undergraduate course lectures in obstetrics and gynecology prepared by Dr Manal Behery Professor OB&GYNE Faculty of medicine,Zagazig University

1. DR Manal Behery
Professor Ob&Gyne
Zagazig University 2014

2. DefinitionDefinition
Intrapartum incision of perineum also called
perinotomy
Types
Median (midline):midline incision of
perineum
Mediolateral :begins in midline but directed
laterally .

3. Types of episotomyTypes of episotomy

4. IndicationsIndications
– Use for maternal or fetal indications
1-Reduce second stage of labor
2-Avoiding severe maternal lacerations
3-Allow slow controlled dilation and delivery
4-With instrumental delivery to reduce trauma to
pelvic floor

5. Does every case needs episotomy?Does every case needs episotomy?
ACOG Do not support routine or “liberal”
use
– Gradual decrease in use in 1980

6. Rapidly do episiotomy inRapidly do episiotomy in
– 1-Non reassuring CTG
– 2-Shoulder dystocia
– 3-Operative vaginal delivery
– 4- Breech Delivery

7. Episotomy for shoulderEpisotomy for shoulder
dystociadystocia

8. Before forceps applicationBefore forceps application

9. Delivery of aftercoming headDelivery of aftercoming head
in breechin breech

10. At what time in labor youAt what time in labor you
should do an episotomy ?should do an episotomy ?

11. Just at Crowning:Just at Crowning:

12. Before Crowning AfterBefore Crowning After
12

13. What type of anesthesia???What type of anesthesia???

14. Local infiltration anathesiaLocal infiltration anathesia

15. Pudendal nerve blockPudendal nerve block
.
.

16. Give plenty of anesthesiaGive plenty of anesthesia
Even patients with epidurals can benefit fromEven patients with epidurals can benefit from
local injection due to varying levels oflocal injection due to varying levels of
anesthesiaanesthesia

17. Muscle cutted in episiotomyMuscle cutted in episiotomy

19. Vaginal RepairsVaginal Repairs
Goal is to return all structures to normal
anatomy
Use the hymen remnant as key landmark
Suture used
– 2-0 Vicryl or monocryl common
– 2-0 chromic maybe used but some
patients can have reactions

21. Episiotomy RepairEpisiotomy Repair

22. Episiotomy RepairEpisiotomy Repair

24. Problems arising from EpisiotomyProblems arising from Episiotomy
24
Pain
Edema
Bleeding
Infection
Defects in wound

25. Extension TearsExtension Tears
Generally
•1st
and 2nd
degree tears are
simple to repair
•If you haven’t done many
3rd
and 4th
degree tears call
for help Gyn or Colorectal

26. Anal sphincter or rectal injuryAnal sphincter or rectal injury

28. Extension tear during episotomyExtension tear during episotomy

29. Extension tear during episotomyExtension tear during episotomy

31. Complete perineal tear

33. Pain after EpisiotomyPain after Episiotomy
Topical lidocaine not effective
.1- Ice packs
2. Pressure dressings
3. Appropriate analgesia

34. Pain out of proportion can be sign of vulvar,Pain out of proportion can be sign of vulvar,
paravaginal, ischiorectal hematoma orparavaginal, ischiorectal hematoma or
cellulitiscellulitis
– Examine patient if stable non expandinghematoma
can monitor

35. Need for surgical interventionsNeed for surgical interventionsNeed for surgical interventionsNeed for surgical interventions
1. Haematomas >5cm in diameter1. Haematomas >5cm in diameter
2. Rapidly expanding2. Rapidly expanding
Infra-levetor hematoma