1. CASE PRESENTATION
A 20yr old Primigravida was given an episiotomy in 2nd
stage for a forceps delivery. Discuss how you will manage her?

2. OUTLINE
Definition
Benefit
Indication
Types
Procedure

3. DEFINITON
Intrapartum incision of the perineum to widen
the introitus.

4. BENEFIT
Prevention of perineal by anatomical incision
and repair of the episiotomy.
Prevention of prolong and overstretch of the
perineum which predisposes to prolapse and
stress incontinence.
Minimising compression and decompression of
the head which causes intracranial haemorrhage.

5. INDICATION
MATERNAL INDICATION
Nearly in all primiparas
Old perineal scar about to rupture.
Prolonged 2nd stage due to rigid perineum.
Prior to most instrumental vaginal delivery as
forceps and vacuum.
Vulval oedema.

6. FOETAL INDICATION
 Large size baby.
 Preterm baby.
 Direct occipito-posterior.
 Breech delivery.

7. TYPES
Median.
Mediolateral

8. MEDIAN
A midline down to but not including the
external anal sphincter.
ADVANTAGES.
It is the easiest to perform and to repair.
Associated with less blood loss.
Less dyspareunia later on.
Better end result cosmetic appearance.

9. DISADVANTAGE.
Its inadventent extension will injure the
external anal sphincter and rectum,this can be
prevented by extending the incision by the
scissors in a J-shaped manner to avoid the
external sphincter.

10. MEDIOLATERAL
The incision extends from the midline of the
fourchette mediolaterally at 5 and 7`o`clock
towards the direction of the ischial tuberosity.
ADVANTAGES.
Extension to the anal sphincter is less common
so it is more suitable for instrumental delivery
and in short perineum.

11. DISADVANTAGES
Difficult to perform.
More blood loss.
More pain and discomfort in perineum.
More dyspareunia later on.
Less end result cosmetic appearance.

12. PROCEDURES
Anaesthesia-Local infiltration, Pudendal nerve
block, Epidural, Spinal or GA can be used.
Timing-When the introitus is distended by the
presenting part or the cup of the Ventous with
the visible diameter not less than 3-4cm,and
done at maximum of a uterine contraction. If
forceps will be used episiotomy is done just
before its application.

13. Incision-The index and the middle finger of
one of the hand introduced between the
presenting part and the proposal site of
perineal incisionto protect the presenting part
and support the tissues that will be incised,
the incision is usually 3-5cm length,including
the posterior vaginal wall, fourchette, perineal
muscles and perineal skin.

14. Repair-Catgut o, Dexon or vicryl 2/0maybe used
to closed the posterior vaginal wall by
continuous sutures where the first stitch
should be above the apex of the vaginal
incision, then the muscles with interupted
sutures and lastly with interupted or
subcuticular sutures

15. P0STNATAL
NSAID diclofenac is used for 1st 72hrs.
Local antiseptic lotion and antibiotic powder
or spray is used for 7 days.