# Episiotomy

## Overview

This module describes how to perform an episiotomy, a perineal incision to widen the vaginal opening to allow passage of the foetus.

## Indications

1. In the second stage of labour where the perineum is tight

   1. To prevent third-degree perineal tears
   2. To shorten the second stage of labour

2. To allow more space for instrumental delivery or breech delivery

## Contraindications

1. Severe deformities of the perineum
   Severe deformities of the perineum

   This may be due to inflammatory bowel disease, lymphogranuloma venereum, or perineal scarring, sometimes seen in patients who have undergone female circumcision. An episiotomy is not indicated in these patients. Call a senior and arrange a caesarean section.

   such as with female genital mutilation

## Patient information and consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“Your baby’s head is almost out, but the opening of your vagina is small and it might tear when your baby’s head passes through. I need to make a small cut in the edge of your vagina to allow your baby to slide out more easily.”

### What can my patient expect?

“I’m going to give you an injection for pain. Then I will make a small cut with scissors while you are bearing down. It shouldn’t hurt. Afterwards I will put in stitches to repair it.”

### What is my patient’s role?

“Tell me if you have any allergies or medical conditions.”

## Preparation

###

### Documentation

1. Patient notes

### Equipment

1. Alcohol-based hand rub

2. Sharps container
   Sharps container

   If a sharps container is not within arm's length, use a kidney dish or other hard container to temporarily hold used sharps and to carry them to the sharps container for disposal.

3. Sterile gloves

4. A 10 ml syringe

5. An aspiration needle (preferably blunt fill) and a small injection needle

6. Lignocaine (1-2% with adrenaline)

7. An alcohol swab

8. Surgical scissors

## Site & Positioning

The patient should ideally be in lithotomy or supine with their knees parted.

## Procedure

Follow medical asepsis with sterile gloves. Due to the nature of delivery, full sterility is often not possible.

1. Perform hand hygiene and don sterile gloves.

2. Draw up a maximum of 10 ml of lignocaine.

3. Inject the lignocaine beneath the skin and vaginal epithelium from the posterior fourchette posteriorly at a 45° angle from the midline.

4. Wait until a contraction occurs and the presenting part is stretching the perineum.

5. Slip two fingers of the non-dominant hand between the perineum and the presenting part.

6. Use the scissors to cut a 3-4 cm incision, starting at the seven o’clock position, and cutting while aiming in a 45° angle from the midline.

7. Deliver the neonate.

8. Dispose of medical waste safely.

9. Record the completion of the procedure in patient notes.

10. After delivery, repair the episiotomy.

## Troubleshooting

There is brisk bleeding from the episiotomy.

Pack some gauze swabs into the wound to control venous bleeding. Arterial bleeders may need to be clamped and tied off later.

I am unsure whether to prescribe antibiotics.

Prophylactic antibiotics are not routinely necessary, but may be indicated in grossly contaminated wounds.

My patient has returned with excessive pain.

Examine the perineum for the presence of a haematoma, infection, or wound dehiscence.

I have heard that midline episiotomies bleed less.

Previously, episiotomies were cut in the midline, which resulted in less bleeding but a higher risk that it might extend into a third degree tear. Mediolateral episiotomies result in more bleeding but a lower risk of third degree tear, and are currently recommended.

## Risks

1. Bleeding & pain

2. Extension into a third degree tear

3. Dyspareunia

4. Sharps injury to healthcare personnel

## References

1. Correa MD, Passini R. Selective Episiotomy: Indications, Technique, and Association with Severe Perineal Lacerations. Rev Bras Ginecol Obstet 2016;38:301–307.

2. Steinberg H. How To Do and Suture an Episiotomy. In: Mash B, Blitz-Lindeque J, eds. South African Family Practice Manual. 2nd ed. Pretoria: Van Schaik Publishers; Theron GB. Intrapartum Care. Bettercare. 2017.