episiotomy , CPT,TYPES OF EPISIOTOMY

1. Episiotomy

2. What is episiotomy
 Episiotomy is the most common operation in
obstetrics.
 It is an incision in the perineum that is either
the midline (a median episiotomy) or begun in
midline but directed laterally away from the
rectum.

3. Episiotomy
• Deliberate Surgical incision
to widen the vaginal
introitus to facilitate the
delivery of baby
• It is one of the most
commonly performed
procedures in obstetrics

4. Origin of
Episiotomy
Difficult to determine the origin
First described in 1742 by Sir Fielding Ould in
his Treatise of Midwifery in Three Parts
About 100 years later, in mid 19th century it was
introduced in USA
Was used only to facilitate an unusually difficult labor

5. Objectives
• To facilitate easy and safe delivery of the fetus:
spontaneous, breech or instrumental
To enlarge the vaginal
introitus
• To reduce rupture of perineal muscles & fascia
• To reduce the stress and strain on the fetal head
To minimize
overstretching of
perineal muscle

7. In 1920 Dr Joseph DeLee first publicly advocated the routine adoption
of mediolateral episiotomy for all deliveries in nulliparous women
By 1930s Diethelm asserted that the indications for episiotomy were
well established and needed no defense
This opinion supported the increasing trend of the use of episiotomy
Trends

8. The Peak
By 1979, episiotomy was
performed in 63% of all deliveries
in the United States, with higher
rates among nulliparas
In Great Britain in the same era,
episiotomy rates ranged from 14-
96% among nulliparas and from
16-71% among multiparas
Was considered standard of care
by many obstetric care providers

9. The Change
In the 1970s and 1980s, however, obstetric
providers began to question the routine use of
episiotomy
Evidence began to emerge that demonstrated
the potential consequences of episiotomy
Increased risk of extension to severe
perineal tears
Increased risk of dyspareunia, and
Future pelvic floor dysfunction

10. Timing of episiotomy
 At the time of crowning
 After application of blades in forceps delivery

11. When to give episiotomy

12. Timing of the episiotomy
when bulging of thinned out perineum
during contraction just prior to crowning
Fails to prevent lacerations of perineal body
During forceps delivery, episiotomy is given after the blade application
If early: Blood loss will be more
If late:
Timing:

13. Maternal Benefits
Short-term benefits
 Ease of repair
compared to a
spontaneous perineal
laceration
 Reduction in severe or
third- or fourth-degree
tears
 Long Term Benefits
 By shortening the time for which the perineum
is stretched during birth
 Episiotomy Prevents
• Pelvic floor relaxation
• Pelvic organ prolapse
• Sexual dysfunction
• Urinary incontinence
• Fecal incontinence

14. Benefits to
Neonate
Prevention of
• Asphyxia
• Cranial trauma
• Cerebral
hemorrhage
• Mental retardation
• Reduction of the
risk of shoulder
dystocia

15. Other
Societies
Major society recommendations
recognize a restricted role for
episiotomy to assist with
Difficult deliveries eg, shoulder
dystocia
Instrumental delivery especially
forceps
To facilitate delivery in breech and in
cases if non-reassuring fetal status
 Possibly to avoid a serious maternal
laceration - Surgical judgement is
required

16. Indications of restricted episiotomy
 Tight perineum
 Operative delivery
 Previous perineal surgery
 Anticipating perineal tears
 Face to pubes
 Persistent OP
 Shoudler dystocia
 Breech

17. Suture Material
• Anatomical repair of the episiotomy
doesn't differ significantly depending on
the type of suture material (n.s.-P>0.05).
 With Vicryl local injury reaction
 erythema
 edema and
 pain less as compared with plain cat
gut - silk group.
 Rapid absorbable synthetic sutures

19. Types of episiotomy
Mediolateral
Diagonal downwards & outwards from midpoint of
fourchette 2.5 cms away from anus
J Shaped
From centre of fourchette, in midline for 1.5cms then
directed downwards & outwards
Median
From centre of fourchette extends posteriorly along
mid line for 2.5 cms
Lateral
1cm away from centre of fourchette extends laterally

21. Types
 Most preferred is :
Mediolateral

22. Steps

23. Structures

24. Steps of mediolateral episiotomy
Step 1:
preliminaries
10ml of 1% lignocaine infiltrated in the line of
proposed incision for local anesthesia
Perineum cleaned with antiseptic lotion & draped

25. Steps of mediolateral episiotomy
Step 2
Incision
Two fingers are placed in the vagina between
presenting part & posterior vaginal wall
Cut starts from centre of fourchette directed
diagonally in a straight line about 2.5 cms away
from anus
Incision made at height of uterine contraction,
to the right or left side

26. Structures cut in episiotomy
Posterior vaginal wall
Superficial & deep transverse perineal muscles
Bulbospongiosus muscle
Part of levator ani muscle
Transverse perineal - pudendal vessels & nerves
Subcutaneous tissue & skin

27. Structures cut

28. Repair of episiotomy
Achieve perfect haemostasis
Obliterate the dead space
Suture without tension
Repair in three layers under strict aseptic precautions
3) Skin and subcutaneous tissue
First suture to be placed at or just above the apex of the tear
1) Vaginal mucosa & submucosal tissue
2) Perineal muscles
mucosa muscles skin

29. Post operative care
 Keep area clean and dry
 Clean with antiseptic solution & apply antibiotic ointment
 Analgesic drugs for pain
 Keep thighs apposed while sitting
 Patient made ambulatory as soon as possible
 Sutures are absorbable, so need not be removed

30. Complications
 Short term
 Perineal lacerations
 Pain
 Haematoma
 Haemorraghe
 Wound dehiscence/oedema
 Anorectal injury
 Uretharal/bladderv
 Long term
 Ch infections
 Anorectal dysfunction
 Urinary incomtinence
 Pelvic organ prolapse
 Sexual dys function
 Pain

31. Complications of episiotomy
Early
Extension of
incision
Vulval hematoma
Infection
Wound dehiscence
Remote
Dyspareunia
Injury to anal
sphincter
Rectovaginal
fistula
Scar
endometriosis

32. Complications

33. tears

34.  Vulvar hematoma is a rare
but potentially fatal
condition if left
undiagnosed and
untreated
 prompt recognition of this
condition is important
 A vulvar hematoma is a
collection of blood in the
vulva
 The vulva is soft tissue
mainly composed of smooth
muscle and loose connective
tissue and is supplied by
branches of the pudendal
artery


35. Indication
Rigid
perineum
Anticipating
perineal tear
Operative
delivery
Previous perineal
surgery
Face to
pubes
Big baby Breech
delivery
Shoulder
dystocia Pelvic floor
repair
Ventose
delivery
Forceps
delivery
Pelvic
reconstructive
surgery

36. KEY MESSAGE
 Vaginal lacerations or tears are very common when giving birth.
 Tears can be around the urethra or in the vagina , perineum or labia
 Vaginal tears are classified by degrees( based on how deep they are) & site
 With proper repair and healing, most women have no long-term issues from having a vaginal
laceration
 1st degree tears don't involve muscle, so they usually heal more quickly and are less painful
 Evaluation is focused on amount of bleeding hemostasis, anatomic distortion and integrity of anal
sphincter( for excluding OASI)

37. To conclude-
Current
Practice
Routine use of episiotomy is not
recommended
Targeted or restricted use of episiotomy is
appropriate
Absorbable, rapid dissolving sutures are
preferred
Proper training in technique of giving
episiotomy, suturing, and diagnosing OASIS is
essential