This presentation has a detailed description of Episiotomy which is the commonest operation performed during childbirth

1. EPISIOTOMY-
THE OBSTETRICIAN’S
SIGNATURE
Dr Mitra Saxena
Director Shri Ashwini Saxena Hospital
REWARI

2. MY NARRATIVE
• What its not …..
• A theoretical lecture ..
• A debate Whats recommended ,what s not
• A Verdict ..Do as I say ..
• What it is ….
• A summary of my own learning experiences ..
• What we learnt from our teachers and text books Munrokerr ,Ian Donald ,Williams
• A revision for my ownself …Especially the ANATOMICAL Images that I have
included

3. LEARNING OBJECTIVES
• Anatomy …Images to memorise for ever
• Perineal body and its importance
• Structures cut
• Sutures and Suturing techniques
• Visuals …LR ,Delivery Trolley ,
Episiotomy ,Hematoma,CPT
• Pearls of wisdom

4. ABOUT EPISIOTOMY- AND ITS JOURNEY
OVER THE YEARS!!!!!
• Most commonly performed
• Least supervised procedure
• Repair of Perineal trauma ,Francois Mauriceau, 1683 London.
• 1742, First description of Episiotomy by Fielding Ould ,Dublin.
• In the United States, episiotomy was once a widely used technique
until 2006 when the American College of Obstetricians and
Gynecologists (ACOG) made a recommendation against its routine
use
• So from Prophylactic to No to Restrictive use ……In an
existential crisis
• FIGO Statement: Restrictive Use Rather Than Routine Use of
Episiotomy
Francois Mauriceau, 1683 London

5. VIEWS FROM TOP AND BOTTOM

6. VISUALS TO MEMORISE

7. WHAT WILL BLEED?!?

8. VISUALS TO MEMORISE-
LITERALLY TO KNOW THIS IN YOUR SLEEP!!!

9. AND NOT TO IGNORE!

10. RESPECT THE PERINEAL BODY
• What constitutes the Perineal body
• The median Raphe of the Levator
Ani between the Anus and the
vagina is reinforced by the central
tendon of the perineum
• Bulbo cavernosus ,Superficial
Transverse perineal ,external anal
sphincter also converge on the
Central tendon
• Episiotomy and tears all can damage
the perineal body (4cm)

11. PERINEAL BODY
FUNCTION
• Anchors the Anorectum
• Anchors the Vagina
• Helps maintain urinary and fecal continence
• Maintains the orgasmic platform
• Prevents expansion of the urogenital hiatus
• Provides a physical barrier between the Vagina and
Rectum
POTENTIAL
MORBIDITY
• Episiotomy may injure the perineal body
• Pudendal Nerve damage may be associated with
concurrent PB Injury
Adapted from Woodman
And Graney 2002

12. PERINEAL TRAUMA
SULTAN , RCOG, ACOG
• FIRST DEGREE –Injury to perineal skin only
• SECOND DEGREE –Injury to Perineum involving
Perineal muscles but not Anal sphincter
• THIRD DEGREE –Injury to perineum involving the
Anal sphincter Complex:
• 3a:Less than 50% of EAS thickness torn
• 3b:More than 50% of EAS thickness torn
• 3c: Both EAS and IAS torn
• FOURTH DEGREE –Injury to perineum involving
EAS, IAS and Anal epithelium
• Button hole tear …Separate entity ..tear in anorectal
epithelium but intact Anal Sphincter complex

13. STRUCTURES CUT ARE
• (1)Posterior vaginal wall
• (2) Superficial and deep transverse perineal muscles, bulbospongiosus and part of
levator ani
• (3) Fascia covering those muscles
• (4) Transverse perineal branches of pudendal vessels and nerves
• (5) Subcutaneous tissue and skin.

14. TYPES OF EPISIOTOMY
• a) Median
• b) Mediolateral
• c) ‘J’ shaped
• d) Lateral
• e) The modified-median
• f) Anterior, and
• g) Radical

15. PURPOSE OF EPISIOTOMY
Precept was easier, cleaner, safer to deal with clean cut incisions rather than jagged ragged
tears
• A clean and controlled incision is easy to repair and heals better
• To expedite Safe Vaginal delivery
• Avoiding irregular tears, extensions, OASIS
• Less post op pain Vs more
• Less problems of Prolapse, Stress, Fecal and flatus incontinence
• Cut short Second stage esp where there is fetal distress

16. TIMING: HAS TO BE JUST RIGHT!!!!
• Bulging thinned perineum during contraction just prior to crowning
(when 3–4 cm of head is visible)
• During forceps delivery, it is made after the application of blades
During Vacuum also it can be made once the extraction is started
In Breech, Shoulder dystocia A Timely Liberal Episiotomy is helpful
• If done early, – the blood loss will be more.
• If done late, – it fails to prevent the invisible lacerations of the
perineal body, EAS, IAS

17. KNOW YOUR LABOUR ROOM AND ITS CONTENTS
WELL!! “A STITCH IN TIME SAVES NINE”

19. BABY CORNER

21. INJECTION CORNER

22. A PLACE FOR EVERYTHING AND EVERYTHING
IN ITS PLACE …
INJECTION CORNER

23. STEPS

24. ASSESSMENT AND REPAIR :
ADEQUATE EXPOSURE ,LIGHT ,ANALGESIA
IDENTIFY ALL EXTENSIONS ,DEPTH,ANY BLEEDERS ,ANORECTUM
4 fingers in Vagina /Index finger in Rectum and palpate the EAS
• The principles to be followed are:
(1) Perfect meticulous hemostasis
(2) Anatomical Reapproximation of all disrupted layers
(3) obliterate the dead space and
(4) suture without tension.

25. CLOSURE OF MUSCLE
• Identify how DEEP is the episiotomy .
• When the Vaginal mucosal incision extends up ..automatically the
episiotomy is deep and deeper muscles would be involved .
• In such cases ,Complete Mucosal closure half way ,approximate the
muscle layer in depth first ..keeping your left Index finger in the gap
,take good bites from both sides ,but don’t tie it too tightly .
• At this point ,a PR done can clearly rule out if stitch has come out
from rectum or not..If episiotomy is closer to midline chances are
higher , If its lateral or mediolateral ,chances are less

26. SUTURE MATERIAL
• Plain Catgut ..Absorbs in 7days least tensile strength maximum
reaction
• Chromic Catgut ..Absorbs in 21 days .Tensile strength more than
Plain Catgut but causes reaction
• Vicryl..Polyglactin 910 ..Synthetic absorbable 90 days .needs to be
removed
• VICRYL RAPIDE absorbs in 42 days ,least reaction ,pain ,good tensile
strength but needs to be removed

27. POST DELIVERY CARE IN HOSPITAL
• Pt is wheeled out after she is stable .
• FIRST HOUR GENTLE ,ONE FINGER PV AND PR IN EVERY PATIENT.
• .In Vaginal deliveries ..For hematomas ..In CS to be vigilant for PPH
VITALS ,PERINEAL CARE
• Warm water wash downs with betadine lotion ,Sterile pad with antiseptic
Ointment ..after every act of passing urine stools or 4 to 6 hourly.
• BSA and Analgesics ..Pt is taught self care of episiotomy.
• Bladder emptying ,Ambulation ,Breast feeding.
• Called with in a week ..Stitches removed at 7th day.

28. PATIENT EDUCATION
• Size of Episiotomy :expected Healing ,Pain ,till first week ,deeper epis,3rd
week, 3rd 4th degree ..4 to 6 weeks
• Suture removal ..S/C ..No ,Interrupted yes
• Constipation ..Diet ,Laxatives ,Water
• Sexual Activity ..after 6 weeks
• Contraception
• HYGIENE ..
• PAIN
• PELVIC FLOOR EXERCISES

29. EARLY COMPLICATIONS
• IMMEDIATE COMPLICATIONS
• (1) Extension of the incision to involve the rectum, OASIS, Deep into Vagina ,PUT
• (2) Vulval hematoma
(3) Infection:
• (A) throbbing pain on the perineum
• (B) rise in temperature
• C) the wound area looks moist, red and swollen and
• (D) offensive discharge
• TREATMENT: (a) To facilitate drainage of pus (b) Local dressing with antiseptic
powder or ointment (c) MgSO4 compression or application of infrared heat to the area
to reduce edema and pain (d) Systemic antibiotic (IV)

30. COMPLICATIONS
(4) Wound dehiscence
Disruption of a sutured repair,
Partial/ Complete..Due to Infection,Blood collection
Expectant ,Secondary Suturing
(5) Injury to anal sphincter causing incontinence of flatus or feces.
(6) Rectovaginal fistula and rarely.
(7) Necrotizing fasciitis (rare) in a woman who is diabetic or immunocompromised

31. CHANGE OF LOYALTY
• (1) Dyspareunia
• (2) Chance of perineal scarring leading to lacerations in subsequent labor
• (3) Scar endometriosis (rare)
• (4) Sexual Dysfunction, Lax outlet
• (5) Flatus , Fecal incontinence ,undiagnosed OASIS
• (6) Sinus
• (7) RVF

32. HEMATOMA ::HONEST OPINION POLL
• HAVE YOU MANAGED A HEMATOMA OF YOURS OR OF A COLLEAGUE
• CAN YOU EVER FORGET THE PATIENTS?
• Be a bit slow ..not too fast ..we are the best person to diagnose the hematoma …So if it’s a big episiotomy
more reason not to rush …
• Don’t ignore vessels or blood filling up..a bleeding vessel doesn’t disappear ..it will cause havoc if its
ignored .
• POST OP PERIOD ..If Pt is C/O unbearable pain Pressure in rectum this could be a vaginal hematoma

33. • Vulval
haematoma
injury to br of
Pudendal art…
• Paravaginal
haematoma

34. WISE TO NEVER COMPROMISE :SAFETY VS
TIME
HURRY and WORRY are deadly combo to make a MESS
Encourage And Ensure not Just cervical dilatation, But the friendly VAGINA ..its when pt,
Accoucher and the SYNTO drip are moving fast that worst Vaginal vault ,Lateral wall and
cervical tears happen
PREVENT OASIS :Mediolateral Epi ,primary repair of EAS
PEEP IN TIME SAVES HOURS OF SWEAT AND GRIME
GOOD LIGHT, GOOD RELAXATION, Identifying the directions of tears, type of bleeding
..Arterial /Venous..and ensuring complete hemostasis

35. PEARLS OF WISDOM
• 1.Its never too late to change your course ….
• 2. Timing,Size,Direction,Support….Save the Extensions….Manage
• 3. CERVIX and VAGINA ..Digital palpation ,Visual Inspection
• 4. RECTUM ,ANAL SPHINCTER COMPLEX
• 5.Each time one stitches the Episiotomy ,DON’T forget its our
AUTOGRAPH,
• Lets keep perfecting it
• 6. COUNSEL ,CONSENT ,COMMUNICATE

37. EACH PATIENT IS UNIQUE
•Every labouring woman doesn’t follow
a guideline and the best judge for her,
her baby, and her perineum is her
Obstetrician