1. An episiotomy is a surgical incision made in the perineum and posterior vagina during childbirth to enlarge the vaginal opening for delivery.
2. While episiotomies were once routinely performed, evidence now supports a more restricted approach and performing them only when necessary to prevent tearing or aid delivery.
3. The main types of episiotomies are median, mediolateral, and lateral, with mediolateral being the most common. Structures that can be cut include the vaginal wall, perineal muscles, and fascia. Potential complications include bleeding, infection, pain during intercourse, and rare cases of rectal tissue or anal sphincter tearing
Preparation for delivery of mother, baby and midwife and equipmentsDR MUKESH SAH
In addition to their delivery bags, midwives “carry” many other invaluable tools ... family planning, delivery preparation, postnatal counseling and breastfeeding. ... With this equipment, we can recover 80% of newborns. ... “Midwifery feels good when both the mother and baby come out of the labor ward alive.
Preparation for delivery of mother, baby and midwife and equipmentsDR MUKESH SAH
In addition to their delivery bags, midwives “carry” many other invaluable tools ... family planning, delivery preparation, postnatal counseling and breastfeeding. ... With this equipment, we can recover 80% of newborns. ... “Midwifery feels good when both the mother and baby come out of the labor ward alive.
Many women experience some minor disorders during pregnancy.
Every system of the body may be affected during pregnancy. These disorders, however , are not minor to the pregnant woman.
Many women experience some minor disorders during pregnancy.
Every system of the body may be affected during pregnancy. These disorders, however , are not minor to the pregnant woman.
An episiotomy is a cut (incision) through the area between your vaginal opening and your anus. This area is called the perineum. This procedure is done to make your vaginal opening larger for childbirth.
Maternal birth canal injury following child birth process are quite common and significant to maternal morbidity and even to death. Also, a second most frequent cause of PPH.
An episiotomy is a surgical procedure to widen the opening of the vagina during childbirth.
During labor, your perineum — the skin and muscles between your vagina and anus — will be numbed with a shot, if you haven't already been given an epidural.
Then, a small, straight incision will be made in the middle of the perineum.
Alternatively, the incision may be made at an angle — a cut that is less likely than a straight incision to tear through the anus, but may take longer to heal.
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.
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Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
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2. EPISIOTOMY AND SUTURING
Introduction:
• Episiotomy is a surgical enlargement of the vaginal
orifice by an incision to the perineum.
• It is clear that much evidence exists supporting a
restricted policy for episiotomy and do not intend to
suggest that episiotomy should be routinely performed.
• Episiotomy is necessary, to achieve optimum outcomes
for mother and infant, without any adverse risk of perineal
or anal sphincter injury.
3. Definition:
• A surgically planned
incision on the perineum
and posterior vaginal wall
during the second stage
of labour to quickly
enlarge the opening for
the baby is called
episiotomy or
Perineotomy.
4. Purposes:
• To prevent the perineum from tearing.
• To allow more space for manipulative vaginal deliveries, e.g.
forceps
• To shorten the second stage of labour e.g. with fetal distress.
• To enlarge the vaginal introitus
• To facilitate easy and safe delivery
• To minimize out stretching and rupture of the perinealmuscles
and fascia
• To reduce the stress and strain on the fetal head
• To reduce prolonged maternal pushing efforts
5. Indication:
Anticipating perineal tear:
• Primi as an elective procedure
• Face to pubis delivery,
• Big baby
• Narrow pubic arch
Inelastic perineum:
• Perineal rigidity in elderly primi
• Old perineal scar of episiotomy
• Perineorrhaphy
Manipulative delivery:
• Needed to get more space
• Forceps
• Breech
• Internal version
To cut the second stage:
• Heart disease
• Severe pre eclampsia or eclampsia
• Post caesarean cases
• Post maturity
Fetal interest:
• Fetal distress
• Premature baby
• Breech delivery – to minimize
compression of the after coming head
6. Risks of the procedure:
• Bleeding
• Tearing the rectal tissues and anal sphincter
• Perineal pain
• Infection
• Perineal hematoma (Collection of blood in the
perineal tissues)
• Pain during sexual intercourse
7. Timing of the episiotomy:
• The timing of performing the episiotomy requires
judgement.
• If done early the blood loss will be more and if done late, it
fails to prevent the invisible lacerations of the perineal
body and thereby fails to protect the pelvic floor.
• Bulging thinned perineum during contraction just prior to
crowning is the ideal time
9. Mediolateral:
• Down wards and out wards
from the mid point of the
fourchette
• Either to the right or left.
• Runs about 2.5 cm away from
the anus
Median:
Centre of the fourchette and
extends posteriorly along
the midline for about 2.5 cm
10. Lateral:
• 1 cm away from the centre
of the fourchette
• Extends laterally
• Might injure the bartholin’s
duct
J shaped:
• Begins in the centre of the
fourchette
• Directed posteriorly along
the midline about 1.5 cm
• Directed downwards and
outwards along 5 or 7 o’
clock position .
11. Merits & demerits of Median:
Merits:
• The muscles are not cut
• Blood loss is least
• Repair is easy
• Post op. comfort is better
• Healing is superior
• Wound disruption is rare
• Dyspareunia is rare
Demerits:
• Extension if occurs may
involve the rectum
• Not suitable for
manipulative delivery or
in abnormal presentation
or position
• Its use is selective
12. Mediolateral:
Merits
• Safety from rectal
involvement
• Incision can be extended
• Demerits:
• Apposition is not so good
• Blood loss is more
• • Post op. discomfort is
more
• • Increased incidence of
wound disruption
• • Dyspareunia
13. Classification of episiotomy:
Classified by degrees that are based on the severity or extent of the tear:
First degree:
• A first-degree episiotomy
consists of a small tear that
only extends through the lining
of the vagina.
• It doesn’t involve the
underlying tissues.
Second degree:
• This is the most common
type of episiotomy.
• It extends through the
vaginal lining as well as
the vaginal tissue.
• However, it doesn’t
involve the rectal lining or
anal sphincter.
14. • Third degree:
• It involves the vaginal
lining, the vaginal tissues,
and part of the anal
sphincter
• Fourth degree:
• The most severe type of
episiotomy includes the
vaginal lining, vaginal
tissues, anal sphincter,
and rectal lining
15. Preparation:
• Explain the procedure to
the mother
• Provide privacy and
drape the mother
• Advice the mother to
empty her bladder /
catheterize the bladder.
• Monitor the uterine
contractions (duration,
frequency and intensity)
• Monitor FHR every 15
mins
• Do per vaginal
examination
• Observe the color of
amniotic fluid
16. Preparation of equipment:
• A sterile delivery packs containing:-
• Episiotomy scissor - 1.
• Artery forceps - 2.
• Sponge holding forceps - 1
• Syringe loaded with 2% of xylocaine(5 to10ml-)
• Cord cutting Scissors- 1
• Bowl for cleaning solution- 1
• 4 x4 gauze pieces – 5
• Cotton balls -7
• Gauze pad for supporting the perineum -2
• Center hole towel
• Cord clamp
• Bulb / mucous sucker
17. INTERVENTION RATIONALE
1 Admit the woman in the labour room Nil
2 Explain the procedure and change her clothing as per
the hospital policy
To preveNt anxiety
3 Obtain verbal consent Nil
4 Place the mother in the lithotomy position For clear view of the perineum
and to assess the progress
5 Arrange the necessary articles near to the mother For convenience and smooth
workmanship
6 Wash hands and wear sterile apron and gloves To prevent infectiom
7 Look for the signs of crowning(perineal bulging, vulval
stretching, anal pouting, hair line seen and head does
not recede back in between the contractions)
To prevent bleeding by giving
timely episiotomy
18. 8 Swab the perineum with antiseptic solution. To prevent the contamination
9 Drape the perineum. To obtain the sterile area for delivery.
10 Rupture the membrane if it’s still intact. To speed up the delivery
11 Place two fingers in the vagina along the proposed line
of incision
To protect the fetal head
Insert and direct the needle beneath the skin at an
angle of approximately 45° for about 4-5 cm in the
same line and withdraw the piston of the syringe prior to
the injection.
Aspiration ensures the needle has not
entered a blood vessel
Infiltrate the perineum continuously as the needle is
slowly withdrawn
To ensure adequate analgesia.
12 Withdraw the needle and apply pressure over the
injection site
Minimise blood loss, and prevents
haematoma formation
19. 13 Place two fingers in the vagina between the
presenting part and the posterior vaginal wall pointing
downwards.
In order to protect the fetal head.
14 Take a straight-bladed, blunt pointed sharp scissors
over the area intended for incision.
Nil
15 Give an episiotomy( a single deliberate cut from the
centre of the fourchette extending laterally for about 3
to 4 either to the right or to the left) during the peak of
uterine contraction when the birth is imminent
A straight cut minimises perineal
damage and facilitates optimal
anatomical realignment.
16 Withdraw the scissors carefully Nil
20. 17 Encourage the mother to bear down when there is a
good uterine contraction.
Nil
18 Give perineal support with right hand and urethral
support with left and exert pressure over the occiput.
Helps for the delivery of the fetal head.
(The forehead, mouth and chin are thus
born successfully by extension).
19 Apply pressure to the episiotomy between contractions
with a sterile pad if there is a delay in the birth.
Controls bleeding from the wound
21. STRUCTURES CUT DURING EPISIOTOMY
• Structures cut during episiotomy
• Posterior vaginal wall
• Superficial and deep transverse perineal
muscles,
• Bulbospongiosus and part of levator ani
• Fascia covering those muscles.
• Transverse perineal branches of pudental
vessels and nerves.
• Subcutaneous tissue and skin.
22. Complications:
• Extension of the incision in to
rectal tissues and anal sphincter
• Vulval haematoma
• Infection
• Pain and swelling
• Offensive discharge