NOTES FOR UNDERGRADUATES AND POSTGRADUATES IN GYNE

1. EPISIOTOMY

2. •DEFINITION :
▷A surgically planned incision on the perineum and the posterior vaginal wall during the second stage of labor is
called episiotomy.

3. OBJECTIVES
▷ To enlarge the vaginal introitus so as to facilitate easy and safe delivery of the fetus
▷ To minimize overstretching and rupture of perineal muscles and fascia;to reduce the stress and strain on the
fetal head

4. INDICATIONS
▷ In elastic (rigid) perineum
▷ Anticipating perineal tear:
ㆍBig baby
ㆍFace to pubis delivery
ㆍBreech delivery and
ㆍShoulder dystocia
▷ Operative delivery:
ㆍForceps delivery
ㆍVentouse delivery
▷ Previous perineal surgery:
ㆍPelvic floor repair
ㆍPerineal reconstructive surgery

5. TIMING OF THE EPISIOTOMY
▷ Bulging thinned perineum during contraction just prior to crowning(when 3-4cm of head is visible) is the ideal
time.
▷ During forceps delivery,it is made after the application of blades

6. TYPES
▷ Mediolateral
▷ Median
▷ Lateral
▷ 'J' shaped

7. RELATIVE MERIT OF MEDIAN AND MEDIOLATERAL
EPISIOTOMY
MEDIAN MEDIOLATERAL
The muscles are not cut Relatively safe from rectal invovement from extension
Blood loss is least If necessary, the incision can be extended
Post operative comfort is maximum
Healing is superior
Wound disruption is rare
Dyspareunia is rare

8. RELATIVE DEMERITS OF MEDIAN AND MEDIOLATERAL
EPISIOTOMY
MEDIAN MEDIO-LATERAL
Extension, if occurs, may involve the rectum Apposition of the tissues is not so good
Not suitable for manipulative delivery or in malpresentation Blood loss is little more
Post-operative discomfort is more
Relative increased incidence of wound disruption
Dyspareunia is comparatively more

9. STRUCTURES CUT ARE:
▷ Posterior vaginal wall
▷ Superior and deep transverse perineal muscles,bulbospongiosus and part of levator ani
▷ Fascia covering those muscles
▷ Transverse perineal branches of pudendal vessels and nerves
▷ Subcutaneous tissue and skin

10. REPAIR
▷ The repair is to be done in the following order:
○ Vaginal mucosa and submucosal tissues
○ Perineal muscles and
○ Skin and subcutaneous tissues

11. POSTOPERATIVE CARE
▷ Dressing
▷ Comfort
○MgSO4 compression
○ Infrared heat
○ Ice pack
○ Analgesic(ibuprofen )
▷ Ambulance
▷ Removal of stitches (6th day)

12. COMPLICATIONS OF EPISIOTOMY
▷ Immediate:
○ Extension of the incision to involve the rectum
○ Vulval hematoma
○ Infection
○ Wound dehiscence
○ Injury to anal sphincter causing incontinence of flatus or feces
○ Rectovaginal fistula
○ Necrotizing fascitis

13. ▷ Remote:
○ Dyspareunia
○ Chance of perineal lacerations in subsequent labor,if not managed properly
○ Scar endometriosis (rare)

14. THANK YOU