:Definition

It is an incision of the pudenda or perineum.

It is also called perineotomy.
Types:
Median (Midline) Episiotomy: Midline incision
Of the perineum.
Mediolateral Episiotomy: Begins in the midline
but is directed laterally away from the rectum.

Types of Episiotomy
I - Median Episiotomy
Easy to repair
Rare faulty healing
Less pain in the perineum
Dyspareunia is rare
Less blood loss
Extension to the anal sphincter and
rectum
is more common

Types of Episiotomy
II - Mediolateral Episiotomy
More difficult to repair
Faulty healing is more common
More pain in the perineum
Dyspareunia is more common
More blood loss
Extension to the anal sphincter and
rectum
is less common

Timing of Episiotomy:
Best time to perform episiotomy is when
the head is visible during a contraction to
a diameter of 3 to 4 cm.
Before the application of forceps or
vacuum extractor.
Too early episiotomy causes bleeding
from the gaping to be considerable.
Too late episiotomy causes the muscles
of the perineal floor to undergo
excessive stretching and lacerations will
not be prevented.

Advantages of episiotomy:
Clean cut incision which is easy to repair
compared to irregular vaginal lacerations
Shorter second stage of labour
Increase in the diameters of Vulval outlet
Reduce
fetal
complications
e.g.
intracranial haemorrhage in preterm fetus.
Reduce maternal complications e.g.
damage to pelvic floor predisposing to
vaginal prolapse, and stress incontinence.

Indications of Episiotomy:
A) Maternal:
Short rigid perineum
Previous perineal or pelvic floor repair
Contracted pelvic outlet
B) Fetal:
Face to pubis delivery
Vaginal breech delivery
Shoulder dystocia
Oversized fetus
Forceps or ventouse delivery

Complications of Episiotomy

Increased blood loss.

Extension to anal sphincter or ischio-rectal

fossa

Haematoma formation.

Infection.

Perineal pain and dyspareunia

Technique:

A vertical incision is made in the perineal

body avoiding the fetal presenting part.

The incision should be approximately

half the length of the perineal body.

Mediolateral incisions should be made at

a 45 degree angle to the midline of the
perineum. The incision should extend
into the vagina approximately 2 to 3 cm.

Repair of Episiotomy:
There are many ways to close an Episiotomy
but the most common procedure is:
Vaginal mucosa and submucosa are closed by
chromic catgut up to and approximating the cut
ends of the hymeneal ring.
Interrupted chromic catgut sutures are used to
approximate the muscles and fascia.
Closure of the superficial fascia by continuous
suture.
Closure of the skin by interrupted simple or
mattress
sutures
or
alternatively
by
subcuticular continuous stitches.

THE ELDERLY PRIMIGRAVIDA

This term is applied to the primigravida whose age is
above 35 years.
During pregnancy and labor these women are more
liable to the following:
Pregnancy induced hypertension with its
complications especially accidental hemorrhage.
Uterine inertia, premature rupture of membranes and
prolonged labor.
Rigid perineum and so low forceps may be needed
more frequently.
The fetus is usually very precious and the rate of
cesarean section is increased for fetal safety.

THE GRAND MULTIPARA

This term is applied to the women who had 5 or more
. previous deliveries
During pregnancy and labor they are more liable to the
:following
Anemia.
Pregnancy induced hypertension with its complications.
Placenta previa.
Diabetes with pregnancy.
Pendulous abdomen with malpresentations.
Uterine inertia, prolonged labor, premature rupture of
membranes and prolapsed cord.

Obstructed labor and rupture uterus due to:

Malpresentations and large sized fetus.
Some osteomalacic changes in the bony
pelvis.
Pendulous abdomen.
Weak uterine muscles.
False sense of security.
Increased incidence of operative delivery
(forceps-C.S).
Post partum hemorrhage, puerperal sepsis
and sub involution.
Higher perinatal mortality.

BLOOD TRANSFUSION IN OBSTETRICS

INDICATIONS
Hemorrhage: during pregnancy or postpartum.
Severe anemia (given very slowly to avoid
overloading the circulation or better give packed RBCs).
Puerperal sepsis and septic abortion: better fresh blood.
Babies with erythroblastosis fetalis.
Exchange transfusion after birth.
Intrauterine transfusion in selected cases.
Hypofibrinogenaemia (DIC)

Complications of blood transfusion

Major anaphylactic reactions
due to incompatibility leading to dyspnea,
cyanosis, rigors, lumbar pain and anuria.
Febrile reactions due to presence of pyrogens as
blood or apparatus. Stop transfusion and give
antipyretics and antihistaminics.
Air embolism.
Circulatory overloading especially in cases of anemia.
Transmission of diseases: AIDS and infective hepatitis.

Precautions
Cross matching
.Rate of transfusion = rate of blood loss
.Blood should not be very cold
.For every 1-liter blood give 10 cc calcium gluconate
.Constant observation
.Monitoring CVP during transfusion in risky cases

MATERNAL MORTALITY
Maternal mortality rate (MMR), is significantly increased in
developing countries, mostly due to inadequate health
services, low socioeconomic standards, lack of health
hygiene and education, and lastly deeply routed
inappropriate health habits.
Incidence: MMR in Egypt is 82/ 100000 deliveries

: Causes of Maternal mortality

Post partum Hemorrhage (PPH): 34%
Pregnancy induced hypertension (PIH): 22%
Antepartum haemorrhage (APH): 9.0%
.Infection: post-partum and post-abortive: 8.0%
Rupture of the uterus: 8.0%
C.S. complications: 7.0%
.Pulmonary embolism and DIC
Medical problems as heart disease with
.pregnancy
.Complications of anaesthesia

CAUSES OF FETAL / NEONATAL

MORTALITY
ANTENATAL INTRAUTERINE FETAL DEATH
Hypertensive disorders of pregnancy
(due to placental insufficiency or separation)
Diabetes with pregnancy.
Rh incompatibility.
Placental insufficiency due to any cause as accidental hemorrhage,
multiple infarctions or abnormally small placenta.
Congenital anomalies of the fetus.
Knots of the cord.
Idiopathic.

II. INTRANATAL DEATH

Asphyxia.
Intracranial hemorrhage.
Intra-amniotic infection.
Birth trauma.

III. NEONATAL DEATH

It is infant death in the first month after delivery
The highest neonatal mortality occurs during the first
week after delivery and is due to:
Prematurity.
Asphyxia neonatorum.
Birth injuries.
Congenital anomalies.
Hemolytic and hemorrhagic diseases of the newly born.
Respiratory distress syndrome.
After the first week: death is mainly due to infection.
N.B: Perinatal mortality: includes antenatal and intranatal
death and death during the first week after delivery