Episiotomy is a surgical cut made in the perineum. This procedure is performed to enlarge the vaginal opening just before childbirth is complete.

Indications for Episiotomy:

To expedite delivery in certain situations:
a. Pre-eclampsia and eclampsia: In these conditions of pregnancy-induced hypertension, a faster delivery can be beneficial for both mother and baby.
b. Cardiac conditions in the mother: To lessen maternal exertion during the pushing stage of labor, reducing strain on the heart.
c. Maternal distress: When the mother is showing signs of exhaustion or other complications, speeding up delivery can reduce her overall stress.
d. Fetal distress: If the baby is in danger during labor, a quick delivery is crucial to prevent potential harm or fetal demise.
e. Umbilical cord prolapse in the second stage of labor (with a live fetus): To swiftly deliver the baby when the umbilical cord descends before the baby, compromising oxygen supply.

To minimize excessive tearing of tissues in specific deliveries:
a. Perineal rigidity: When the perineal tissues are unusually stiff and resistant to stretching, increasing the likelihood of tearing.
b. Forceps-assisted delivery: To provide more space and reduce trauma during operative vaginal deliveries using forceps.
c. Face to pubis presentation: In cases where the baby’s face is facing the pubic bone, episiotomy may be used to ease delivery and prevent severe tearing.

To lessen the possibility of intracranial hemorrhage in certain infant scenarios:
a. Preterm births: In deliveries of premature babies, to reduce pressure on the delicate fetal head during delivery.
b. Post-term pregnancies: With post-mature babies, the head may be less pliable, and episiotomy can help prevent injury.
c. After the baby’s head is born in breech deliveries: To provide more room for the body to follow, particularly the head in a breech birth.
d. Narrow subpubic arch: If the bony arch under the pubic bone is narrow, limiting space for the baby to pass.
e. History of previous third-degree perineal lacerations: To potentially avoid recurrence of severe perineal tears in subsequent deliveries.

Types of Episiotomy

1. Lateral Incision:
   This type of cut is made sideways, across the labia majora. It’s recognized as technically challenging to repair adequately.
   Disadvantages:

• Higher chance of significant blood loss.

• Potential for injury to the Bartholin’s glands, which are involved in vaginal lubrication.

• Can be more uncomfortable for the woman postpartum.

• Generally slower wound healing compared to other types.

1. Medial Lateral:
   This is the most frequently used and generally preferred approach, especially for midwives.
   The cut begins at the vaginal fourchette and extends diagonally outward and downward across the perineum, typically for a length of 2 to 3 centimeters.
   Advantages:

• Typically heals well with good approximation of tissues.

• Relatively straightforward for midwives to perform and repair effectively.

• Reduces the likelihood of damage to major blood vessels.

• Decreases the chance of extensive perineal tearing during childbirth.

• Can shorten the pushing stage of labor.

• Helps to prevent injuries to both the Bartholin’s glands and the anal sphincter muscle complex.

1. Medial or Central or Midline:
   This incision starts directly at the center of the fourchette and proceeds straight back toward the anus, along the midline of the perineum.
   Advantages:

• Generally less bleeding compared to other types.

• Often reported to be more comfortable for the mother in the postpartum period.

• Technically simpler to perform and easier to repair.
  Disadvantages:

• Increased risk of the incision extending into or through the anal sphincter muscles.

• If repair is not done meticulously, it could potentially lead to a rectovaginal fistula (RVF), an abnormal connection between the rectum and vagina.

1. J-shaped:
   This type is usually performed by a physician. It begins at the center of the fourchette, and then curves away from the anal sphincter at a distance of about 2.5 centimeters to avoid anal sphincter injury.

2. Bilateral:
   Similar to the lateral incision, but performed on both sides of the perineum.
   It originates at the fourchette and extends outwards laterally on both sides.
   Note: Bilateral episiotomy is generally not recommended due to the increased possibility of damage to the Bartholin’s glands on both sides.

Precautions during episiotomy:

1. Timing: It’s essential to avoid performing the episiotomy either too early when the perineum is not sufficiently stretched or too late when uncontrolled tearing may have already occurred.

2. Presentation: In a cephalic (head-first) presentation, the baby’s head should be visibly distending the perineum. In a breech presentation, the anterior shoulder should be causing perineal distention before the incision is considered.

3. Contraction Height: The ideal time to perform the episiotomy is during a uterine contraction. This helps to make the tissues firmer and allows for a cleaner, more controlled incision.

Basic Principles Before Perineal Repair:

1. Prompt Repair: Repair of the episiotomy should be undertaken as soon as possible after delivery to minimize blood loss and reduce the development of swelling in the perineal tissues.

2. Aseptic Conditions: Strictly maintain aseptic technique throughout the repair process to minimize the risk of wound infection.

3. Equipment Verification: Ensure all necessary instruments and suture materials are readily available and in sterile condition. Conduct swab and needle counts before and after the procedure to prevent retained foreign bodies.

4. Adequate Anesthesia: Confirm that the episiotomy site is properly and effectively anesthetized prior to commencing repair to ensure patient comfort and minimize pain.

Basic Principles After Repair:

1. Achieve Hemostasis: Ensure complete control of bleeding from the episiotomy site to prevent hematoma formation and further blood loss.

2. Post-repair Assessment: Conduct both rectal and vaginal examinations after repair to verify the integrity of the repair, confirm that no other tears were missed, and importantly, to ensure that the rectal mucosa has not been inadvertently stitched.

3. Swab Removal Check: Double-check to ensure that all swabs or packs used during the repair process have been completely removed.

4. Comprehensive Documentation: Document all findings and the details of the repair procedure meticulously for accurate medical records and continuity of care.

5. Post-repair Instructions: Educate the woman on appropriate pain management options, emphasize the importance of perineal hygiene, advise on maintaining a healthy diet, and instruct on performing pelvic floor exercises to promote healing and recovery.

Method of Local Infiltration and Surgical Technique:

Required Materials:
A sterile episiotomy pack should contain:

• Sterile episiotomy scissors.

• Suture needle and absorbable suture material (cut gut or synthetic).

• Needle holder for manipulating the needle.

• Sterile gauze pads and cotton swabs for cleaning and hemostasis.

• Sterile surgical gloves.

• Syringe for anesthetic administration.

• Local anesthetic solution (Lignocaine).

• Antiseptic solution for skin preparation (e.g., Hibicet or Chlorhexidine).

Method of Local Anesthetic Infiltration:

1. Maintain a completely sterile environment throughout the procedure.

2. Explain the procedure to the woman to ensure she is informed and understands what is happening.

3. Prepare the local anesthetic by drawing up the required amount of lignocaine (typically 10mls of 0.5% or 5-7mls of 1%).

4. Cleanse the vulva and perineum with an antiseptic solution to reduce bacterial load.

5. During a uterine contraction, when the baby’s head or presenting part is distending the vulva, place two fingers of the non-dominant hand inside the vagina between the fetal head and the perineum. This is to protect the fetal scalp from accidental injection of local anesthetic.

6. Insert the needle into the perineal tissue at the intended site of incision. Before injecting, gently pull back on the syringe plunger to check for blood aspiration. If blood is aspirated, it indicates needle placement in a blood vessel; reposition the needle and re-aspirate until no blood is drawn back.

7. Inject the local anesthetic slowly and evenly into the perineal tissues, creating a field block.

Performing the Episiotomy:

1. With two fingers still positioned vaginally to protect the fetal head, position the episiotomy scissors at the intended incision site at the peak of a uterine contraction.

2. Make a single, decisive, and clean cut approximately 3cm in length. For a mediolateral episiotomy, direct the cut diagonally outwards and downwards.

3. Immediately after the incision, apply direct pressure to the area with a sterile gauze swab to control any bleeding.

Episiotomy Repair Technique:

Preparation Prior to Repair:

1. Ensure Patient Comfort and Position:

   • Position the woman comfortably, usually in the lithotomy position.

   • Remove any soiled linen or drapes from beneath the perineal area.

   • Adjust the examination light to provide optimal visualization of the vagina and perineum.

2. Communication and Reassurance:

   • Communicate with the woman throughout the repair process.

   • Explain each step of the procedure to alleviate anxiety and ensure cooperation.

   • Provide reassurance and emotional support.

3. Prepare Sterile Field:

   • Don fresh, sterile surgical gloves.

4. Assess Anesthesia Effectiveness:

   • Check if the local anesthesia administered earlier is still providing adequate pain relief.

   • If the woman reports feeling pain, administer additional local anesthetic before starting the repair.

5. Clean the Area:

   • Remove any blood clots, meconium, or debris from the birth canal to ensure a clean repair site.

6. Identify the Extent of the Tear and Apex:

   • Carefully assess the extent and depth of the episiotomy and any associated vaginal tears.

   • Locate the apex (uppermost point) of the episiotomy, which is the starting point for repair.

7. Insert Vaginal Pack (Optional):

   • Insert a rolled vaginal pack into the vagina to absorb blood and improve visualization. Secure the end of the pack externally with artery forceps to prevent it from being lost inside.

8. Initiate Suturing at the Apex:

   • Begin suturing the episiotomy repair from the apex of the vaginal mucosa incision.

9. Repair Vaginal Mucosa:

   • Using a continuous suture technique with absorbable suture material, suture the vaginal mucosa.

   • Pass the needle through the vaginal mucosa from the inside and bring it out onto the perineal wound edge.

10. Close Deep Muscle Layer:

    • Continue the continuous suturing technique downwards to close the deeper muscle layers of the perineum. The same continuous method can be extended to close the subcutaneous tissue layer.

11. Skin Closure:

    • The skin can be closed using either interrupted sutures or the same continuous subcuticular suture technique.

12. Remove Vaginal Pack and Assess Closure:

    • Carefully remove the vaginal pack by gently pulling on the artery forceps.

    • Inspect the vagina for any residual bleeding or hematoma.

    • Perform a digital rectal examination by inserting a finger into the rectum to confirm that the rectal mucosa has not been inadvertently sutured and to assess the integrity of the anal sphincter if a midline episiotomy was performed.

13. Clean and Dress the Perineum:

    • Gently clean the perineal area with antiseptic solution or sterile water after completing the repair.

    • Apply a sterile perineal pad for the woman’s comfort and to absorb any minimal post-repair bleeding.

14. Provide Post-repair Instructions:

    • Advise the woman on proper perineal care, including hygiene practices (washing the area gently after voiding or defecating, and patting dry), pain management, and signs of infection to watch for.

    • Give instructions on when to seek medical attention for any concerns.

15. Dispose of Materials:

    • Dispose of all used materials, needles, and sharps properly in appropriate containers, following standard infection control protocols.

Note: The usual healing duration for an episiotomy is approximately 4 to 6 weeks. This timeline can vary depending on the size and type of the incision, as well as the suture material used for closure.