Definition
Episiotomy is a surgically planned incision on the perineum and posterior vaginal wall performed during the second stage of labor to facilitate delivery.
Purposes
- To substitute a straight surgical incision for the laceration that may otherwise occur.
- To facilitate repair of incised area and promote healing.
- To spare the newborn’s head from prolonged pressure and to avoid pushing against rigid perineum.
- To shorten the second stage of labor.
- To speed delivery if there is fetal distress.
- Prior to an assisted delivery, such as forceps or Ventouse extraction.
- To minimize the risk of intracranial damage during preterm and breech delivery.
- To prevent overstretching of the perineal muscles.
Types of episiotomies
- Median or midline: Incision is made in the middle of the perineum and directed toward the anus.
- Mediolateral: Incision begins at the midline and is directed laterally.
Indications
- Inelastic rigid perineum.
- Primigravida.
- Anticipated perineal tear.
- Operative delivery.
- Previous perineal surgery.
Articles
A sterile tray containing:
- Sterile syringe with needle.
- Needle holder-1.
- Episiotomy scissors-1.
- Suture cutting scissors-1.
- Cutting needle–1 for skin.
Round body needle–1 for muscles. - Thumb forceps.
- Suture material-2-0 chromic catgut-1.
- Kidney tray.
- Plain lignocaine 2%.
- Antiseptic solution.
- Sterile gloves.
- 4×4 gauze pieces.
- Tampons.
Procedure
| Nursing Action | Rationale | |
| 1. | Place the patient on the delivery table in dorsal recumbent position when the fetal head is distending the perineum. | Gives clear visualization. |
| 2. | Infiltrate the perineum using 10 mL of local anesthetic. Wait for 3-5 minutes for the anesthetic to act. | Minimizes pain during incision. |
| 3. | Place your index and middle fingers in the vagina with palmar side down and facing you. Separate them slightly and exert outward pressure on the perineal body. | Provides protection to the presenting part in two ways: The fingers are against the presenting part and are thick enough so that the scissors, if properly placed, will not hurt the baby. The outward pressure directs the perineal body away from the baby The pressure also flattens the perineal body a bit more, making it easier to incise using a single cut. |
| 4. | Place the blades of the scissors in a straight up and down position, so that one blade is against the posterior vaginal wall and the other blade is against the skin of the perineal body with the point where the blades cross at the middle of the posterior fourchette. | |
| 5. | Adjust the length of the blades of the scissors on the perineal body and predict the length of the incision accordingly. | The length of the incision should be adequate to deliver the fetal head. |
| 6. | A mediolateral episiotomy of 4-5 cm long is cut at a slant, starting at the midline of the fourchette with the points of the scissors directed toward the ischial tuberosity on the same side as the incision. | Obtains a clean cut to deliver the fetal head without undue pressure or damage to maternal soft structures. |
| A midline episiotomy is cut in the middle of the central tendinous points of the perineum from the posterior fourchette down to the external anal sphincter. (the ideal timing of episiotomy is a bulging thin perineum at the peak of a contraction just prior to crowning). | Timing of the cut helps provide clear view of the area and reduces possibility of severe bleeding. | |
| 7. | If a midline episiotomy was cut, palpate for the external anal sphincter. | Avoids injury to external anal sphincter. |
| 8. | Cut again if needed, avoid snipping. Two cuts should accomplish the incision. | |
| 9. | Extend the vaginal side of the incision if needed by incising the vaginal band. For this, the scissors must come from above the backside of the hand to slide down the fingers and make the cut. | Protects the fetal presenting part. |
| 10. | Apply pressure with 4″ ×4″ sponges. | Controls any slight bleeding present. |
| 11. | After completion of delivery assist for suturing of episiotomy incision. | |
| 12. | Wipe the wound area with sterile antiseptic cotton swabs. | Prevents spread of microorganisms. |
| 13. | Focus light on the perineal area. | Gives clear visualization of the perineum. |
| 14. | Diagnose the degree of perineal tear, if any. | |
| 15. | Pack the vagina with vaginal plug or tampon. | Continuous bleeding may obscure the place of suturing. |
| 16. | Visualize the apex of the mucosa, start suturing little above the apex. Appose the vaginal tear by continuous suture using a round body needle. | |
| 17. | Repair the perineal muscles by interrupted sutures include the deeper tissue to enclose dead space. | Promotes healing. |
| 18. | Perineal skin is apposed by mattress suture. | Reduces discomfort in postpartum period. |
| 19. | Remove the vaginal pack which was inserted during suturing. | Promotes safety and comfort. |
| 20. | Clean the perineum and apply perineal pads. | Promotes comfort and hygiene. |
| 21. | Straighten patient’s legs and assist her to supine position with legs crossed. | Makes the patient comfortable and reduces the chance of bleeding. |
| 22. | Wash and dry the instruments used for episiotomy along with those used for conduct of delivery and suturing. | For further disinfection and safe reuse. |
| 23. | Record in the labor record, the time episiotomy was performed, type of episiotomy, suturing carried out, and patient’s reaction. | Acts as a communication between staff members. |
After care
- Check for any bleeding from inner areas or hematoma formation.
- Check vital signs.
- Check for any other tear or laceration.
Complications
- Hematoma.
- Infection.
- Wound dehiscence.
- Perineal laceration.
- Dyspareunia.
- Scar endometriosis.
Special considerations
- Repair of the skin edges should begin at the fourchette so that vaginal opening is properly aligned.
- A rectal examination is made when suturing is completed in order to ensure that no sutures have penetrated the rectal mucosa to prevent fistula formation.
- The thread should not be pulled too tightly to prevent edema formation.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
- Annamma Jacob, Manual of Midwifery and Gynaecological Nursing, 4th Edition, 2023, Jaypee Publishers, ISBN: 978-9356961593
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