2026 Obstetrics 2 M.06 Episiotomy, Lacerations PDF

PCC SOM 2026 OBSTETRICS 2 M.06 EPISIOTOMY, LACERATIONS OBSTETRICS 2 LECTURE LECTURER: Dr. Ruth Ramos Taguiling DATE: October 2024 TOPIC OUTLINE GOAL SELECTIVE vs. ROUTIN...

PCC SOM 2026 OBSTETRICS 2 M.06 EPISIOTOMY, LACERATIONS OBSTETRICS 2 LECTURE LECTURER: Dr. Ruth Ramos Taguiling DATE: October 2024 TOPIC OUTLINE GOAL SELECTIVE vs. ROUTINE EPISIOTOMY TYPES OF EPISIOTOMY TIMING OF EPISIOTOMY STRUCTURES CUT SELECTIVE vs ROUTINE EPISIOTOMY TIMING OF THE EPISIOTOMY REPAIR EPISIOTOMY TECHNIQUE SELECTIVE ROUTINE PATIENT PREPARATION when clinicians used generally done INSTRUMENTS /MATERIALS NEEDED EPISIORRHAPHY their clinical judgment late in the 2nd to determine the need stage to prevent for episiotomy where serious perineal Episiotomy - incision of the pudenda the benefits most likely damage caused by Perineotomy – is incision of the perineum outweigh the risks of tearing and to adverse outcomes facilitate birth of baby RECOMMENDATIONS Selective use of episiotomy rather than routine ACOG (2020c) Evidence shows lower rates of severe perineal trauma in women undergoing spontaneous birth with a restrictive/selective use of episiotomy (Dillon, 2019; Jiang, 2017) Note: In common parlance, the term episiotomy is often INDICATIONS used synonymously with perineotomy. 1. Events that Increase fetal jeopardy a. Non reassuring FHR GOAL b. Prolonged 2ndstage To enlarge introitus to facilitate easy delivery 2. Operative delivery (forceps) Minimize rupture of perineal muscles & facia 3. Anticipate perineal tear (big baby, breech, Substitution of a straight surgical incision, which shoulder dystocia) is easier to repair – for the ragged laceration that 4. Rigid perineum –Impending perineal tear otherwise might result 5. Previous perineal surgery (pelvic floor repair; reconstructive surgery) The long-held beliefs that postoperative pain is less and healing improved with an episiotomy compared with a TYPES OF EPISIOTOMY tear, however, appeared to be incorrect (Larsson and colleagues, 1991) A. MEDIAN or MIDLINE Incision made in the midline B. MEDIOLATERAL (MLE) incision from midline fourchette to (R/L) laterally and downward away from the rectum NOTE TAKERS: ABDELKAWI / KELLY / LOCANO / PADAGAS / SANTIAGO / Page 1 | 4  PCC SOM 2026 OBSTETRICS 2 M.06 EPISIOTOMY, LACERATIONS When used in conjunction with forceps delivery, most practitioners perform an episiotomy after application of the blades. ✓ Too early: considerable bleeding ✓ Too late: lacerations will not be prevented ** best to do it during CROWNING (when fetal head dilates the introitus to 4-5 cm diameter) MIDLINE EPISIOTOMY MEDIOLATERAL EPISIOTOMY ✓ Easier to repair ✓ May extend if big baby ✓ Less blood loss or need to manipulate ✓ Faster healing ✓ Avoid injury or ✓ Less painful extension of cut to the anal sphincter STRUCTURES CUT A. Posterior vaginal wall B. Superior and deep transverse perineal muscles, bulbocavernosus (bulbospongiosus) and part of ✓ Except for the ✓ Use a MLE when a levator ani important issue of 3rdor 4th degree C. Transverse perineal branches of pudendal vessels third-and 4th degree extension is likely and nerves extensions, midline D. Subcutaneous tissue and skin episiotomy is superior. TIMING OF THE EPISIOTOMY REPAIR TIMING OF EPISIOTOMY Common practice is to defer episiotomy repair until the placenta has been delivered Perform episiotomy when the head is visible during permits undivided attention to the signs of a contraction to a diameter of 4 to 5 cm placental separation and delivery episiotomy repair is not interrupted ✓ especially if manual removal must be performed EPISIOTOMY TECHNIQUE Several techniques ESSENTIAL: ✓ Hemostasis ✓ Anatomical restoration without excessive suturing NOTE TAKERS: ABDELKAWI / KELLY / LOCANO / PADAGAS / SANTIAGO / Page 2 | 4  PCC SOM 2026 OBSTETRICS 2 M.06 EPISIOTOMY, LACERATIONS PATIENT PREPARATION Proper Positioning Drapes, Sepsis & Antisepsis Adequate Lighting Adequate Anesthesia INSTRUMENTS / MATERIALS NEEDED Sterile gauze pad and sanitary napkins Approximate mucosa using a continuous interlocking Needle holder or running closure technique 2–0 suture or vicryl Thumb/Tissue forceps rapide Scissors Up to the mucocutaneous junction Lidocaine 5 ml syringe Suture Material ✓ 3-0 chromic catgut; derivatives of polyglycolic acid (Vicryl Rapide, Ethicon) Approximate muscles (trans. perineal & bulbocavernosus) Running or figure of eight 2–0 suture Approximate subcutaneous (fatty) layer) EPISIORRHAPHY Expose the area Identify apex of incision Infiltrate local anesthesia or bilateral pudendal block Start 1 cm beyond apex Approximate skin techniques: Continuous running or subcuticular stitch or series of inverted T sutures NOTE TAKERS: ABDELKAWI / KELLY / LOCANO / PADAGAS / SANTIAGO / Page 3 | 4  PCC SOM 2026 OBSTETRICS 2 M.06 EPISIOTOMY, LACERATIONS 9. When a 3rd or 4th degree extension is likely, which is more superior to be used? A. Median Episiotomy B. Mediolateral Episiotomy C. Both D. Neither 10. True/False: Episiorrhaphy is done starting 1cm beyond the apex. KEY ANSWERS 1. Episiotomy 2. False – Selective episiotomy is recommended Checkpoint 3. Mediolateral Episiotomy 4. B 1. This is defined as the incision of the pudenda. 5. E 2. True/False: Routine use of episiotomy is much 6. False – should be done after the placenta has been preferred than selective episiotomy. delivered 3. A type of episiotomy where an incision is made from 7. C midline fourchette to (R/L) laterally and downward 8. A away from the rectum. 9. B 4. When is episiotomy best performed? 10. True A. When fetal head is engaged B. During crowning C. When fetal head is already delivered D. During the 3rd stage of labor 5. These are the structures that are cut during episiotomy EXCEPT A. Posterior vaginal wall B. Superior perineal muscles C. Subcutaneous Tissue D. Skin E. None of the Above 6. True/False: Repair of episiotomy is done before the delivery of the placenta. 7. Anesthesia used in episiorrhaphy A. Propofol B. Ketamine C. Lidocaine D. Sevoflurane 8. Episiotomy done too early would result to which among the followings? A. Bleeding B. Lacerations C. Injury to the placenta D. A & B NOTE TAKERS: ABDELKAWI / KELLY / LOCANO / PADAGAS / SANTIAGO / Page 4 | 4