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7.7. What is an episiotomy?

ANM Pelvis Dissection 50

An episiotomy is made from the fourchette (at the midline on the most posterior point of the vaginal
vestibule) to avoid injury to the labia and greater vestibular gland or duct.

The cut is made in a posterolateral direction rather than directly posterior, to avoid injury to the
external anal sphincter and anal canal.

Some small blood vessels are likely to be severed, with resultant bleeding requiring at least firm
pressure to the wound edges or clamping and ligature to a bleeding point. The transverse perineal
branch derived from the internal pudendal artery is the major branch particularly endangered.

If the cut is made too far into the ischioanal fossa, inferior rectal branches of the pudendal nerve and
internal pudendal artery are also endangered. These supply the external anal sphincter.

If the cut is directed too lateral, posterior labial branches derived from the pudendal nerve and internal
pudendal artery are endangered.

Three major layers are cut


the vaginal wall
perineal body (fibromuscular tissue just lateral to its tendinous centre)
overlying skin.

Each respective component of the wound is closed layer by layer to control bleeding and reduce dead
space (which would otherwise become occupied by haematoma). Local anaesthetic may be infiltrated
via the wound (if adequate anaesthesia has not already been provided).

The first stage is to repair the vaginal mucosa (including any lacerations) which also prevents internal
bleeding.

The second stage is the repair of the perineal body (including the bulbospongiosus and transverse
perineal muscles) which also provides most of the strength for the closed wound.

The third stage is the repair of the skin (and subcutaneous tissue) with special care that it is neither too
tight nor too loose, which may otherwise result in painful coitus.

Indication:
Made during childbirth to prevent tearing of vagina & tissues
Delay in 2nd stage of labour due to tight perineum, foetal / maternal distress with head on perineum
Breech deliveries
7.8. Describe, with the aid of a video, the steps of Digital per rectal (PR) examination ANM Pelvis
Dissection 46

https://youtu.be/fUwLRtJN4Aw

Steps of Digital Per Rectal (PR)


1. Lie on their left hand side with their knees drawn up towards their chest, their feet pushed
forwards and their anus exposed.
2. Separate the buttocks and inspect the area around the anus. Look for any abnormalities
including skin tags, haemorrhoids and fissures.
3. Place your finger on the anus so that it points anteriorly and apply pressure to the midline of
the anus.
4. Maintain the pressure so that your finger enters the rectum. Initially you need to assess anal
tone by asking the patient to squeeze your finger.
5. Systematically examine the rectum by sweeping the finger both clockwise and anti-clockwise
around the entire circumference. You should be feeling for any abnormalities such as
impacted faeces, masses or ulcers.
6. Assess the prostate gland
7. Remove your finger and examine the glove for the colour of any faeces as well as the
presence of any mucus or blood.

7.8.1. In a PR examination, describe the structures/spaces that can be palpated by the gloved index
finger

1. walls of anal canal, including the external sphincter


2. walls of rectum, particularly the mucosa (through 360 degrees)
2. cervix in the female, prostate in the male (anteriorly)
3. ischial spines (laterally)
4. coccyx & sacrum (posteriorly)

The fundus of the uterus (in a female) may be palpable if the uterus is retroverted or retroflexed. The
seminal vesicles (in a male) may be palpable if they are able to be reached.

Tenderness on the right may be elicited from an inflamed appendix if its tip is located in the pelvic
cavity.

7.9. Why is the ischioanal (ischiorectal) fossa clinically important?


1. Because of its great tendency to get infected (fat-filled space located lateral to the anal canal and
inferior to the pelvic diaphragm)
Iscioanal fossa communicate with each other behind the anal canal
Infections may occur from:
Boils/abrasions of the perianal skin
Lesions within the rectum and anal canal(especially infection of the branched anal glands)
May follow pelvic infection bursting through levator ani

2. Pudendal nerves can be blocked in Alcocks canal on either side to give regional anesthesia in
obstetrical forceps delivery

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