Episiotomy: Difference between revisions
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==Repair== | ==Repair== | ||
*Examine 360 degrees for other non-hemostatic lacerations that require sutures | *Examine 360 degrees for other non-hemostatic lacerations that require sutures | ||
*Use 2-0 or 3-0 vicryl rapide or similar | *Use 2-0 or 3-0 vicryl rapide or similar - the same suture will be used to close all tissue | ||
*Start an anchoring stitch | *Start an anchoring stitch at apex within vaginal mucosa | ||
*Continuous | *Continuous LOCKing sutures along vaginal mucosa/submucosa | ||
*Once at the hymen/perineal muscles, tie suture, but don't cut continuous end | *Once at the hymen/perineal muscles, tie suture, but don't cut continuous end | ||
*Bury the knot within the perineum | *Bury the knot within the perineum, and come out with the needle at the apex of the perineum | ||
*Continue suturing up to skin in a NON-locking fashion | |||
*At apex of skin, perform dermal approximations down to distal skin edge | |||
*Return to apex of skin with a subcuticular stitch (like a monocryl skin closure) and tie knot | |||
*Bury knot in superficial perineum/subQ and cut remaining suture from needle | |||
==Sources== | ==Sources== | ||
*Lappen et al. Episiotomy and Repair Technique. Updated Feb 27, 2014. http://emedicine.medscape.com/article/2047173-technique#showall | *Lappen et al. Episiotomy and Repair Technique. Updated Feb 27, 2014. http://emedicine.medscape.com/article/2047173-technique#showall | ||
Revision as of 14:42, 11 August 2015
Episiotomy
- Midline episiotomy - easier to heal, less painful, but can extend to anus
- Mediolateral - unlikely to extend to anus
- Anatomic structures - vaginal epithelium, transverse perineal muscle, bulbocavernosus muscle, perineal skin
- ACOG recommends restricting episiotomies, and prefers mediolateral to median (Level A, 2006)
- Current data is of poor quality in regards to benefits to mother or baby
- Procedure avoids spontaneous tearing and/or aids in difficult delivery:
- Shoulder dystocia (contentiously the only indication)
- If possible, avoid even in these situations:
- Baby is large or in breech
- Labor is going too quickly
- Extraction instruments needed (forceps, vacuum assisted)
- Contraindications:
- IBD
- Perineal malformations
Procedure (Mediolateral)
- May be performed on either side
- Anesthetic to include local, Pudendal nerve block, epidural if available
- Protect fetal head with operator hand, and cut along operator hand
- Begin incision at posterior fourchette, continue at angle of 45 - 90 degrees relative to perineal body
- Incise to generally 3-4 cm in length
Complications
Repair
- Examine 360 degrees for other non-hemostatic lacerations that require sutures
- Use 2-0 or 3-0 vicryl rapide or similar - the same suture will be used to close all tissue
- Start an anchoring stitch at apex within vaginal mucosa
- Continuous LOCKing sutures along vaginal mucosa/submucosa
- Once at the hymen/perineal muscles, tie suture, but don't cut continuous end
- Bury the knot within the perineum, and come out with the needle at the apex of the perineum
- Continue suturing up to skin in a NON-locking fashion
- At apex of skin, perform dermal approximations down to distal skin edge
- Return to apex of skin with a subcuticular stitch (like a monocryl skin closure) and tie knot
- Bury knot in superficial perineum/subQ and cut remaining suture from needle
Sources
- Lappen et al. Episiotomy and Repair Technique. Updated Feb 27, 2014. http://emedicine.medscape.com/article/2047173-technique#showall