Episiotomy

• Review for indications.

• Review general care principles  and apply antiseptic solution to the perineal area.

• Provide emotional support and encouragement. Use local infiltration with lignocaine or a pudendal block.

• Make sure there are no known allergies to lignocaine or related drugs.

• Infiltrate beneath the vaginal mucosa, beneath the skin of the perineum and deeply into the perineal muscle (Fig P-39) using about 10 mL 0.5% lignocaine solution.

Note: Aspirate (pull back on the plunger) to be sure that no vessel has been penetrated. If blood is returned in the syringe with aspiration, remove the needle. Recheck the position carefully and try again. Never inject if blood is aspirated. The woman can suffer seizures and death if IV injection of lignocaine occurs.

• At the conclusion of the set of injections, wait 2 minutes and then pinch the incision site with forceps. If the woman feels the pinch, wait 2 more minutes and then retest.

Anaesthetize early to provide sufficient time for effect. 

Figure P-39

Infiltration of perineal tissue with local anaesthetic

• Wait to perform episiotomy until:

- the perineum is thinned out; and

- 3-4 cm of the baby’s head is visible during a contraction. 

Performing an episiotomy will cause bleeding. It should not, therefore, be done too early. 

• Wearing high-level disinfected gloves, place two fingers between the baby’s head and the perineum.

• Use scissors to cut the perineum about 3-4 cm in the mediolateral direction (Fig P-40). 

• Use scissors to cut 2-3 cm up the middle of the posterior vagina.

• Control the baby’s head and shoulders as they deliver, ensuring that the shoulders have rotated to the midline to prevent an extension of the episiotomy.

• Carefully examine for extensions and other tears and repair (see below).

Figure P-40

 Making the incision while inserting two fingers to protect the baby’s head

REPAIR OF EPISIOTOMY

• Apply antiseptic solution to the area around the episiotomy.

• If the episiotomy is extended through the anal sphincter or rectal mucosa, manage as third or fourth degree tears, respectively.

• Close the vaginal mucosa using continuous 2-0 suture (Fig P-41 A):

- Start the repair about 1 cm above the apex (top) of the episiotomy. Continue the suture to the level of the vaginal opening;

- At the opening of the vagina, bring together the cut edges of the vaginal opening;

- Bring the needle under the vaginal opening and out through the incision and tie.

• Close the perineal muscle using interrupted 2-0 sutures (Fig P-41 B).

• Close the skin using interrupted (or subcuticular) 2-0 sutures (Fig P-41 C).

Figure P-41

Repair of episiotomy 

COMPLICATIONS

• If a haematoma occurs, open and drain. If there are no signs of infection and bleeding has stopped, reclose the episiotomy.

• If there are signs of infection, open and drain the wound. Remove infected sutures and debride the wound:

- If the infection is mild, antibiotics are not required;

- If the infection is severe but does not involve deep tissues, give a combination of antibiotics:

- ampicillin 500 mg by mouth four times per day for 5 days;

- PLUS metronidazole 400 mg by mouth three times per day for 5 days.

- If the infection is deep, involves muscles and is causing necrosis (necrotizing fasciitis), give a combination of antibiotics until necrotic tissue has been removed and the woman is fever-free for 48 hours:

- penicillin G 2 million units IV every 6 hours;

- PLUS gentamicin 5 mg/kg body weight IV every 24 hours; 

- PLUS metronidazole 500 mg IV every 8 hours;

- Once the woman is fever-free for 48 hours, give:

- ampicillin 500 mg by mouth four times per day for 5 days;

- PLUS metronidazole 400 mg by mouth three times per day for 5 days;

Note: Necrotizing fasciitis requires wide surgical debridement. Perform secondary closure in 2-4 weeks (depending on resolution of the infection).

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