Epi overview


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Epi overview

  2. 2. WHAT IS AN EPISIOTOMY? • A surgical procedure where an incision into the perineum ( the area of skin between the vagina and anus ) is made to enlarge the space at the outlet
  3. 3. INDICATION • In anticipation of difficult delivery e.g. big baby, instrumental delivery, vaginal breech delivery • Women with previous perineal surgery e.g. Fenton operation
  4. 4. Other reasons…
  5. 5. • Substitutes a straight, neat surgical incision instead of the ragged laceration that otherwise frequently results. It is easier to repair and heals better than a tear. • Cunningham, MacDonald and Gant (1989):
  6. 6. • Avoid extended tear of the perineum e.g. third and fourth degree tears
  7. 7. • It reduces the incidence of cystocoele, rectocoele, uterine prolapse and stress incontinence resulting from pelvic floor relaxation due to overstretching of perineum during delivery • Pritchard, MacDonald and Gant (1985):
  8. 8. • To avert ‘brain damage’ by lessening the pounding of the head on the perineum • De Lee (1920):
  9. 9. Are these reasons valid?
  10. 10. What the evidence says…
  11. 11. Protect against brain damage? • A woman’s perineum is soft, elastic tissue, not concrete. No one has ever shown that an episiotomy protects fetal neurologic wellbeing, not even in the tiniest, most vulnerable preterm infants, let alone a healthy, term newborn. • (Lobb, Duthie and Cooke, 1986)
  12. 12. Reduces perineal trauma, - a nice clean cut is better than a jagged tear? • Episiotomies are not easier to repair, do not heal better than tears
  13. 13. Episiotomies avoid extended tears? • Episiotomies do not prevent tears into or through the anal sphincter. • Episiotomy correlates strongly with deep tears (p<0.003)
  14. 14. Prevent pelvic floor relaxation? • Episiotomy is not done until the head is almost ready to be born. By then, the pelvic floor muscles are already fully distended/stretched. How is cutting a muscle and stitching it back together preserves its strength?
  15. 15. Cont. • No evidence that routine episiotomy reduces the risk of severe perineal trauma, improves perineal healing, prevents fetal trauma or reduces the risk of urinary stress incontinence. • Sleep, Roberts and Chalmers 1989
  16. 16. • Other facts about episiotomies…
  17. 17. • If a woman does not have an episiotomy, she is likely to have a small tear, but with rare exceptions the tear will be, at worst, no worse than an episiotomy.
  18. 18. • Episiotomy increases blood loss
  19. 19. • Episiotomies are not less painful than tears. They may cause prolonged problems with pain, especially pain during intercourse.
  20. 20. • As with any other surgical procedures, episiotomies may lead to infection, including fatal infections e.g. necrotizing fasciitis and clostridial myonecrosis. • 9 cases, 7 dies, two had extensive surgeries and prolonged hospitalizations. • Soper 1986; Sutton et. Al. 1985; Ewing, Small and Elliot 1979; Golde and Ledger 1977
  21. 21. • Epidurals increase the need for episiotomy, They also increase the probability of instrumental delivery. Instrumental delivery increases both the odds of episiotomy and deep tears.
  22. 22. • The lithotomy position increases the need for episiotomy, probably because the perineum is tightly stretched.
  23. 23. • The birth attendant’s philosophy, technique, skill and experience are the major determinants of perineal outcome.
  24. 24. • Some techniques for reducing perineal trauma that have been evaluated and found to be effective are: Prenatal perineal massage, slow delivery of the head, supporting the perineum, keeping the head flexed, delivering the shoulders one at a time and doing instrumental deliveries without episiotomy.
  25. 25. • A regular exercise program strengthens the pelvic floor
  26. 26. Restricted versus routine episiotomy Relevant morbidities Relative Risk Post. Perineal trauma 0.88 Need for suturing 0.74 Healing cx at 7 days 0.69 Vaginal or perineal trauma 1.11 Dyspareuria 1.02 Urinary incontinence 0.98 • Carroli and Belizan 2000; Eason et. Al. 2000; WHO 1999.
  27. 27. In conclusion… Episiotomy is a surgical procedure which carries the usual surgical complications and should ONLY be done when indicated
  28. 28. Aim of this workshop is NOT to promote the practise of episiotomy, but rather to ensure good perineal outcome after delivery
  29. 29. Thank you