cares of the perineum during 2nd stage

Question 1

how to prevent tears

Answer 1

daily perineal massage
discuss controlled head delivery with mom
allow mom to push as she desires
use positions that either promote or slow progress
hot compresses
perineal massage while pushing
perineal support while head is delivering
apply counter pressure to head as it delivers
flex fetal head as it delivers
avoid episiotomy
judicious use of vacuum

Question 2

details of perineal massage

Answer 2

begin at 35-37 weeks
5-10 mins daily
use oil
usually partner does it
insert fingers all the way and apply downward pressure on the posterior perineum; move fingers side to side slightly

Question 3

what kind of position would slow the delivery of the head of she is progressing quickly

Answer 3

a position that does not utilize gravity- side lying or hands and knees

Question 4

if she is not progressing quickly, what position would be best

Answer 4

a position that utilizes gravity- squatting, standing, or semi-sitting

Question 5

median or midline episiotomy

Answer 5

vertical incision into the midline of the perineum from the posterior fourchette toward the anus

Question 6

advantages of median/midline episiotomy

Answer 6

a. Easiest to repair
b. Faulty healing is rare
c. Less painful postpartum and less dyspareunia
d. Less blood loss

Question 7

disadvantages of median/midline episiotomy

Answer 7

Extension into anal sphincter more common (3-15%)
More common with narrow suprapubic angle, large baby, short perineum
Complications from poor repair-rectal incontinence, fistula formation

Question 8

mediolateral episiotomy

Answer 8

Starts at the hymenal ring and extends downward at an angle of at least 45° from the midline.

The incision must begin centrally to avoid the Bartholin’s glands and to leave at least 1 cm lateral to the rectal sphincter to allow for repair

Question 9

advantages of mediolateral episiotomy

Answer 9

extension into anal sphincter is uncommon

Question 10

disadvantages to mediolateral episiotomy

Answer 10

a. More difficult to repair
b. Faulty healing in 10% of cases
c. More pain postpartum (1/3 of cases) and more dyspareunia
d. Greater blood loss

Question 11

appropriate indications for episiotomies in naturopathic midwifery

Answer 11

expediting delivery with fetal distress
prolonged crowning (10-20 mins)
instrumentation with tight perineum
shoulder dystocia with tight perineum (only helpful if episiotomy will assist the midwife to perform maneuvers for shoulder dystocia)

Question 12

procedure to prepare for episiotomy

Answer 12

discuss with patient and partner
wait until the head is stretching the perineum- +4, crowning
1-2cc of 1-2% lidocain with 25g needle straight into perineum from introitus

Question 13

episiotomy technique

Answer 13

1. After anesthetizing and during contraction insert blunt blade of sterile scissors parallel to perineum using 2 fingers to guide blade and protect baby’s head-keep edges of scissors perpendicular to plane of perineum
2. Before cutting palpate anal sphincter with thumb and avoid cutting
3. Estimate the length of incision before cutting and cut straight down midline once to that point-repeated snipping creates a more jagged edge
4. Length of cut will double vaginal opening
5. After cutting, support tissue with gauze and pressure to minimize extending-if bleeding is marked apply pressure to incision with gauze
6. If perineum is too tight to fit fingers and scissors in try pushing the wrinkle n fetal scalp up out of way and slide blunt blade down along inside of perineum a short way
7. If she pushes after one cut and still makes no progress, extend the cut straight down by ½ inch
8. Be careful to not catch a vaginal fold into incision, causing a hole in the rectal wall-inspect before repair to insure posterior wall is intact

Question 14

advantages of episiotomy

Answer 14

A. Shortens seconds stage for the baby with fetal distress or for the exhausted mother
B. Provides room for emergency procedures
C. Decreases the incidence of labial and urethral lacerations
D. Easier to repair than a tear (so this only benefits the provider, not the mom)

Question 15

disadvantages of episiotomy

Answer 15

A. Increased incidence of 3rd and 4th degree perineal lacerations
B. Increased pain immediately and 3 months postpartum
C. Pelvic floor strength is weakest among women with episiotomies when compared to women with an intact perineum or a spontaneous tear