Episiotomy and Repair

8/4/2019 Episiotomy and Repair

http://slidepdf.com/reader/full/episiotomy-and-repair 1/20

EPISIOTOMY AND

REPAIR



EPISIOTOMY

in a strict sense, is incision of the Pudenda.

Perineotomy is the incision of the perineum.

In common parlance, however, episiotomy is

often used synonymously with perineotomy.

Median or midline episiotomy

incision may be made in the midline

Mediolateral episiotomy May begin in the midline but directed laterally and

downward away from the rectum.



Episiotomy

It substitutes a straight, neat surgical incision forthe ragged laceration that otherwise frequentlyresult in a difficult childbirth.

It is easier to repair and heals better than a tear. With mediolateral episiotomy, the likelihood of

lacerations into the rectum is reduced. Another advantage but unproven benefit of

routine episiotomy is that it prevents pelvic

relaxation that is cystocele, rectocele andurinary incontinence. However to have thisbenefit, the perineal incision should not be doneat the time of maximal distention.



Lacerations of the Birth Canal

Third degreeLacerations

Extend through the

skin, mucousmembrane, perinealbody and involve theanal sphincter. Mayalso extend a distanceup to the anterior wallof the rectum.



Lacerations of the Birth Canal

4th degree lacerations

Third degree tears thatextend through the

rectal mucosa toexpose the lumen ofthe rectum



Important questions concerning

episiotomy

How long before delivery should it beperformed ?

Should a median or mediolateral incisionbe made ?

Should the incision be sutured before orafter expulsion of the placenta?

What are the best suture materials andtechnique to employ ?



Timing of Episiotomy

If performed unnecessarily early, bleedingfrom the gaping wound may beconsiderable during the interim between

the incision and the birth of the baby.

If performed too late, the muscles of theperineal floor already will have undergone

excessive stretching, and one of theobjectives of the operation is defeated.



Timing of Episiotomy

It is common practiceto perform episiotomywhen the head is

visible during acontraction to adiameter of 3-4 cm



Midline versus Mediolateral

Easy to repair

Faulty healing rare

Less painful in

puerperium Dyspareunia rarely

follows

Anatomical end

results almost alwaysexcellent

More difficult to repair

Faulty hearing morecommon

Pain in one third ofcases for a few days

Dyspareuniaoccasionally follows

Anatomical endresults more or lessfaulty in 10% of cases



Midline versus Mediolateral

Blood loss less

Extension through theanal sphincter and

into the rectum israther common

Blood loss greater

Extension through thesphincter is

uncommon



Timing of the repair of Episiotomy

The most common practice is to defer repair ofthe episiotomy until after the placenta has beendelivered

for us to give undivided attention to the signs ofplacental separation and to deliver the organ just assoon as it has separated.Early delivery of theplacenta is believed to decrease the loss of bloodfrom the implantation site, since it prevents thedevelopment of extensive retroplacental bleeding

Episiotomy repair is not interrupted or disrupted bythe obvious necessity of delivering the placenta.



Technique

There are many ways to close theepisiotomy incision, but hemostasis andanatomical restoration without excessive

suturing are essential for success of anymethod



Repair of Median Episiotomy

Chronic catgut 00 orpreferably 000, isused as a continuous

suture to close thevaginal mucosa andsubmucosa




After closing the vaginalincision andreapproximating the cutmargins of the hymenal

ring, the suture is tied andcut.

Next 3 or 4 interruptedsutures of 00 or 000

catgut are placed in thefascia and muscle of theincised perineum.




A continuous suture isnow carrieddownward to unite the

superficial fascia.




Completion of repair.The continuoussuture is carried

upward as asubcuticular stitch.




Completion of repair ofmedian episiotomy. A fewinterrupted sutures of 000chromic catgut are placed

through the skin andsubcutaneous fascia andloosely tied.

This closure avoids

burying 2 layers of catgutin the more superficiallayers of the perineum.



Pain Relief After Episiotomy

For the relief of episiotomy pain, a heat lamphas been a standard remedy.But during thesummer months, it may produce morediscomfort rather than remedy.

An ice collar applied early tends to reduceswelling and allay discomfort.

Analgesic can give considerable relief. Since pain may be a signal of a large vulvar,

paravaginal or ischiorectal hematoma orperineal cellulitis, it is essential to examine thesesites carefully if pain is severe or persistent.

Episiotomy and Repair

Documents

Transcript of Episiotomy and Repair