenting • Perform a mediolateral episiotomy. part of the fetus. • Repair an episiotomy. C. Types of episiotomy There are two methods of performing anPERFORMING AN episiotomy:EPISIOTOMY 1. Mediolateral or oblique. 2. Midline. The midline episiotomy has the danger that itA. The purpose of an episiotomy can extend into the rectum to become a third-1. To aid the delivery of the presenting part degree tear while the mediolateral episiotomy when the perineum is tight and causing often results in more bleeding. This skills poor progress in the second stage of labour. workshop will only deal with the mediolateral2. To prevent third-degree perineal tears. episiotomy because it is used most frequently,3. To allow more space for operative or is safe, and requires the least experience. manipulative deliveries, e.g. forceps or breech deliveries. D. Performing a mediolateral episiotomy4. To shorten the second stage of labour, e.g. with fetal distress. The incision should only be started during a contraction when the presenting part is stretching the perineum. Doing the episiotomyB. Preparation for an episiotomy too early may cause severe bleeding andIf you anticipate that an episiotomy may be will not immediately assist the delivery. Theneeded, you should inject local anaesthetic incision is started in the midline with the
  • 2. 200 MATERNAL CAREFigure 9A-1: The method of performing a left mediolateral episiotomyscissors pointed 45° away from the anus. It stopped by packing a swab into the wound.is usually directed to the patient’s left but Suturing the episiotomy usually stops thecan also be to the right. Two fingers of the venous bleeding but arterial bleeders need toleft hand are slipped between the perineum be tied off.and the presenting part when performing amediolateral episiotomy. REPAIRING ANE. Problems with episiotomies EPISIOTOMY1. The episiotomy is done too soon: This can result in excessive bleeding as the presenting part is not pressing on the F. Preparations for repairing an episiotomy perineum. An episiotomy will not help the 1. This is an uncomfortable procedure for the descent of a high head. patient. Therefore, it is essential to explain2. Extension of the episiotomy by tearing: to her what is going to be done. This is not only a problem in a midline 2. The patient should be put into the episiotomy. Mediolateral episiotomies lithotomy position if possible. may also tear through the anal sphincter 3. It is essential to have a good light that must into the rectum. However, extension of be able to shine into the vagina. A normal mediolateral episiotomies are less likely to ceiling light usually is not adequate. occur than a midline episiotomy. 4. Good analgesia is essential and is usually3. Excessive bleeding may occur: provided by local anaesthesia which is • When the episiotomy is done too early. given before the episiotomy is performed. • From a mediolateral episiotomy. As 20 ml of 1% lignocaine may be safely • After the delivery. infiltrated, 5–10 ml usually remains to beArterial bleeders may have to be temporarily given in sensitive areas. An episiotomyclamped, while venous bleeding is easily
  • 3. SK ILLS WORKSHOP : PER FORMING AND REPAIRING AN EPISIOTOMY 201Figure 9A-2: The method of safely handling a needleFigure 9A-3: An episiotomy wound should not be sutured until there is good 6. Absorbable suture material should be analgesia of the site. used for the repair. Three packets of5. In order to prevent blood which drains chromic 0 are required. Two on a round out of the uterus from obscuring the (taper) needle for the vaginal epithelium episiotomy site, a rolled pad or tampon and muscles, and one on a cutting needle should be carefully inserted into the vagina for the skin. With smaller episiotomies above the episiotomy wound. As this is one packet on a round needle and one on uncomfortable for the patient, she should a cutting needle may be sufficient. Non- be reassured while this is being done. absorbable suture material such as nylon and dermalon are very uncomfortable and
  • 4. 202 MATERNAL CAREFigure 9A-4: Suturing the vaginal epithelium should not be used. Remember that the 1. The vaginal epithelium. patient has to sit on her wound. 2. The muscles. 3. The perineal skin.G. 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 (highest point) of the episiotomy Step 1 must be visualised and a suture put in at the apex. Place a suture (stitch) at the apex of the2. Dead space must be closed. incision in the vaginal epithelium. Then insert3. The same opposing tissue must be brought one or two more continuous sutures in the together using the skin vaginal epithelium vaginal epithelium. Do not complete suturing juncture as an anatomical landmark. the vaginal epithelium when the episiotomy4. Tissues must be brought together but not is large or deeply cut but leave this suture and strangulated by excessive tension on the do not cut it. When placing the suture at the sutures. apex, be very careful not to prick your finger5. Haemostasis must be obtained. with the needle.6. The needles must be handled with a pair Step 2 of forceps and not by hand, and should be 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 eliminate any ‘dead space’, i.e. any spaces between theH. The method of suturing an episiotomy muscles where blood can collect. RememberThree layers have to be repaired: that the sutures must be inserted at 90 degrees to the line of the wound.
  • 5. SK ILLS WORKSHOP : PER FORMING AND REPAIRING AN EPISIOTOMY 203Figure 9A-5: Suturing the musclesFigure 9A-6: The correct position of the skin and vaginal epithelium
  • 6. 204 MATERNAL CAREFigure 9A-7: The repair of the skinWhen suturing the muscles, be careful not tight as they only need to bring the edges ofto put the suture through the rectum. If you the vaginal epithelium together.make sure that the point of the needle is seen Step 4when crossing from the one side to the otherof the deepest part of the wound, the stitch Use interrupted sutures with an absorbablewill not be too deep. ‘Figure 8’ stitches (double suture material to repair the perineal skin.stitches) are used to suture the muscle layer. Mattress sutures may be used. Do not pull theWhen the muscles have been correctly sutured sutures tight as they only need to bring thethe cut edges of the vaginal epithelium and edges of the skin together. Sutures that are toothe skin should be lying close together. The tight become uncomfortable for the patient.markers 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 rectalStep 3 wall by mistake. 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 is comfortable.
  • 7. 10 Managing pain during labourBefore you begin this unit, please take the PAIN RELIEF IN LABOURcorresponding test at the end of the book toassess your knowledge of the subject matter. Youshould redo the test after you’ve worked through 10-1 What is analgesia?the unit, to evaluate what you have learned. Analgesia means the relief of pain. Drugs used to relieve pain are called analgesics. Objectives Analgesics must not be confused with sedatives which do not relieve pain but only make the patient drowsy. When you have completed this unit you should be able to: 10-2 What is anaesthesia? • Explain the differences between Anaesthesia means the loss of all sensation, analgesia, anaesthesia and sedation. including pain. Local anaesthesia causes the • List the causes of pain in labour. loss of all sensation in that region of the body. • List which drugs can be given during With general anaesthesia the patient loses labour for analgesia. consciousness. • Ensure that a patient has adequate pain 10-3 What causes pain during labour? relief during labour. • List the dangers of the drugs which can Pain in labour is caused by: be used for pain relief. 1. Contractions. They progressively increase • Prepare a patient for general in duration and frequency during the first anaesthesia. stage of labour and become more painful. Contractions are most painful when the cervix is fully dilated and the patient has an urge to bear down. At first the pain is felt over the abdomen but later, when the cervix is nearly fully dilated, pain is felt in the lower back.