1. EPISIOTOMY
An episiotomy also known as perineotomy, is a
surgically planned incision on the perineum
and the posterior vaginal wall during second
stage of labor.

2. • Indications
• There is a serious risk to the mother of second or third
degree tearing
• In cases where a natural delivery is adversely affected, but
a Caesarean section is not indicated
• 'Natural' tearing will cause an increased risk of maternal
disease being vertically transmitted
• The baby is very large
• When perineal muscles are excessively rigid
• When instrumental delivery is indicated
• When a woman has undergone FGM (female genital
mutilation), indicating the need for an anterior and or
mediolateral episiotomy
• Prolonged late decelerations or fetal bradecardia during
active pushing
• The baby's shoulders are stuck (shoulder dystocia), or a bony
association.

3. Types:
• Medio-lateral: The incision is made downward and outward from
midpoint of fourchette either to right or left. It is directed diagonally in
straight line which runs about 2.5cm away from the anus (midpoint
between anus and ischial tuberosity).
• Median: The incision commences from centre of the fourchette and
extends on posterior side along midline for 2.5cm.
• Lateral: The incision starts from about 1 cm away from the centre
of fourchette and extends laterally. Drawback include chance of injury
to Bartholin's duct. It is totally condemned it.
• 'J' shaped: The incision begins in the centre of the fourchette and is
directed posteriorly along midline for about 1.5cm and then directed
downwards and outwards along 5 or 7 o'clock position to avoid the anal
sphincter. This is also not done widely.

7. Relative merits and demerits of median and medio-lateral episiotomy
Median Medio-lateral
The muscles are not cut relative safety from rectal
Blood loss is least involvement from extension.
Repair is easy If necessary, the incision can be
Merits Post operative comfort is extended.
maximum
Healing is superior
Wound disruption is rare
Dyspareunia is rare
Extension, if occurs, may Apposition of the tissues is not
involve the rectum. so good.
Not suitable for manipulative Blood loss is little more,
delivery or in abnormal Post operative discomfort is
presentation or position. As such, more
its use is selective. Relative increased incidence of
Demerits
wound disruption
Dyspareunia is comparatively
more

8. • Steps of medio- lateral episiotomy.
• Median incisions are believed to be less painful than
mediolateral, but when properly repaired there is little
difference. Mediolateral incisions are only rarely extended into
the rectum and anal sphincter and are often used when more
room is required for the delivery process.
• A right-handed obstetrician usually incises from the posterior
fourchette at the midline toward the patient's left ischial
tuberosity. The same structures are separated as with the median
incision, and the ischiorectal fossa is exposed. a mediolateral
incision has the advantage that it can be extended through the
levator ani muscles, expanding the outlet.
• A. Incision from midline toward ischial tuberosity. B. Repair of
vaginal wall. C. Approximation of leavatores. D. Approximation of
bulbocavernosus muscle. E. Reconstruction of urogenital
diaphragm. F. Skin closure.

9. • the mediolateral episiotomy be performed as a two-step procedure. The
first incision is made in the soft tissues of the fourchette and the vagina,
followed by incision of the perineum, extending in the mediolateral
direction.
• Repair is similar to the midline repair. Blood loss can be greater, however,
and for this reason repair often is begun before the placenta has been
expressed. Before beginning the repair, the rectal mucosa should be
palpated for any defects. The vaginal mucosa and underlying supportive
tissues are repaired with a running locked suture. The vaginal closure
allows reapproximation of the hymenal ring and subsequent anatomical
accuracy.
• The deep tissues of the perineal body are closed with interrupted fine
absorbable suture . Attention made to close the dead space as well as to
obtain hemostasis is important, as it is for the median closure. The skin is
closed as with the median closure. The Vaginal and rectal examination at
the conclusion of the procedure is again important to ensure that no
suture has been placed in the rectal mucosa and that the closure is
adequate.

11. • Post operative care
Dressing : the wound is to be dressed each time
following urination and defaecation to keep the area
clean and dry.
 Dressing is done by using antiseptic soaked swabs.
 The attendant should wear a mask while doing
dressing.
Comfort : to relieve pain in the area, magnesium
sulphate compress to be given
 Analgesic drugs may be given according to
instruction.
Ambulance: the is allowed to move out of the bed
after 24 hours.
Removal of stitches : the stitches are to be cut on 6th
day.

12. Complications
Immediate Remote
I. Extension of the incision to I. Dyspareunia .
involve the rectum. II. Chance of perineal
II. Vulval haematoma. lacerations.
III. Infection. III. Scar endometriosis (rare).
IV. Wound dehiscence.