This document discusses episiotomies and perineal tears that can occur during childbirth. It defines an episiotomy as a surgically planned incision made in the perineum and posterior vaginal wall during the second stage of labor. It notes that routine episiotomies are no longer commonly performed and discusses the types of episiotomies including midline and mediolateral, along with their risks and benefits. Perineal tears are also defined as tears between the vagina and rectum that can range in severity from first to fourth degree. Risk factors, complications, classification, management, and prevention of perineal tears are outlined.

1. EPISIOTOMIES AND
PERINEAL TEARS
DR. RUKIA (MD)

3. Introduction.
• DEFINITION.
• Surgically planned incision on the perineum
and posterior vaginal wall during second stage
of labor

4. CONTROVERSY ABOUT COMMON
USAGE
• Routine episiotomies have lost popularity
• WHO recommends an episiotomy rate of 10%
• Associated problems
– Unsatisfactory anatomical results
– PPH
– Dyspareunia
– Perineal pain

5. 1. Midline episiotomy
• Complications
– Spontaneous extension involving injury to the
anal sphincter and/or rectal mucosa.
– Higher incidence of rectovaginal fistulas
• Advantages
– Easy and satisfactory repair
– Blood loss is least
– Repair is easy
– Postoperative comfort is maximum
– Healing is superior
– Dyspareunia is rare
TYPES OF EPISIOTOMIES

6. 2. Mediolateral episiotomy
• Complications
– Poor wound healing
– Long-term pelvic pain
– Dyspareunia.
– Apposition of the tissues is not so good
– Blood loss is little more
– Postoperative discomfort is more
• ADVANTAGES
• Relative safety from rectal involvement from extension
• If necessary, the incision can be extended

7. • Operative vaginal deliveries requiring
additional room to safely accomplish the
delivery
– Vacuum extraction deliveries - may be facilitated
by an episiotomy
• Fetal distress
• Short or inelastic perineum
• Previous pelvic floor surgery
INDICATIONS FOR EPISIOTOMY

8. 1. Ascertain the full extent of the laceration
2. Appose the tissues appropriately
3. Suture materials – absorbable
4. Repair in layers
– Inside layer – interrupted
– Outside layer – interrupted/continuous
PRINCIPLES OF EPISOTOMY REPAIR

9. perineal tear
• Definition.
• A perineal tear is a tear in the skin and/or
muscles between the vagina and the rectum.
Perineal tears can range in severity.

10. Classification.
• First degree: Tear involving the vaginal mucosa
and connective tissue.
• Second degree: Tear involving the perineal
muscles (perineal body) and therefore
includes episiotomy.
• Third degree: Second degree tears with
disruption of the anal sphincter.
• Fourth degree: Third degree tears with tone
anal epithelium or rectal mucosa.

11. Predisposing Factors
• Rigid perineum.
• Short or inelastic perineum.
• All malpresentations.
• Previous tears.
• Genital mutilations.
• Big baby.
• Episiotomy.
• Operative vaginal deliver

12. Complication of Perineal Tears
• Postpartum haemorrhage
• Fistula formation.
• Infection (sepsis).
• Dyspareunia.
• Faecal incontinence

13. Management.
• First and second degree tears:
–Infiltrate the wound with lignocaine 1% .
–Repair the tear by suturing absorbable suture
material.
• Third and fourth degree tears.
– Should be repaired by the experienced
medical personnel
–General anaesthetic or epidural or spinal
anaesthetic is necessary

14. Post Repair Care
• Sitz bath PPM OR DETOL.
• Personal hygiene.
• Antibiotics.
• Give stool softener for one week (for third and
fourth degree tears)

15. Prevention
• Remind the woman when to push and when
not to push.
• Perform episiotomy early in patients with
indications. I.e. inelastic perineum, shoulder
dystocia.
• Deliver the head slowly.
• Proper monitor of labour.