USING ANESTHESIA 



Injecting anesthesia for a hospital-based episiotomy. In a home birth episiotomy (which is rare), we find this is not necessary since we use the episiotomy as a last resort and the perineal tissue is usually stretched to a very thin maximum already and not requiring anesthesia. Anything given to the mother will cross the placenta and have effect on the baby. 



VARIOUS TYPES OF EPISIOTOMY INCISIONS 

Medio-lateral (posterio-lateral) - Is a favorite of birth practitioners and does not require careful control of the baby's head which may damage or tear through the anal sphincter. Often it is used to help with forceps and vacuum extraction types of deliveries. The incision is begun at the center of the fourchette and directed posterio-laterally, usually to the woman's right. It should be not more than 3 cm long and is directed diagonally in a straight line which runs 2-5 cm distant from the anus. If the anus is considered to be 6 on the clock, the incision would be directed to 7 o'clock. 

Median - The incision, begun at the center of the fourchette, is directed posteriorly for approximately 2-5 cm in the midline of the perineum. It is a favored by experienced birth practitioners that have careful control of the baby's head as it passes through the vaginal opening. There is a great risk that the incision will be extended during delivery and can go directly into the anal sphincter resulting in a third degree tear. When vaginal manipulation is necessary or the baby is large, the median incision does not provide as much space as the medio-lateral incision. The advantages are (a) less bleeding, (b) more easily and successfully repaired, (c) greater subsequent comfort for the woman. 

J-Shaped - The incision is begun at the center of the fourchette and directed posteriorly to the mid-line for about 2 cm and then directed outwards toward 7 on the clock to avoid the anus. The suturing of this incision is difficult. Shearing of the tissues occurs. The repaired wound tends to be puckered. 

Lateral - The incision is begun one or more cm distant from the center of the fourchette and is not a favored incision. Bartholin's duct may be severed. The levator ani muscle is weakened. Bleeding is more profuse. Suturing is more difficult and the women experiences subsequent discomfort. 





A mediolateral episiotomy is cut. This is a standard procedure in a hospital birth and is supposed to help facilitate descent of the baby's presenting part (head or buttocks) and the common use of forceps to aid in the delivery of the fetal head. 



Care must be taken to prevent injury to the fetal presenting part. A blunt-ended side of the scissors should be used on the inside of the perineum and the presenting part protected by the practitioner doing the episiotomy. 



Inspection of the episiotomy is done and the extent of the wound is assessed. Careful inspection includes matching up of land marks (such as the hymenal tags). 





Assessment includes determination of damage. With a first degree tear or incision, only the fourchette is damaged. 



A second degree tear or incision has damage beyond the fourchette, into the muscle tissue but not involving the rectum or anal sphincter. 



A third degree tear or incision has damage into or through the anal sphincter. 



Locating and finding the apex of the incision and the matching sides. Repair of the episiotomy is achieved by closure of the vaginal wall, interrupted sutures into the levatores ani, and interrupted sutures to the skin. 



Care is taken to expose the apex of the incision in the vaginal wall and a continuous absorbable suture is used to close the vaginal wall. 



The wound is closed to the introitus. 



Care is take to ensure that the introitus is not constricted. 



Interrupted absorbable sutures are inserted into the levatores ani. 



Interrupted mattress sutures are used to close the skin.