EPISIOTOMY

Definition:
Episiotomy, also known as perineotomy, is a surgical incision of the perineum and the
posterior vaginal wall generally done by a midwife or obstetrician. Episiotomy is usually
performed during second stage of labor to quickly enlarge the opening for the baby to pass
through. 
Purposes:
1. To enlarge the vaginal orifice.
2. To avoid intra-cranial hemorrhage to fetal head as prolonged compression on fetal head
can cause hypoxia to a premature baby.
3. To avoid an irregular perineal tear which can be: partial or complete. A clean-cut incision
is easy to repair and heals better than a repaired laceration.
4. To cut short the second stage of labour in case of maternal and fetal distress, thereby
reducing the bearing down efforts of mother and hasten the birth of the baby.
5. To facilitate the vaginal and uterine manipulation.
6. To avoid prolonged stretching of perineal floor thereby preventing the permanent
weakening of vaginal and bladder support which results in cystocele.
Indication:
 Anticipating perineal tear-primigravida and nullipara women, mal-presentations e.g. face
and breech, face to pubis delivery, narrow sub-pubic arch.
 Primigravida with rigid perineum where the perineum get stretched by the head of big
baby.
 Instrumental vaginal deliveries e.g. obstetrics forceps, vacuum extraction and version
where more space is needed for manipulation.
 To cut short the second stage of labour for any maternal and fetal distress e.g. eclampsia,
heart disease, fetal distress with head on the perineum, pre-maturity, post-maturity and to
minimize compression on the after coming head of the fetus.
 History of gynecological operations in the vaginal in past. Posterior colpoperineoraphy,
anterior colporaphy, repair of urinary stress incontinence and repair of 3 rd degree perineal
tear.
 Impending perineal tear.
Types of Episiotomy:
There are four main types of episiotomy:

 Medio-lateral: The incision is made downward and outward 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 (1 in) away from the anus (midpoint between the anus and the ischial
tuberosity).
 Median: The incision commences from the centre of the fourchette and extends on
the posterior side along the midline for 2.5 cm (1 in).
 Lateral: The incision starts from about 1 cm (0.4 in) away from the centre of the
fourchette and extends laterally. Drawbacks include the chance of injury to
 the Bartholin's duct, therefore some practitioners have strongly discouraged lateral
incisions.
 J-shaped: The incision begins in the centre of the fourchette and is directed
posteriorly along the midline for about 1.5 centimetres (0.59 in) and then directed
downwards and outwards along the 5 or 7 o'clock position to avoid
the internal and external anal sphincter. This procedure is also not widely practised.

Timings of Incision:
The timing of performing episiotomy requires judgement. The episiotomy involves incision
of the fourchette the superficial muscle and skin of the perineum and posterior vaginal wall. It
can therefore successfully speed delivery only when the presenting part is directly applied to
these tissues. Bulging thinned perineum during contractions just prior to crowning is the ideal
time.

Episiotomy articles needed:

Procedure:
1. Infiltrate the perineum with 10 ml of 1 percent solution of Lignocaine. Lignocaine is less
is less toxic and safe. Its onset of action is 1-2 minutes and action lasts for 1 hour.
2. While infiltrating, take caution against intravenous/intraarterial injection, by withdrawing
the piston of syringe before injecting. The toxic reaction may happen with
intravenous/intraarterial injection or excessive doses.
3. The toxic reactions include perioral /tip of tongue paraesthesia, drowsiness, twitching of
face and limbs and convulsions and finally respiratory depression.
4. Treatment is supportive but early recognition is important.
Incision:
1. Two fingers are placed in the vagina between the presenting part and posterior vaginal
wall.
2. A curved or straight, blunt pointed sharp scissors, one blade of which is placed inside, in
between the fingers and the posterior vaginal wall and the other on the skin is used to
make the incision.
3. The incision should be made at the height of the uterine contraction when an accurate
idea of the extent of incision can be better judged from the stretched perineum.
4. Deliberate cut should be made starting from the center of fourchette extending laterally
either to the right or left.
5. It is directed diagonally in a straight line, which runs about 2.5 cm away from anus.
6. The incision should be adequate to serve the purpose for which it is needed i.e. according
to the individual need.
Records:
Complete labour record, which includes:
1. Drugs administered
2. Duration and progress of labour
3. Reasons of performing episiotomy
4. Details of woman’s condition including APGAR score are recorded.
Risks of an Episiotomy:
Some possible complications of an episiotomy may include:
 Bleeding
 Tearing into the rectal tissues and anal sphincter muscle which controls the passing of
stool
 Swelling
 Infection
 Collection of blood in the perineal tissues
 Pain during intercourse
 BIBLIOGRAPHY
 Manocha Lata Sneh, “Procedures and Practices in Midwifery”, Published by “Kumar
Publishing House”, page no. 251-257

 https://en.wikipedia.org/wiki/Episiotomy