episiotomy repair procedure. suturing techniques and step by step repair of episiotomy. complications associated with episiotomy and repair. nurses midwives and doctors should acquire skills and knowledge to perform this procedure.

1. Repair of an Episiotomy
PRESENTER: DR.UMAR MUSA BABA
MB;BS CCUCM CHN
HOUSE OFFICER, ABUTH SHIKA
DEPARTMENTOF OBSETRICS AND GYNAECOLOGY
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2. Outline
• Introduction
• Aims of episiorrhaphy
• Pre-procedure evaluation
• Procedure
• Post-procedure care
• Complications
• Conclusion
• References
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3. Introduction
• Episiotomy is the surgical enlargement of the vaginal orifice during
labor and delivery.
• It is the most common surgical procedure performed on women
worldwide.
• The practice was introduced in the 18th century without
having strong scientific evidence of its benefits.
• Its use was justified by the prevention of severe perineal tears, better
future sexual function and a reduction of urinary and fecal
incontinence.
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4. Types of episiotomy
• Midline (median): incision extends downwards from
fourchette towards the anus.
• Mediolateral: the incision starts at the fourchette and is
directed diagonally(inferiorlaterally) to avoid the anal
sphincter.
• Lateral: no longer used
• J shaped
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5. Aims of episiorrhaphy
It is important to repair an episiotomy as soon as possible after delivery
for the following reasons;
➢ To secure hemostasis and reduce blood loss.
➢ To prevent infection
➢ To ease patient's discomfort
➢ Prevent oedema of the tissues which will make the repair more
difficult.
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6. Pre-procedure evaluation
• Practitioners should be familiar with the
perineal tissues and muscles involved in an episiotomy
which includes;
a. Posterior vaginal wall
b. Subcutaneous fat
c. Perineal skin layer
d. Superficial muscles (bulbocavernosus and transverse
perineal)
e. Deep muscles (pubococcygeus).
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7. Pre-procedure evaluation
• Explain the procedure to the woman and obtain an informed verbal
consent.
• The woman should be in a comfortable position with her legs apart,
ideally in a lithotomy position to improve visibility and access to the
perineum during the procedure.
• Ensure all the necessary equipment is available.
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8. Instruments
• An appropriate source of light
• Surgical glove and a latex glove
• Antiseptic solution
• A needle and a syringe containing 1% lidocaine
• Gauze and swab
• A suture trolley containing a needle holder, an absorbable synthetic
suture material and a sterile pad
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9. Procedure
• Place the patient in lithotomy position, under a good light source.
• It's an aseptic procedure, the practitioner will wash his hands and put
on a surgical glove.
• Drape the area leaving only the repair site.
• Using aseptic technique, cleanse the perineal area with savlon or
antiseptic solution.
• Assess the episiotomy, perineum, vagina, vulva and rectum.
• Infiltrate the field with 10ml of 1% lidocaine and wait
for approximately 3-5 minutes for the analgesia to take effect.
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10. Procedure
• Insert a perineal pad into the birth canal to prevent
bleedingand lochia fromobscuringthe repairfield.
• Locate the apex of the episiotomy and go 1cm abovethe
apex.
• Suture the vaginal mucosa bycontinuous interlocking
stitches usingvicryl 2/0. (from 1cm abovethe apex down
to the fourchette orhymenal ring).
• Suture the perineal muscle by simple interruptedstiches
also usingvicryl 2/0, usuallydone in two layers (deep
and superficial).
• Close the skin using a simple interruptedsuturing
technique.
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11. Procedure
• Remove the perineal pad that was earlier inserted into the birth
canal.
• Do a vaginal examination after suturing to confirm that the vaginal
canal is not narrowed.
• Perform a rectal examination on completion of the repair to
ensure that no suture material has been inserted through the rectal
mucosa.
• Cleanse the perineal area and apply a sterile pad.
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12. Post operative care
• Keep the perineum clean and dry.
• Give analgesics for pain relief.
• Routine prophylactic antibiotics may not be necessary; therefore, give
antibiotic as indicated.
• Sitz bath
• Advice the woman on perineal hygiene and pelvic floor exercises.
• Laxatives
• Encourage liberal fluid intake and high fiber diet.
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13. Complications
Morbidity associatedwith perineal injury and repair is a significant health
problem for women. Complications can be early or late.
➢ Early Complications
a. Extension of the incision to involve the rectum.
b. Vulva hematoma.
c. Infection.
d. Wound dehiscence.
e. Injury to the anal sphincter leading to incontinence of faeces.
f. Necrotizing fasciitis.
g. Rectovaginal fistula.
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14. Complications
➢ Late complications
a. Dyspareunia.
b. Risk of perineal laceration in subsequent delivery.
c. Implantation dermoid.
d. Scar endometriosis.
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15. Conclusion
Skillful repair of an episiotomy is an important aspect of maternal
health care. It is essential that doctors and midwives have the
knowledge and skills to undertake this procedure in a safe and effective
manner.
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16. References
• Steen M, Cummins B. How to repair an episiotomy. NursStand 2016
• Basic steps in OandG Procedures
• OandG synopsis
• Repair of perineal trauma, episiotomy including management
of OASIS guideline
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