pronounced eh-pees-ee-oh-tom-ee

An episiotomy is a surgical incision performed to the perineal tissues that is designed to enlarge the vulval outlet during delivery.

It is essential that the mother consents to such a procedure, it is essential that the mother is given full informed choice of the indications and implications of the intervention.

Was once "routine" practice in midwifery, trends of routine episiotomy declined in the mid/late 80's with thanks to many research studies proving its routine use causes long-term damage to the pelvic floor, and often extend to a 3rd degree tear if done incorrectly.

"The risks and benefits of episiotomy have been well reviewed (Carroli & Belizan 2001). The rationale for its use depends largely on the need to minimise the risk of severe, spontaneous, maternal trauma and to expedite birth when there is evidence of fetal compromise. However, during a normal birth the indications for its use are few and the midwife should use her skills to avoid this intervention if at all possible" (Taken from Myles Textbook for midwives 2004).

An episiotomy involves incision of the fourchette, the superficial muscles and the skin of the perineum and the posterior vaginal wall. It can therefore successfully speed the birth only when the presenting part is directly applied to these tissues.
If the episiotomy is performed too soon it will fail to release the presenting part and haemorrhage from the cut vessels may ensue.
If performed too late there will be not enough time to infiltrate with a local anaesthetic. There is also little reason to perform an episiotomy if a tear has already begun.

Prior to incision

Infiltration of the perineum
The perineum should be adequately anaethetised prior to incision, most commonly used is Lidocaine (lignocaine), either 0.5% 10ml or 1% 5ml. The advantage of the concentrated solution is that less is required.
It takes 3/4 mins to have an effect, and if possible 2/3 contractions should occur between infiltration and incision.
The timing of course is not always easy to calculate, however it is far better to infiltrate and not perform an episiotomy, than to risk/perform incision without effective anaesthetic.

Prior to infiltration
The perineum should be cleansed with antiseptic solution (however I have never seen this).
Two fingers are inserted into the vagina, along the line of the proposed incision in order to protect the fetal head.
The needle is then inserted beneath the skin to 4/5 cm depth following the same line, the syringe should be withdrawn slightly prior to injection to check whether or not the needle is in a blood vessel. If blood is aspirated, the needle should be repositioned and the procedure repeated until no blood is withdrawn.
Lidocaine, is then continuously injected as the needle is slightly withdrawn, the incision line and also, on either sides of the incision line are infiltrated for optimum effects. Most practioners it seems use 20mls in total (1%/2% dependant upon preferred) to infiltrate, this seems to make for a painless incision.

The incision
Types of incision
Mediolateral
Evidence suggests that this is the only type of incision that should be performed, (to reduce the risk of 3rd degree tear, thus reduce the risk of damage to the anal sphincter).
A mediolateral incision begins at the midpoint of the fourchette and is directed at a 45-60 degree angle towards the midline, between the ischial tuberosity and the anus. This line avoids the danger of perforating the anal sphincter and bartholins gland, but it is more difficult to repair.

To make the incision-dependant upon trust, however most seem to include these in the delivery/instrument packs, the scissors are straight bladed and blunt ended known as Mayo scissors. They need to be sharp thus ensuring a clean incision.

Two fingers are inserted into the vagina (in the same way as you would infiltrate) and the opened blades are got into position. The incinsion is preferrably performed during a contraction when the tissues are stretched allowing a clear view of the area, and bleeding is less likely to be severe. A single, deliberate concise cut 4-5cms long is made (mediolaterally). Birth of the head should follow immediately and its advance must be controlled in order to prevent further extension of the episiotomy.

If there is any delay before the head emerges, pressure should be applied to the episiotomy site betweens contrations (with sterile cotton wool/gauze) in order to minimse bleeding, as the woman is at a greater risk of postpartum haemorrhage (pph) due to the episiotomy unless it is compressed.

http://www.rcog.org.uk/resources/Pub...eal_repair.pdf

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