Perineal Lacerations Episiotomy

Perineal Lacerations
Episiotomy
C. Savona-Ventura
Perineal lacerations
✔ 1st degree: involves the anterior part of the
perineum and the posterior wall of the
vagina.
✔ 2nd degree: involves the perineum up to the
external sphincter with a corresponding
tear in the vagina.
✔ 3rd degree: includes the anal sphincter and
possibly extends to the anal canal.

Episiotomy
✔A deliberate incision in the
perineum to enlarge the introitus
and straighten the birth canal
(remove the curve of the birth
canal)
Episiotomy
✔A very ragged vaginal tear is an
unsatisfactory thing to sew up. When an
episiotomy extends, it will extend but
very seldom extends into the rectum.
Tearing of the perineum may easily be
uncontrolled.

Episiotomy:Absolute Indications
✔All cases of fetal distress.
✔All cases of prematurity.
✔Primigravid breech deliveries.
✔All cases of face-to-pubes. OP position.
✔After previous Pelvic Floor Repair
surgery
Episiotomy: Relative Indications
✔Narrow subpubic arch.
✔Failure to advance because of perineal
rigidity.
✔Presenting part on pelvic floor >30
min.
✔Most cases of face presentation.
✔When perineal skin starts to tear.

Episiotomy: Prof. G.B. Schembri 1896
✔ “... to avoid the laceration from running down
the raphe, and risking to injure the sphincter of
the anus, two small cuts (1/4 inch) are made with
a flat bladed and blunt pair of scissors, one on
each side of the lower third of the vulva, directed
obliquely outwards and downwards towards the
trochanters....”
Episiotomy/Laceration rate:
SLH
✔ 1938: 1.1% of hospital deliveries.
23 perineal lacerations: of which 4 were
episiotomies, 3 were third degree tears.
6 cases of obstetric genital fistuale.
✔ 1951: 7.5% of hospital deliveries
✔ 1995: episiotomies - 39.2%
1-2nd degree tears - 25.1%
3rd degree tears - 0.1% [6 cases]

Episiotomy repair:
Prof. S.L. Pisani, 1883
✔“ ......it-tarbia xi drabi baqget gaddeyya
minn jo nofsu, yeu cartititu mil furketta
sat-toqba tal fundament. U gal mara din hi
hsara kbira, tasseu li it-tobba isewwuha;
izda tibqa’ deyyem tiswia, u wisq ahyar li il
perineu yibqa’ shih.”
Episiotomy repair
Prof. G.B. Schembri, 1896
✔ “In case of rupture of the perineum operated
upon by the surgeon, great care is to be taken by
the midwife to keep away from the sutured
surface, any discharge derived from the vulva
(locchia), or from the rectum and bladder. ....To
avoid streching on the sutures, the lower limbs
are to be kept together by means of a napkin or a
bandage passed round the knees.”

Perineal repair: 1st-2nd degree tears
✔ Give local anaesthesia (1% lignocaine to skin and
subcutaneous tissues).
✔ Vaginal skin is sutured from apex with a
continuous running absorbable.
✔ Perineal muscles sutured with interrupted
stitches closing all dead space.
✔ Perineal skin closed with interrupted stitches.
Avoid excessive tightening of sutures.
Perineal repair: 3rd degree
✔Perform in Operating Theatre, possibly
under anaesthesia.
✔Repair anal canal with interrupted
absorbable suture with knots tied into
canal.
✔Suture external sphincter muscles with
absorbable sutures.
✔continue as for 2nd degree tear.