EPISIOTOMY-- Procedure

Well ... I think the most common surgical procedure being done in SAT might be Episiotomy...

'Coz now a days all the FTND's are indications for Episiotmy... So letz seee how it's supposed to be done.. May be you may find some differences in what'z being done here.. This blog's just a basic idea and you can modify it according to your knowledge, experience and the teachings....

EPISIOTOMY
As before any surgery, prepare the patient and instuments ... As i said in my previous blog, you need to read it from your texts.. But something about asepsis in perineal area follows..


- Wash the area with soap and water, if necessary;
- Apply antiseptic solution (e.g. iodophors, chlorhexidine) three times to the area using a high-level disinfected or sterile ring forceps and a cotton or gauze swab. If the swab is held with a gloved hand, care must be taken not to contaminate the glove by touching unprepared skin;
- Begin at the centre of the area and work outward in a circular motion away from the area;
- At the edge of the sterile field discard the swab.
Never go back to the middle of the prepared area with the same swab. Keep your arms and elbows high and surgical dress away from the surgical field.

Provide emotional support and encouragement. This is very important as a stressful patient has more chances of complications in any surgical procedures..

Provide local anaesthesia. Lignocaine?? well.. then know this too...

Lignocaine preparations are usually 2% or 1% and require dilution before use.For most obstetric procedures, the preparation is diluted to 0.5%, which gives the maximumeffect with the least toxicity. Combine: lignocaine 2%, 1 part; normal saline or sterile distilled water, 3 parts (do not use glucose solution as it increases the risk of infection).
OR..
lignocaine 1%, 1 part; normal saline or sterile distilled water, 1 part.


Infiltrate beneath the vaginal mucosa, beneath the skin of the perineum and deeply into the perineal muscle using about 10 mL 0.5% lignocaine solution.

Note: Aspirate (pull back on the plunger) to be sure that no vessel has been penetrated. If blood is returned in the syringe with aspiration, remove the needle. Recheck the position carefully and try again. Never inject if blood is aspirated. The woman can suffer seizures and death if IV injection of lignocaine occurs.
At the conclusion of the set of injections, wait 2 minutes and then pinch the incision site with forceps. If the woman feels the pinch, wait 2 more minutes and then retest.
Anaesthetize early to provide sufficient time to effect..


Wait to perform episiotomy until:
- the perineum is thinned out; and
- 3–4 cm of the baby’s head is visible during a contraction.
Performing an episiotomy will cause bleeding. It should not, therefore, be done too early.

Wearing high-level disinfected gloves, place two fingers between the baby’s head and the perineum.

Use scissors( you know which scissors!!) to cut the perineum about 3–4 cm in the mediolateral direction.

Use scissors to cut 2–3 cm up the middle of the posterior vagina.

Control the baby’s head and shoulders as they deliver, ensuring that the shoulders have rotated to the midline to prevent an extension of the episiotomy.

Carefully examine for extensions and other tears and repair.

IF NO TEARS....... WELL DONE MY BOY......(Girls do forgive) :P

REPAIR OF EPISIOTOMY

Note: It is important that absorbable sutures be used for closure. Polyglycolic sutures are preferred over chromic catgut for their tensile strength, non-allergenic properties and lower probability of infectious complications and episiotomy breakdown. Chromic catgut is an acceptable alternative, but is not ideal. But you know what we are using.......

Apply antiseptic solution to the area around Episiotomy.

If the Episiotomy is extended through the anal sphincter or rectal mucosa, ....boooohooooooo.....
It's not yur day out!!!!!....... Manage it as a 3rd or 4th degree tears respectively. Well.. I'll tell you the management in the end of this blog or in the next post,.. (As my hands are aching due to long typing.. i don't know much of typing).

Close the vaginal mucosa using continuous 2-0 suture

Start the repair about 1 cm above the apex (top) of the episiotomy. Continue the suture to the level of the vaginal opening;
- At the opening of the vagina, bring together the cut edges of the vaginal opening;
- Bring the needle under the vaginal opening and out through the incision and tie.

Close the perineal muscle using interrupted 2-0 sutures .

Close the skin using interrupted (or subcuticular) 2-0 sutures .

YIPPIEEEEE,... DONE...

NOW SCRIBBLE THE ADVICES IN THE CASE SHEET N GO GET YURSELF SOME REST...

Sad part is yet to come....

THE COMPLICATIONS

If a haematoma occurs, open and drain. If there are no signs of infection and bleeding has stopped, reclose the episiotomy.

If there are signs of infection, open and drain the wound. Remove infected sutures and debride the wound:
- If the infection is mild, antibiotics are not required;
- If the infection is severe but does not involve deep tissues, give a combination of antibiotics:
- ampicillin 500 mg by mouth four times per day for 5 days;
- PLUS metronidazole 400 mg by mouth three times per day for 5 days.


For deep and severe infections like Necrotising Fascits, just call in the seniors or try some good Combinations of antibiotics, preferably i.v...............................


So thatz all for now...................... the next small blog will tell you how to manage a case of 3rd degree or 4th degree episiotomy tear!!!!!!!!!!

bbyeeeeeeeeeeeeeee lolzz.......