Episiotomy

Last updated 20.09.12

 

Index

 

Definition

-  Incision made in perineum to aid fetal delivery & prevent tearing during labour

 

Features

-  Reduces damage to perineum, postpartum pelvic floor dysfunction, blood loss & neonatal trauma

-  Decreased risk if larger angle of episiotomy

-  50% risk reduction for every 6o away from midline

-  Restrictive use rather than routine use in Australia

-  Commonly performed throughout the world, rates vary

-  Increased use in some countries, decreased in Western practice

-  Iatrogenic perineal trauma

-  Reduces incidence of 3rd & 4th degree perineal tears

 

Indications

-  NOT used routinely in Aus

-  Shoulder dystocia

-  Serious risk of 2nd or 3rd degree tearing (perineal trauma)

-  Large fetus

-  Rigid perineal muscles

-  Short perineal body

-  Hx of surgical repair of pelvic floor, bladder or fistula

-  Instrumental delivery

-  Breech delivery

-  Prolonged late decelerations or fetal bradycardia on CTG when actively pushing

-  When reduced maternal effort is required: cardiac disease, epilepsy

 

Complications

-  Infection (post partum infection)

-  Wound infection

-  Abscess

-  Haematoma formation

-  Rectovaginal fistula

-  Dysparaenia

-  PPH

-  Impaired faecal continence

-  Esp midline episiotomy

-  Mediolateral ass w less risk

-  Routine episiotomy does not prevent

-  Extension to third or fourth degree tear

-  0.6-9% rate w mediolateral episiotomy

 

Equipment

-  20ml syringe

-  19G & 22G needle

-  Lidocaine 1% 10ml

-  Mayo episiotomy scissors

 

Procedure

-  Explanation & consent (verbal)

-  LA

-  Local infiltration of 1% Lignocaine

-  OR Pudendal block

-  Insert 2 fingers into vagina to protect fetal head & guide scissors

-  Between presenting part & skin

-  Direct syringe at 45o for 4-5cm

-  Aspirate then inject 3ml+/- Lidocaine as needle withdraws

-  Repeat injection in fan shaped pattern without needle tip leaving skin

-  Ideally wait 3-5min prior to cut for full LA effect

-  Reinsert 2 fingers into vagina between presenting part & skin

-  Ensure good vision

-  Avoid Bartholins glands

-  Right medio-lateral incision made w scissors (rarely left or midline)

-  Single straight deliberate cut 3-4cm into perineum at height of contraction

-  Incision should start at midline at fourchette

-  Pressure maintained on fetal head to control speed, maintain flexion & prevent extension

-  Apply pressure to episiotomy between contractions

-  Inspect perineum post delivery

-  Suture of episiotomy site after delivery: Perineal repair

-  Consider short term laxatives to avoid constipation or straining at defecation

 

Episiotomy

 

 

 

 

Reference

 

Pic: en.wikipedia.org/wiki/File:Medio-lateral-episiotomy.gif

KEMH Guidelines: Infiltration of the Perineum & Cutting an Episiotomy, July 2011

RCOG Greentop No. 29, 3rd & 4th Degree Perineal Tears, Management, 01/03/2007