Episiotomy in Childbirth

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Questions and Answers

When is the best time to perform an episiotomy?

During the first stage of labor

Before the onset of contractions

During crowning (correct)

After the baby's head is delivered

What is a significant advantage of a midline episiotomy compared to a mediolateral episiotomy?

It is performed at an earlier stage

It reduces the risk of infection

It may extend if the baby is large

It has less blood loss (correct)

Which structure is NOT typically cut during an episiotomy?

Subcutaneous tissue and skin

Posterior vaginal wall

Transverse perineal branches of pudendal vessels

Uterine ligaments (correct)

Why might a mediolateral episiotomy be preferred over a midline episiotomy?

It avoids injury to the anal sphincter Signup and view all the answers

What is the primary concern regarding third or fourth degree extensions during an episiotomy?

Injury to anal sphincter Signup and view all the answers

What is the primary difference between selective and routine episiotomy?

Selective episiotomy is based on clinical judgment. Signup and view all the answers

What is an episiotomy?

An incision of the pudenda. Signup and view all the answers

When is routine episiotomy typically performed?

Late in the second stage of labor. Signup and view all the answers

What does evidence suggest about the use of selective episiotomy?

It reduces rates of severe perineal trauma. Signup and view all the answers

What is the goal of performing an episiotomy?

To facilitate the birth of the baby. Signup and view all the answers

What is the common term used synonymously with episiotomy?

Perineotomy. Signup and view all the answers

Which organization provides recommendations regarding episiotomy use?

ACOG. Signup and view all the answers

What is a potential risk of routine episiotomy?

Higher rates of severe perineal trauma. Signup and view all the answers

What is the primary goal of enlarging the introitus during delivery?

To facilitate easy delivery Signup and view all the answers

Which type of incision is classified as median or midline?

An incision made in the midline of the perineum Signup and view all the answers

Which of the following is a reason for anticipating a perineal tear?

Big baby, breech presentation, or shoulder dystocia Signup and view all the answers

What misconception exists about episiotomy compared to perineal tears?

Episiotomy is always less painful than tearing Signup and view all the answers

What might result from an operative delivery using forceps?

Indication for performing an episiotomy Signup and view all the answers

What does a rigid perineum indicate during delivery?

Increased risk of impending perineal tear Signup and view all the answers

What is indicated by previous perineal surgery?

Increased risk of further perineal laceration Signup and view all the answers

What distinguishes a mediolateral episiotomy from a midline one?

It is made to the left or right side away from the rectum Signup and view all the answers

What is the common practice regarding the timing of episiotomy repair?

Repair should be deferred until after the placenta has been delivered Signup and view all the answers

Which technique is essential during episiotomy repair?

Hemostasis and anatomical restoration Signup and view all the answers

When should the episiotomy be performed in relation to contractions?

When the head is visible to a diameter of 4 to 5 cm during a contraction Signup and view all the answers

What should be ensured regarding sepsis before performing an episiotomy?

Proper draping, sepsis, and antisepsis Signup and view all the answers

Which suture material is commonly used in episiotomy repair?

Vicryl Rapide or derivatives of polyglycolic acid Signup and view all the answers

What is NOT a part of the instruments/materials needed for episiotomy repair?

Non-sterile scissors Signup and view all the answers

Why is it important to have adequate lighting during the episiotomy repair process?

To assist in proper suturing and minimize errors Signup and view all the answers

What should be monitored after performing an episiotomy during labor?

Signs of placental separation and delivery Signup and view all the answers

What is the purpose of an episiotomy?

To incise the pudenda Signup and view all the answers

When beginning episiorrhaphy, where should the incision start?

1 cm beyond the apex Signup and view all the answers

Which technique is commonly used for skin approximation in episiorrhaphy?

Continuous running suture Signup and view all the answers

Which type of episiotomy is preferred when a third or fourth degree extension is likely?

Mediolateral Episiotomy Signup and view all the answers

Is it true that routine use of episiotomy is preferred over selective episiotomy?

False Signup and view all the answers

What is the immediate action before starting episiorrhaphy?

Infiltrating local anesthesia Signup and view all the answers

Which of the following accurately describes a mediolateral episiotomy?

An incision made laterally and downward from midline Signup and view all the answers

When should an episiorrhaphy be performed in relation to the delivery of the placenta?

After delivery of the placenta Signup and view all the answers

Study Notes

Episiotomy

Episiotomy is an incision of the pudenda during childbirth.
Perineotomy is an incision of the perineum specifically.
The terminology is used synonymously in common practice.
It enlarges the introitus to facilitate easier delivery.
It substitutes a straight surgical incision for a ragged tear (easier to repair).
The goal is to minimize the rupture of perineal muscles and fascia.

Selective vs. Routine

Selective episiotomy: Clinicians use their judgment to determine the need for episiotomy when the benefits outweigh the risks and adverse outcomes.
Routine episiotomy: Performed late in the second stage of labor without clinical indication.
ACOG recommends the selective use of episiotomy.

Indications

Events that increase fetal jeopardy:
- Non-reassuring fetal heart rate (FHR)
- Prolonged second stage of labor
Operative delivery (forceps):
Anticipated perineal tear:
- Large baby
- Breech presentation
- Shoulder dystocia
Rigid perineum: Impending perineal tear
Previous perineal surgery: Pelvic floor repair or reconstructive surgery

Types of episiotomy

Median or Midline: Made in the midline.
Mediolateral (MLE): Incised from the midline fourchette to laterally and downward, away from the rectum.
When used in conjunction with forceps delivery, episiotomy is usually performed after applying the blades.
Performing episiotomy too early can lead to excessive bleeding.
Performing it too late will not prevent lacerations.

Timing of episiotomy

Best practice is to perform episiotomy during crowning.
Crowning occurs when the fetal head dilates the introitus to 4-5 cm in diameter.

Advantages and Disadvantages

Midline episiotomy:
- Easier to repair
- Less blood loss
- Faster healing
- Less painful
Mediolateral episiotomy:
- May extend if the baby is large or if manipulation is required.
- Can help avoid injury or extension of the cut to the anal sphincter, unlike midline.

Structures Cut

Posterior vaginal wall
Superior and deep transverse perineal muscles, bulbocavernosus (bulbospongiosus) and part of the levator ani
Transverse perineal branches of pudendal vessels and nerves
Subcutaneous tissue and skin

Timing of Repair

The episiotomy repair is commonly deferred until after the placenta has been delivered.
This allows undivided attention to the signs of placental separation and delivery.
It ensures that the repair is not interrupted, especially if a manual removal of the placenta is needed.

Episiotomy Technique

Several techniques exist.
It is essential to achieve hemostasis and anatomical restoration without excessive suturing.

Patient Preparation

Proper positioning
Drapes, sepsis, and antisepsis
Adequate lighting
Adequate anesthesia

Instruments and Materials

Sterile gauze pad and sanitary napkins
Needle holder
Thumb/Tissue forceps
Scissors
Lidocaine
5 ml syringe
Suture Material
- 3-0 Chromic catgut
- Derivatives of polyglycolic acid (Vicryl Rapide, Ethicon)

Episiorrhaphy

Expose the area
Identify the apex of the incision
Infiltrate local anesthesia or bilateral pudendal block
Start 1 cm beyond the apex
Approximate mucosa using a continuous interlocking or running closure technique with 2-0 suture or vicryl rapide, up to the mucocutaneous junction.
Approximate muscles (transverse perineal & bulbocavernosus) with running or figure of eight 2-0 suture.
Approximate the subcutaneous (fatty) layer.
Approximate skin with continuous running or subcuticular stitch, or a series of inverted T sutures.

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Description

This quiz covers the concept of episiotomy, including the differences between selective and routine practices, as well as the indications for performing this procedure during childbirth. Understand the clinical considerations that guide the use of episiotomy in obstetric care.