Episiotomy/perineal tears

Question 1

Episiotomy - indications

Answer 1

1. Breech
2. Shoulder dystocia
3. Forceps/ventouse
4. Extensive lower genital tract scarring (e.g. poorly healed 3rd/4th degree tears)
5. Fetal distress (?)

Question 2

Episiotomy - method (5)

Answer 2

1. If woman does not have epidural, perineum should be infiltrated with lignocaine
2. Two fingers placed between baby’s head and perineum to protect baby
3. Sharp scissors to make single cut in perineum about 3-4cm long
4. Will cause bleeding so must not be done too early and should be repaired ASAP
5. Check for extension/other tears (including PR to ensure no trauma to anal sphincter)

Question 3

Episiotomy - general complications (same as for perineal trauma)

Answer 3

1. Bleeding/haematoma (localised mass of extravasated blood)
2. Pain
3. Infection
4. Scarring
5. Dyspareunia

Question 4

Perineal tears - classification

Answer 4

1st degree = injury to skin only
2nd degree = injury to perineum involving perineal muscles (includes episiotomy)
3rd degree = injury to perineum involving anal sphincter complex (?)
4th degree = injury to perineum involving anal sphincter complex + anal/rectal epithelium

Question 5

Perineal tears - principles of repair

Answer 5

1. Lithotomy position
2. Good light source, adequate analgesia
3. Identify apex of cut and start suturing from just above this point
4. Loose, continuous non-locking suturing technique to appose each layer. Perineal skin sutured with subcuticular suture
5. PR exam to ensure that no suture has accidentally passed into rectum/anal canal