Introduction
Episiotomy is the incision into the perineum and the vagina (using scissors or a scalpel) to increase the size of the orifice.
Indications for performing an episiotomy are: avoiding tears of the vagina, perineum and anal sphincter, and shortening the delivery stage. There can be both maternal and foetal reasons for the latter. The majority of parturitions do not require an episiotomy.
The perineum can be incised in two ways. In the mediolateral episiotomy, the perineum and vagina are incised from the median posterior commissure at an angle of about 45° dorsally, left or right of the anus. The technique for this type of episiotomy will be described later in greater detail. A median episiotomy proceeds in a median line from the posterior commissure to the anus. This gives rise to a wound with equal edges that is simpler to suture and causes fewer complaints in the confinement period than a mediolateral episiotomy. The chance of rupturing to the anal sphincter and the rectum is, however, relatively large. That is why the median episiotomy is not the treatment of choice in the Dutch obstetric tradition.
Preparation
Sufficient disinfection and good anaesthesia are important. Bacteriological testing has revealed that more than 70% of episiotomy wounds are infected with microorganisms. This is hardly surprising considering the proximity of an important potential source of infection, the rectum. Yet an infection occurs in only 3% of all cases. Whether or not an infection develops depends on:
- The virulence of the microorganism.
- The number of microorganisms.
- The resistance of the immune system of the woman.
Nothing can be done to influence the virulence of the bacteria and the resistance of the immune system of the woman during parturition, but something can be done about the number of bacteria. If practitioners discover that more than 3% of episiotomies are infected in their practice, they should examine whether improvements need to be made regarding the disinfectants used, their disinfectant technique or the suturing.
Material [Figure 36]:
- Episiotomy scissors or scalpel.
- Infiltration anaesthetic.
- Hypodermic syringe (10 ml).
- Hypodermic needle (long).
- Sterile drapes or ironed cotton clothes.
- Povidone-iodine solution 10% or chlorhexidine 1%.
- Gauze squares.
- Gloves (sterile).
Figure 36
The best moment to perform the episiotomy depends on the indication. In order to prevent perineal scarring, in the case of a head presentation, the best moment is at the start of the contraction during which the child is to be born or, at most, two to three contractions before this.
Ensure sufficient analgesia. This can be provided by local infiltration with an anaesthetic or by pudendal nerve block as this nerve can be reached transvaginally or via the perineum. The latter technique is less simple and will not be discussed here. Infiltration anaesthesia with 10 to 20 ml (100-200 mg) lidocaine 1%, or prilocaine 1% without adrenalin, is the most usual form of analgesia. The time to effect is 3 to 5 minutes.
An episiotomy is usually performed with a special pair of scissors. A cleaner wound can be obtained with a scalpel. A pair of scissors bruises the tissue, a knife gives more vital wound edges that heal better, but it can prove difficult to carefully protect the presenting part of the foetus during incision. A combination is also possible. In this case, a scalpel should be used to incise the skin and subcutis and subsequently the scissors should be used to cut further into the vagina.