Episiotomy

Episiotomy
Definition
An episiotomy is a planned incision on the perineum and posterior vaginal wall to enlarge
the vaginal orifice during the second stage of labour for obstetrical purpose.
This is an incision through the perineal tissues which is designed to enlarge the vulval outlet
during birth.
Purpose
1. To minimize over stretching of perineal muscle as in case of very large baby.
2. To enlarge the vaginal orifice so it facilitates easy and safe delivery of the fetus3.
4.
5.
6.
spontaneous or manipulative.
To speed up delivery in fetal distress in second stage of labour.
To an assisted delivery such as forceps or ventouse extraction.
To prevent a recurrence of previous third or fourth degree tears.
To decrease the length of second stage for women who are ill with heart disease and
eclmpsia etc.
Indications
Episiotomy should not be performed routinely. It should be considered only in the following
cases:
1. Fetal distress in second stage of labour.
2. Complicated vaginal delivery such as breech, shoulder dystocia, forceps, vaccum
3.
4.
5.
6.
7.
extraction etc.)
Scarring from female genital cutting or poorly healed third and fourth degree of tears.
Maternal distress due to exhaustionor heart failure.
A very tight perineum that prevents delivery.
Manipulative delivery such as vaccum, forceps, breech extraction, internal version.
To cut short the second stage of labour especially for woman who is at risk for bearing
down efforts, eg. Heart disease, pre-eclampsia, post caeserean cases, post maturity.
8. Premature baby to minimize compression of the soft and flexible skull bone there by
preventing intracranial damage.
9. Cord prolapse in second stage of labour.
10. Big baby.
Advantages of episiotomy
Maternal
A clean and controlled incision is easy to repair and heals better than lacerated wound.
Timely episitomy saves perineum from laceration, heamatoma and complete perineal
tear.
Shortening of second stage of labour and it reduce the bearing down efforts which is
beneficial in womans with cardiac disease or severe pre-eclampsia or eclampsia.

Prevent postpartum genital prolapse.
Fetal
Minimizes intracranial injury especially in premature babies.

Prevent fetal asphyxia by reducing longer stay in the perineum.
Disadvantage
Blood loss 100-200 ml from episiotomy wound.

Increased perineal trauma
Vulval haematoma and infection
Painful wound
Dysparuenia due to over stitching.
Timing of episiotomy
Judgement is needed for the episiotomy must be made neither too soon nor too late. An
episiotomy involves incision of the fourchette, superficial muscle and skin of the
perineum and the posterior vaginal wall.

If the episiotomy is performed too early it will fail to release the presenting part and
bleeding from cut vessels. In addition, the levator ani muscle will not have had time to be
displaced laterally and may be incised as well.
If performed too late there will not be enough time to infiltrate with local anaesthesia and
tear and laceration may occur.

It is best to make the episiotomy when bulging thinned perineum during contraction just
prior to crowning.
Types of Episiotomy
The following are the types of episiotomy.
1. Mediolateral
2. Median
3. Lateral
4. J shaped
1. Mediolateral incision
The incision is made downwards and outwards from the midpoint of the fourchette either to the
right or left. It is directed diagonally in a straight line which runs about 2.5 cm away from the
anus (midpoint between anus and ischial tubersity). It is commonly used by midwife.
Advantages
It avoids the danger of damage to both anal sphincter and Bartholins gland.
Rectal involvement from episiotomy extension is less.
Easy to do repair
If needed incision can be extended.
Disadvantages
Apposition of the tissue is not so good.
Blood loss is little more.
Dyspareunia is comparatively more.
Post operative discomfort and pain more.
Relative increased incidence of wound disruption.
2. Median incision
This is midline incision which follows the natural line at insertion of perineal muscle. Incisions
commence from the centre of the fourchette and extend posteriouly along the midlinefor about
2.5cm. This incision reduces blood loss but higher incidence of damage of anal sphincter.
Advantages
Muscle are not cut

Blood loss is least
Easy to repair
Post-incisional comfort is maximum
Wound healling is superior and disruption is rare
Dysparenuia is rare
Disadvantage
If extension occurs, may involve rectum
Not suitable for manipulative delivery or in abnormal presentation or position
3. Lateral incision
The incision starts from about 1cm away from the centre of fourchette and extends laterally. It
has got many drawbacks including chance of injury to the bartholins duct. It is totally
condemned (strong disapproval of something).
4. J shaped incision
The incision begins in the centre of the fourchette and is directed posteriorly along the midline
for about 1.5cm and then directed downwards along 5 or 7 oclock position to avoid anal
sphincter. This is also not done widely.
Equipment needed for episiotomy
1. perineal sheet
2. Sponge holder
3. Small bowl 1
4. Episiotomy scissor 1
5. Suture cutting scissor 1
6. Needle holder 1
7. Tooth dissecting forceps 1
8. Chromic catgut 2-0
9. Injection xylocain 2% or 1% or 0.5%
10. 5cc or 10cc disposable syringe with needle
11. Gauze pieces and cotton balls 5-6
12. Perineal pads 2

13. Sterile water or antiseptic solution
14. For staff (plastic apron, mask, cap and high level disinfected or sterile gloves).
METHODS OF EPISIOTOMY
Step -1 Methods of infiltration
1.
2.
3.
4.
5.
6.
The perineum is thoroughly swabbed with antiseptic solution and draped properly.
Draw 10ml of 0.5% lignocaine or xylocaine.
Two fingers are inserted into the vagina along the line of proposed incision.
The needle is inserted beneath the skin for 4-5cm following the same line.
Withdraw the piston to check whetherr the needle is inserted into the blood vessels.
If blood is aspirated reposition the needle and repeate process until no blood is
withdrawn.
7. Lignocain is continuously injected as the needle is withdrawn and needle must be
redirected towards the either sides of the first injection just before the tip is withdrawn.
8. Wait 2 minutes and then pinch the incision site with forcep. If the woman feels the pich,
wait 2 more minutes and then retest.
Step-2 Method of incision
1. Wait to perform the episiotomy until the perineum is thinned out and 3-4 cm of the babys
head is visible during contraction.
2. Two fingers are inserted into the vagina and the open blades are positioned. The blades
should be sharp to ensure clean episiotomy.
3. Make an incision during contraction. A single deliberate (planned) cut 4-5cm long is
made at the correct angle or at 7 oclock from centre of fourchette extending laterally
either left or right diagnolly in a straight line runs about 2.5cm away from the anus
(mediolateral).
4. Delivery of the head should follow immediately, therefore control the head and support
the perineum to prevent or avoid the extension of the episiotomy.
5. If there is delay in the delivery of the head pressure should be applied to the episiotomy
site to minimize bleeding.
Structures cut in episiotomy
Posterior vaginal wall

Superficial and deep transverse perineal muscle, bulbospongiosus and part of levator ani.
Fascia covering the muscles.
Transverse perineal branches of pudendal vessels and nerves.
Subcutaneous tissue and skin.
Degree of perineal tears

1. First degree tears involve the vaginal mucosa and connective tissue.
2. Second degree tears invlove the vaginal mucosa, connective tissue and underlying
muscles.
3. Third degree tears involve complete transection of the anal sphincter.
4. Fourth degree tears involve the rectal mucosa.

Episiotomy

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Episiotomy

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What are the different types of episiotomy and their characteristics?

What are the indications for performing an episiotomy?

Episiotomy

beneficial in womans with cardiac disease or severe pre-eclampsia or eclampsia.

Minimizes intracranial injury especially in premature babies.

Blood loss 100-200 ml from episiotomy wound.

perineum and the posterior vaginal wall.

tear and laceration may occur.

Muscle are not cut

12. Perineal pads 2

Structures cut in episiotomy

Posterior vaginal wall

Degree of perineal tears

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