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 for
the ragged laceration that otherwise frequently result 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 and urinary incontinence. However to have this benefit, the perineal incision should not be done at the time of maximal distention.

Lacerations of the Birth Canal

Lacerations of the vagina and perineum are
preventable with an appropiate episiotomy and avoidance of midforceps delivery. First degree laceration
Involve the fourchet, the perineal skin, and vaginal mucous membrane but not the underlying fascia and muscle Involve in addition to skin and mucous membrane, the fascia and muscles of the perineal body but not the rectal sphincter. These tears usually extend upward on one or both sides

2nd degree laceration

Lacerations of the Birth Canal

Third degree
Lacerations
Extend through the skin, mucous membrane, perineal body and involve the anal sphincter. May also extend a distance up to the anterior wall of the rectum.

Lacerations of the Birth Canal

4th degree lacerations
Third degree tears that extend through the rectal mucosa to expose the lumen of the rectum

Important questions concerning episiotomy

How long before delivery should it be
performed ? Should a median or mediolateral incision be made ? Should the incision be sutured before or after expulsion of the placenta? What are the best suture materials and technique to employ ?

Timing of Episiotomy
If performed unnecessarily early, bleeding
from the gaping wound may be considerable during the interim between the incision and the birth of the baby. If performed too late, the muscles of the perineal floor already will have undergone excessive stretching, and one of the objectives of the operation is defeated.

Timing of Episiotomy
It is common practice
to perform episiotomy when the head is visible during a contraction to a diameter of 3-4 cm

Midline versus Mediolateral

Easy to repair Faulty healing rare Less painful in
puerperium Dyspareunia rarely follows Anatomical end results almost always excellent

More difficult to repair Faulty hearing more

common Pain in one third of cases for a few days Dyspareunia occasionally follows Anatomical end results more or less faulty in 10% of cases

Midline versus Mediolateral

Blood loss less Blood loss greater Extension through the Extension through the
anal sphincter and into the rectum is rather common sphincter is uncommon

Midline versus Mediolateral

With proper selection of cases, it is possible to
secure the advantages of median episiotomy and at the same time reduce to a minimum its one disadvantage, the greater risk of third degree extension.
If the perineal body is short, there is greater likelihood of third degree laceration. It is also greater when the fetus is large, when the occiput is posterior, in midforceps and breech deliveries

Timing of the repair of Episiotomy

The most common practice is to defer repair of
the episiotomy until after the placenta has been delivered
for us to give undivided attention to the signs of placental separation and to deliver the organ just as soon as it has separated.Early delivery of the placenta is believed to decrease the loss of blood from the implantation site, since it prevents the development of extensive retroplacental bleeding Episiotomy repair is not interrupted or disrupted by the obvious necessity of delivering the placenta.

Technique
There are many ways to close the
episiotomy incision, but hemostasis and anatomical restoration without excessive suturing are essential for success of any method

Repair of Median Episiotomy

Chronic catgut 00 or
preferably 000, is used as a continuous suture to close the vaginal mucosa and submucosa

Repair of Median Episiotomy

After closing the vaginal
incision and reapproximating the cut margins of the hymenal ring, the suture is tied and cut. Next 3 or 4 interrupted sutures of 00 or 000 catgut are placed in the fascia and muscle of the incised perineum.

Repair of Median Episiotomy

A continuous suture is
now carried downward to unite the superficial fascia.

Repair of Median Episiotomy

Completion of repair.
The continuous suture is carried upward as a subcuticular stitch.

Repair of Median Episiotomy

Completion of repair of
median episiotomy. A few interrupted sutures of 000 chromic catgut are placed through the skin and subcutaneous fascia and loosely tied. This closure avoids burying 2 layers of catgut in the more superficial layers of the perineum.

Pain Relief After Episiotomy

For the relief of episiotomy pain, a heat lamp
has been a standard remedy.But during the summer months, it may produce more discomfort rather than remedy. An ice collar applied early tends to reduce swelling and allay discomfort. Analgesic can give considerable relief. Since pain may be a signal of a large vulvar, paravaginal or ischiorectal hematoma or perineal cellulitis, it is essential to examine these sites carefully if pain is severe or persistent.