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When you have completed this skills chapter you should be able to:
If you anticipate that an episiotomy may be needed, you should inject local anaesthetic into the perineum. An episiotomy should not be done without adequate analgesia. The local anaesthetic is injected below the skin and vaginal epithelium in the area where the episiotomy will be cut. The nerve fibres that relay pain stimuli are below the skin and epithelium. Usually 10–15 ml 1% lignocaine (Xylotox) supplies adequate analgesia for performing an episiotomy. Be very careful that the local anaesthetic is not injected into the presenting part of the fetus.
There are two methods of performing an episiotomy:
The midline episiotomy has the danger that it can extend into the rectum to become a third-degree tear while the mediolateral episiotomy often results in more bleeding. This skills chapter will only deal with the mediolateral episiotomy because it is used most frequently, is safe, and requires the least experience.
The incision should only be started during a contraction when the presenting part is stretching the perineum. Doing the episiotomy too early may cause severe bleeding and will not immediately assist the delivery. The incision is started in the midline and most posterior in the vaginal opening (intriotus) with the scissors pointed at 45° away from the anus. It is usually directed to the patient’s left but can also be to the right. 2 fingers of the left hand are slipped between the perineum and the presenting part when performing a mediolateral episiotomy.
Figure 9A-1: The method of performing a left mediolateral episiotomy
Arterial bleeders may have to be temporarily clamped, while venous bleeding is easily stopped by packing a swab into the wound. Suturing the episiotomy usually stops the venous bleeding but arterial bleeders need to be tied off.
Figure 9A-2: The method of safely handling a needle
Three layers have to be repaired:
Figure 9A-3: An episiotomy wound
There are four important steps in the repair of an episiotomy wound.
Step 1: Place a suture (stitch) at the apex of the incision in the vaginal epithelium. Then insert one or two more continuous sutures in the vaginal epithelium. Do not complete suturing the vaginal epithelium when the episiotomy is large or deeply cut but leave this suture and do not cut it. When placing the suture at the apex, be very careful not to prick your finger with the needle.
Figure 9A-4: Suturing the vaginal epithelium
Step 2: Insert interrupted sutures in the muscles. Start at the apex of the wound. The aim is to bring the muscles together firmly and to eliminate any ‘dead space’, i.e. any spaces between the muscles where blood can collect. Remember that the sutures must be inserted at 90 degrees to the line of the wound.
When suturing the muscles, be careful not to put the suture through the rectum. If you make sure that the point of the needle is seen when crossing from the one side to the other of the deepest part of the wound, the stitch will not be too deep. ‘Figure 8’ stitches (double stitches) are used to suture the muscle layer. When the muscles have been correctly sutured the cut edges of the vaginal epithelium and the skin should be lying close together. The markers for correct alignment are:
Figure 9A-5: Suturing the muscles
Step 3: Return to the vaginal epithelium and complete the continuous catgut suture, ending at the junction with the skin. Do not pull the sutures tight as they only need to bring the edges of the vaginal epithelium together.
Figure 9A-6: The correct position of the skin and vaginal epithelium
Step 4: Use interrupted sutures with an absorbable suture material to repair the perineal skin. Mattress sutures may be used. Do not pull the sutures tight as they only need to bring the edges of the skin together. Sutures that are too tight become uncomfortable for the patient.
Figure 9A-7: The repair of the skin
When the suturing is complete: