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8/4/2019 Episiotomy and Repair
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EPISIOTOMY AND
REPAIR
8/4/2019 Episiotomy and Repair
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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.
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Episiotomy
It substitutes a straight, neat surgical incision forthe ragged laceration that otherwise frequentlyresult 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 andurinary incontinence. However to have thisbenefit, the perineal incision should not be doneat the time of maximal distention.
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8/4/2019 Episiotomy and Repair
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Lacerations of the Birth Canal
Third degreeLacerations
Extend through the
skin, mucousmembrane, perinealbody and involve theanal sphincter. Mayalso extend a distanceup to the anterior wallof the rectum.
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Lacerations of the Birth Canal
4th degree lacerations
Third degree tears thatextend through the
rectal mucosa toexpose the lumen ofthe rectum
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Important questions concerning
episiotomy
How long before delivery should it beperformed ?
Should a median or mediolateral incisionbe made ?
Should the incision be sutured before orafter expulsion of the placenta?
What are the best suture materials andtechnique to employ ?
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Timing of Episiotomy
If performed unnecessarily early, bleedingfrom the gaping wound may beconsiderable during the interim between
the incision and the birth of the baby.
If performed too late, the muscles of theperineal floor already will have undergone
excessive stretching, and one of theobjectives of the operation is defeated.
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Timing of Episiotomy
It is common practiceto perform episiotomywhen the head is
visible during acontraction to adiameter of 3-4 cm
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Midline versus Mediolateral
Easy to repair
Faulty healing rare
Less painful in
puerperium Dyspareunia rarely
follows
Anatomical end
results almost alwaysexcellent
More difficult to repair
Faulty hearing morecommon
Pain in one third ofcases for a few days
Dyspareuniaoccasionally follows
Anatomical endresults more or lessfaulty in 10% of cases
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Midline versus Mediolateral
Blood loss less
Extension through theanal sphincter and
into the rectum israther common
Blood loss greater
Extension through thesphincter is
uncommon
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Timing of the repair of Episiotomy
The most common practice is to defer repair ofthe episiotomy until after the placenta has beendelivered
for us to give undivided attention to the signs ofplacental separation and to deliver the organ just assoon as it has separated.Early delivery of theplacenta is believed to decrease the loss of bloodfrom the implantation site, since it prevents thedevelopment of extensive retroplacental bleeding
Episiotomy repair is not interrupted or disrupted bythe obvious necessity of delivering the placenta.
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Technique
There are many ways to close theepisiotomy incision, but hemostasis andanatomical restoration without excessive
suturing are essential for success of anymethod
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Repair of Median Episiotomy
Chronic catgut 00 orpreferably 000, isused as a continuous
suture to close thevaginal mucosa andsubmucosa
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Repair of Median Episiotomy
After closing the vaginalincision andreapproximating the cutmargins of the hymenal
ring, the suture is tied andcut.
Next 3 or 4 interruptedsutures of 00 or 000
catgut are placed in thefascia and muscle of theincised perineum.
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Repair of Median Episiotomy
A continuous suture isnow carrieddownward to unite the
superficial fascia.
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Repair of Median Episiotomy
Completion of repair.The continuoussuture is carried
upward as asubcuticular stitch.
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Repair of Median Episiotomy
Completion of repair ofmedian episiotomy. A fewinterrupted sutures of 000chromic catgut are placed
through the skin andsubcutaneous fascia andloosely tied.
This closure avoids
burying 2 layers of catgutin the more superficiallayers of the perineum.
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Pain Relief After Episiotomy
For the relief of episiotomy pain, a heat lamphas been a standard remedy.But during thesummer months, it may produce morediscomfort rather than remedy.
An ice collar applied early tends to reduceswelling and allay discomfort.
Analgesic can give considerable relief. Since pain may be a signal of a large vulvar,
paravaginal or ischiorectal hematoma orperineal cellulitis, it is essential to examine thesesites carefully if pain is severe or persistent.