◾Definition- A surgically planned incision on the perineum and the posterior Vaginal wall during the second stage of labour is called Episiotomy/ Parineotomy.
It is commonly performed obstetric operation.
◾Objectives-
- To enlarge the vaginal introitus so as to facilitate easy and safe delivery of the fetus
- To minimise overstretching and rupture of perineal muscles and fascia.
◾Common indications are-
- Threatened perineal injury in primigravidae
- Rigid perineum
- Forceps, breech, occipito- posterior or face delivery
◾Timing of Episiotomy- Bulging thinned perineum during contraction just prior to crowning (when 3-4 cm of heads visible) is the ideal time.
◾Types-
- Medio-lateral/ postero-lateral – The incision is made downwards and outwards from the midpoint of the Fourchette to the right or left. It is directed diagonally.
- Median – The incision starts from the centre of the Fourchette and extends posteriorly.
- Lateral – The incision starts from about 1 cm away from the centre of the Fourchette and extends laterally. There may be chances of injury.
- ‘J’ shaped – The incision begins in the centre of Fourchette, then directed posteriorly along the midline for about 1.5 cm and then directed downwards and outwards along 5 or 7 o’clock position.
Only medio- lateral or median episiotomy is done commonly.
◾Steps of Medio-lateral Episiotomy
Step- I: Preliminaries – The perineum is swabbed with antiseptic (povidone- iodine) lotion and draped properly.
Local anaesthesia- The perineum, in the line of proposed incision is infiltration with 10 ml of 1% solution of lignocaine.
Step- II: Incision –
- Two fingers are placed in the vagina between the presenting part and the posterior Vaginal wall.
- Incision is made by Episiotomy scissors
- The incision should be made at the height of an Uterine contraction when an accurate idea of extent of incision can be better judged.
- Deliberate cut should be made starting from the centre of the Fourchette extending laterally.
Structures to be cut are-
- Posterior Vaginal wall
- Superficial and deep transverse perineal muscles, bulbospongiosus and part of levator ani
- Fascia covering those muscles
- Transverse perineal branches of pudendal vessels and nerves
- Subcutaneous tissue and skin
Step- III: Repair – The repair is done soon after expulsion of Placenta.
Early repair prevents sepsis and eliminates the patient’s prolonged apprehension of ‘stitches’. Steps of repair:-
- Wound on inspection
- Repair of vaginal mucosa and perineal muscles by interrupted sutures
- Apposition(side by side) of the skin margins
- Repaired wound on inspection
◾Post Operative care
- Dressing– wound is to be dressed each time following urination and defecation to keep the area clean and dry. The dressing is done by swabbing with cotton swabs soaked in antiseptic solution followed by application powder or ointment (Furacin or Neosporin).
- Comfort– To relieve pain in the area, magnesium compress or application of infra red heat may be used. Ice pack reduce swelling and pain. Analgesics (Ibuprofen) may be given.
- Ambulation- Rest for 24 hours.
- Removal of stitches- The wound is sutured by catgut or Dexon which will be absorbed. If non- absorbable material like silk or nylon is used, the stitches are cut on 6th day.
◾ Complications-
- Extension of the incision to involve the rectum.
- Vulval haematoma (collection of blood that pools in the soft tissue of the vagina or vulva)
- Infection
- Wound dehiscence
- Dyspareunia
- Chance of perineal laceration