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Episiotomy

EPISIOTOMY: An Episiotomy is a surgical incision of the perennial body. The perineum is evaluated prior to the time of delivery to determine whether or not an Episiotomy is indicated. The perineum is evaluated for its length, thickness and distensibility. A short perineum may indicate performing a mediolateral Episiotomy rather than a median Episiotomy, in order to avoid injury to the rectal sphincter and valve Indications: Any conditions that places the woman at risk for perineal tearing: 1) Large size baby: A baby estimated to be 4000gms or more may cause need for an Episiotomy either to prevent laceration or in anticipation of a possible shoulder dystocia. 2) Pre-term or small for gestational age (SGA) baby in order to minimize the risk of intra cranial hemorrhage. 3) An uncontrolled woman who is unable to respond to instructions as to when to push and when to breathe, inorder to slowly ease the head out. 4) Anticipation of shoulder dystocia. 5) Fetal malpresentations and malpositions. In these situatuations, the widest diameter of the fetal head coming through the pelvic outlet and vaginal orifice is larger than usual. 6) A thick perineum, which is rigid and resistant to distention. 7) An inevevitable laceration evidenced by narrow white lines resembling stretch marks and visible just beneath the skin. These appear just prior to laceration and probably represent beginning of tearing of the underlying tissues. A quick Episiotomy prior to the moment of crowning is indicated to avoid an inevitable tear. 8) Prior to an assisted delivery such as forceps or vaccum extraction. 9) To speed up delivery if there is fetal distress Types of Episiotomy: The type of Episiotomy is designated by the site and direction of the incision. There are two main types of Episiotomies: 1) Midline or median 2) Mediolateral, which may be to the right or left 3) Lateral and J shaped Episiotomies (both are not done currently due to several drawbacks) Midline or median: Midline (median) Episiotomy is most commonly used in United States. Midline Episiotomy is cut into the central tendinous point of the perineum. It follows the natural line of insertion of the tetineal muscle. Advantages: 1) Easily repaired. 2) Generally less painful. 3) Minimal blood loss. Disadvantages: 1) Higher incidence of damage to the anal sphincter. Mediolateral Episiotomy:

Mediolateral Episiotomy is used in operative births when the need for posterior extension is likely. Mediolateral Episiotomy is cut at a slant, starting at the midpoint of the posterior forchette and is directed at 45 degrees angle towards a point midway between the ischial tuberosity and the anus. The cut maybe to either the left or right and about 2.5cms. Advantages: 1) Extension into the rectum is less likely. 2) Avoids danger of damage to anal sphincter and bartholin glands. Disadvantages: 1) Blood loss is greater. 2) Repair is more difficult. 3) During healing the area is more painful 4) Possible damage to tubococcygeal muscle. Principles: The following principles should be observedregardless of which type of Episiotomy is cut: 1) The presenting part of the Fetus is protected from injury. 2) A single cut in any direction is far preferable to repeated snipping beacause the latter will leave jagged ends. 3) The Episiotomy should be large enough to meet the purpose for deciding to cut it. 4) The timing of the cut should be such that lacerations are prevented (too late) and unnecessary blood loss avoided (too early). The perineum should be bulging, the vaginal orifice distended by approximately a 3cm diameter of presenting part between contractions, and delivery of the presenting part should be expected to occur within the next two to four contractions. CONDUCTING THE DELIVERY: Management of the delivery includes the hand maneuveres used to assist the babys birth, the immediate care of the new born and the following management decisions: 1) Delivery of the babys head: In preperation for the delivery of the baby, the mothers perineum needs to be swabbed, the delivery area draped with sterile linen and a pad used to cover the anus. Delivery of the head between contractions: The idea behind delivering the babys head between contractions is that the combinationof the contractions and the maternal pushing effort actually constitutes exertion of a double force at the moment of birth. This makes the birth of the head more rapid and the relase of restraining pressure more abrupt both of which increase the risk of intracranial damage to the baby and laceration to the woman. If the woman is in control of herself it is possible for her to follow the midwifes instructions and then gently push in between contractions, an action that will ease the babys head out with the least amount of trauma to the baby and the woman. Ritgens maneuver: The midwife or obstetrician controls the delivery of the head by this technique. It is performed as follows: 1) Place the pads of your fingertips on the portion of the vertex showing at the vaginal introitus. As more of the head is accessible at the vaginal introitus, spread your fingers over the vertex of the babys head with the finger tips

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pointing towards the as yet unseen face and your elbow pointing upward towards the mother. Allow the head to gradually extend beneath your hand by exerting control, but not prohibitive, pressure with your hands. Use the length of your fingers in doing this and not just the finger tips. Proper control of the head in this manner will prevent excessive crowning and preserve the perineum. An additional maneuver of supporting the perineum may also be used. For this, cover the hand not being used on the babies head with a towel. Place the thumb in the crease of the groin midway on one side of the perineum. Place the middle finger in the crease of the groin midway on the other side of the perineum. Apply pressure with the thumb and the finger downward and then inward towards each other across the perineal body. While doing this combination of head control and perineal support, observe the perineum in the space between the thumb and the middle finger. As the perineum distends, the decision is made as to whether an Episiotomy is required. Infiltrate the perineum, cut a mediolateral episiotomy and secure hemostasis if required. Watch the perineum, while the head born by extension. As soon as the head is born, (during the resting phase before the next contraction) Place the finger tip of one hand