Periniotomy: Why a Liberal Procedure

 

Banita Rana

Nursing Tutor, Obstetrics and Gynaecoloical Nursing, Shri Mata Vaishno Devi College of Nursing, Kakryal, Katra.

 

ABSTRACT:

Episiotomy was previously recommended in 1920 to prevent severe perineal tears and lacerations, but later on it was adopted as a standard practice and now its routine use has been questioned. Various studies found that routine use of episiotomy can change the perineal flora and not all the labor need episiotomy.

 

 

INTRODUCTION:

Perineotomy is also called an episiotomy which is a surgical procedure in which an incision is given on the posterior vaginal wall and perineum is opened in order to easy delivery of a new-born. This procedure is done during second stage of labor under general anaesthesia and after the delivery of baby suturing is done.¹ An episiotomy used to be a normal part of labor in past because it was considered that it prevent severe vaginal tears after delivery. It was also believed that an episiotomy would heal better than a natural or spontaneous tear. but it has become less common in recent years in various developed countries.

 

In the United States, as of 2012, it was performed in 12% of vaginal births.² According to a study conducted by Shalini Singh and Tushita Thakur in 18 tertiary care hospitals in India in the year 2016 among 1,20,243 vaginal deliveries, episiotomy was performed in 76,305 of (63.4 per cent) cases.³

 

The body of the women is created in such a way that she can undergo this event very smoothly, no doubt she may suffer from a terrible pain but she is able to pick up that pain. Various researches suggests that an episiotomy may actually cause more problems than it prevents and also it can cause infection and other complications.

 

Definition:

Episiotomy is defined as a surgical planned incision on the perineum and the posterior vaginal wall during the second stage of labor is called episiotomy. It is infact inflicted second stage perineal injury.

 

Types of Episiotomy:

·       Mediolateral:

Incision is made downwards and outwards from the midpoint of the fourchette either to the right or to the left. It runs about 2.5cm away from the anus (between anus and ischial tuberosity)

·       Median:

The incision commences from about 1 cm away from the center of the fourchette and extends posteriorly along the midline for about 2.5cm

·       Lateral:

The incision starts from about 1 cm away from the center of the fourchette and extends laterally. It can cause injury to the Bartholin’s gland.

·       “J” shaped:

The incision begin in the center of fourchette and is directed posteriorly along the midline for about 1.5 cm and then directed downwards and outwards along 5 or 7 O’clock to avoid anal sphincter⁴.

 

Indications for Episiotomy:

·       To prevent perineal trauma

·       Easy to repair

·       Fetal weight greater than 4 kg

·       Prolonged second stage of labor

·       Shoulder dystocia

·       Forceps delivery

·       Ventouse delivery

·       Previous history of perineal tear

·       Rigid perineum

·       Fetal distress

·       Twin delivery

·       Preterm baby

 

Prognosis of episiotomy:

According to a systematic review on use of episiotomy in Obstetrical care various outcomes related to episiotomy was addressed which include

 

·       Episiotomy and maternal postpartum outcomes:

According to liberal and restrictive use of episiotomy, the restrictive use groups had less severe posterior perineal trauma, less need for suturing, higher probability of having an intact perineum, no greater or lesser risk of wound healing complications and higher likelihood of resuming intercourse earlier.

 

·       Episiotomy incision type and maternal morbidity:

According to the types of episiotomy women with midline episiotomy are at greater risk of anal sphincter injuries than women with mediolateral episiotomy.

 

·       Episiotomy and urinary incontinence, fecal incontinence and pelvic floor defects:

Episiotomy is associated with lower pelvic floor muscle strength than spontaneous tears. There is high prevalence of anorectal dysfunction at 3 months with episiotomy. Episiotomy confers no benefits with respect to preserving continence or pelvic floor muscle function. Overall episiotomy apparently did not protect against incontinence, prolapse, or decrements in pelvic floor muscle function by 3 months postpartum.

 

·       Episiotomy and future sexual function:

Women in the restrictive group resumed intercourse an average of 1 week than the liberal group. Women with episiotomy had the slowest return to intercourse. Pain with the intercourse 3 months after delivery followed a similar pattern⁵.

 

Risks of an episiotomy:

·       Bleeding

·       Tearing into the rectal tissues and anal sphincter muscle which controls the passing of stool

·       Swelling

·       Infection

·       Collection of blood in perineal tissues

·       Pain during sex.

 

Ways to reduce prevalence of episiotomy:

·       Perineal massage

·       Horizontal position during second stage of labor:- supine with footholds, lithotomy with knees turned in, or lateral positions)

·       Valsalva pushing

·       Hands on technique at childbirth

·       Warm compresses on perineum.

 

Care of episiotomy:

Dressing:

The wound to be dressed each time following urination and defecation to keep the area clean and dry. The dressing is done by swabbing with cotton swabs soaked in antiseptic solution (povidine-iodine) followed by application of antiseptic powder or ointment (furacin and neosporin)

 

Comfort:

To relieve pain in the area, MgSO₄ compression or application of infrared heat may be used. Ice packs reduce swelling and pain. Analgesics can be given when required.

 

Ambulance:

The patient is allowed to move out of the bed after 24 hours. Prior to that, she is allowed to roll over on to her side or even to sit but only with thighs apposed.

 

Removal of stitches:

When the wound is sutured by catgut or Dexon which will be absorbed the sutures need not be removed. But if non absorbable material (silk or nylon) is used, the stitches are to be cut on 6^th day⁴.

 

REFERENCES:

1.      https://en.wikipedia.org/wiki/Episiotomy

2.      American College of Obstetricians Gynecologists' Committee on Practice Bulletins—Obstetrics (July 2016). "Practice Bulletin No. 165: Prevention and Management of Obstetric Lacerations at Vaginal Delivery". Obstetrics and Gynecology. 128 (1): e1–e15. doi:10.1097/AOG.0000000000001523. PMID 27333357.

3.      Singh Shalini, Thakur Tushita, Chandhiok Nomita, Dhillon Balwant Singh. Pattern of episiotomy use and its immediate complications among vaginal deliveries in 18 tertiary care hospitals in India. June 2016. Indian Journal of Medical Research volume:143, issue: 4 Page No: 474-480.

4.      Konar Hiralal. DC Dutta’s Textbook of OBSTETRICS. 8^th edition. New Delhi: Jaypee, 2015, 647-650.

5.      Viswanathan M, Hartmann K, Palmieri R, Lux L, Swinson T, Lohr KN. et al. The use of episiotomy in Obstetrical Care: A Systematic Review. Published on 01 May 2005, (112):1-8. https://ncbi.nlm.nih.gov/book/NBK11967/

 

 

Received on 09.02.2021         Modified on 26.02.2021

Accepted on 19.03.2021      ©A&V Publications All right reserved