Epiosotmy is a surgically planned incision given on the perineum during labor

1. EPISIOTOMY

2. DEFINITION
Episiotomy is surgically planned incision given on
the perineum during second stage of labor to
enlarge the vaginal introitus, thereby facilitating
safe and easy delivery of the fetus.

3. OBJECTIVES
To enlarge the size of vaginal orifice
To prevent perineal tear
To reduce stress and strain on fetal head
To cut short second stage of labor

4. INDICATIONS
Large fetus >4,000 g
Preterm or small for gestational age baby in order to minimize
the risk of intracranial hemorrhage
Presence of rigid perineum
Face to pubis delivery, breech delivery or shoulder dystocia
In fetal distress, to make the delivery fast
When large lacerations seem inevitable
In case of operative delivery like forceps/ventose
Previous history of pelvic floor repair, perineal reconstructive
surgery

5. TIMING OF EPISIOTOMY
Bulging thinned perineum during contraction along
with bearing down efforts by the mother just prior
to crowning is the ideal time for giving episiotomy.

6. TYPES OF EPISIOTOMIES
Mediolateral : incision is given downward and
outward from the midpoint of fourchette.The cut
may be given either toward right or left side and
about 2.5 cm.

7. Median/midline:The incision is given from the
center of fourchette and extends posteriorly.The
cut is 2.5 cm in length

8. Lateral: Incision starts from about 1 cm away from
the center of fourchette and extends laterally.

10. J shaped:The incision starts from the centre of
fourchette and directed posteriorly about 1.5
cm and then points downward and outward
along 5 or 7 o’ clock

11. ADVANTAGES
MATERNAL BENEFITS
1. Clear incision is easy to repair
2. Healing is better than lacerated wound
3. Helps cut short the second stage of labor
4. Lessens the chance of trauma to the pelvis floor muscles
5. Tear may be avoided
6. There is less stretching of and less damage to the
bladder, anterior vaginal wall and urethra

12. FETAL BENEFITS
1. Episiotomy makes the birth safer and easier
2. It prevents intracranial birth injuries

13. COMPLICATIONS
IMMEDIATE
1. Extension of episiotomy wound
2. Vulval hematoma
3. Infection
4. Recto-vaginal fistula/vesicovaginal fistula
5. Wound impairment

14. REMOTE
1. Dyspareunia
2. Chances of perineal laceration in subsequent labor
3. Scar endometriosis

15. REPAIR OF EPISIOTOMY
 Requirement
Provide lithotomy position
A good source of light is needed
Instruct the mother to spread the thighs
Clean the perineal area with antiseptic solution
Drape the patient properly under aseptic precaution
Evacuate the uterine cavity for retained clots or placenta
Vaginal pack may be inserted and placed high up, if the wound site is
obscured by oozing of blood from above, but it must be documented and
removed , else it may lead to sepsis

16. Suture material
Dexon or number ‘0’ chromic catgut is usually used to repair
episiotomy. It is an absorbable suture and is spontaneously
sheds off after 7-8 days of repair. Silk or nylon
(nonabsorbable) sutures may be used and removed on 6th
day.

17. EPISIOTOMY SUTURING
 The sequence of episiotomy suturing is as follows:
a) Vaginal mucosa: it is sutured first. First inspect the apex of
tear and first suture is applied just above the apex.
Continuous suture is used to repair vaginal mucosa from
above downward till the fourchette is reached.
b) Perineal muscles: Interrupted sutures are used to repair
perineal muscle same from above downward till the
fourchette is reached.
c) Skin : Mattress suture or figure of eight is used to repair skin.

18. EPISIOTOMY CARE
 Maintenance of perineal hygiene: instruct to clean episiotomy
wound after every urination and defecation.
 Provide perineal care twice daily and clean the episiotomy
wound with antiseptic solution
 Assess the wound healing status every time with REEDA scale
 If there is impaired wound healing, provide sitz bath using
MgSO4, moist and dry heat therapy or use analgesic drugs/
antibiotic therapy
 Do not sit with cross legs because stitches may break

19. Instruct the mother to ambulate to avoid stretch on the
perineal wound
If nonabsorbable sutures are used, stitches are removed
on 6th
day.
Advise the mother for abstinence for 6 weeks after
delivery.