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

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