Episiotomies

Question 1

Definition of Episiotomy

Answer 1

Episiotomy is defined as a surgical incision made in the perineum to increase the diameter of the vulval outlet (introitus), to facilitate a vaginal delivery.

Question 2

Indications for episiotomy

Answer 2

Shortens the time for which the perineum is stretched during birth to prevent tear
Fetal malpositioning e.g. occipito-posterior position
Breech delivery, esp. primigravida
Instrument delivery (Forceps or vacuum extractor)
Completion of the second stage of labor*

Question 3

Indications continued

Answer 3

Decreased maternal trauma
Ease of repair
Reduction of the risk of shoulder dystocia*
Previous vaginal repair with dense scar tissue
Fetal distress

Question 4

What does episiotomy prevent in neonates

Answer 4

In neonate it helps to prevent:
asphyxia
cranial trauma
cerebral hemorrhage

Question 5

Fetal maneuvers for shoulder dystocia

Answer 5

Rubins maneuver

Woodscrew maneuver

Question 6

Maternal maneuvers for shoulder dystocia

Answer 6

Mc Roberts maneuver

Suprapubic pressure

Question 7

Types of episiotomies

Answer 7

Midline
Mediolateral
Lateral
J-shaped

Question 8

Maternal factors that increase risk of deep perineal tears

Answer 8

Primiparity
Maternal height <145cm
Fetal birth weight >3500g
Forceps extraction

Question 9

Classifications of episiotomies

Answer 9

1st degree - frenulum, vaginal mucosa and perineal skin
2nd degree - muscle and fascia
3rd degree - anal sphincter
4th degree - rectal mucosa

Question 10

What anesthetic is used

Answer 10

10ml of 1% lignocaine

Question 11

Common and occasional nerve supply to perineum

Answer 11

Via perineal nerve, from pudendal nerve, from sacral nerves S2, S3, S4
Occasionally via cutaneous branch of inferior rectal nerves

Question 12

What are appropriate techniques for anesthesia

Answer 12

Local infiltration
Pudendal nerve block (not if from inferior rectal nerves)
Neuraxial analgesia (eg, epidural or saddle block).

Question 13

How to do manage an episiotomy

Answer 13

Evaluate the degree
Suture needed
Identify apex and suture 1cm proximally
Vaginal mucosa then muscle layer then skin

Question 14

How do you line up the suture for an episiotomy and why

Answer 14

Sutures should be placed perpendicular to the angle of the incision to prevent anatomic distortion of the perineum and vaginal opening

Question 15

Early complications of episiotomies

Answer 15

Vulval/ perineal hematoma
Infection
Recto vaginal fistula
Wound dehiscence

Question 16

Late complications of episiotomies

Answer 16

Dyspareunia

Scar endometriosis

Question 17

Aftercare of episiotomies

Answer 17

Sitz baths
Hygiene 
Keep it dry
Kegel exercises 
Ice before 24hrs postpartum
Warm baths 24hrs post partum