Definition:

It is an incision of the pudenda or perineum.

It is also called perineotomy.

Types:

Median (Midline) Episiotomy: Midline incision

Of the perineum.

Mediolateral Episiotomy: Begins in the midline

but is directed laterally away from the rectum.

I - Median Episiotomy

• Easy to repair

• Rare faulty healing

• Less pain in the perineum

• Dyspareunia is rare

• Less blood loss

• Extension to the anal sphincter and rectum

is more common

Types of Episiotomy

II - Mediolateral Episiotomy

• More difficult to repair

• Faulty healing is more common

• More pain in the perineum

• Dyspareunia is more common

• More blood loss

• Extension to the anal sphincter and rectum

• is less common

Types of Episiotomy

Timing of Episiotomy:• Best time to perform episiotomy is when

the head is visible during a contraction to a diameter of 3 to 4 cm.

• Before the application of forceps or vacuum extractor.

• Too early episiotomy causes bleeding from the gaping to be considerable.

• Too late episiotomy causes the muscles of the perineal floor to undergo excessive stretching and lacerations will not be prevented.

Advantages of episiotomy:

• Clean cut incision which is easy to repair compared to irregular vaginal lacerations

• Shorter second stage of labour

• Increase in the diameters of Vulval outlet

• Reduce fetal complications e.g. intracranial haemorrhage in preterm fetus.

• Reduce maternal complications e.g. damage to pelvic floor predisposing to vaginal prolapse, and stress incontinence.

Indications of Episiotomy:A) Maternal:• Short rigid perineum• Previous perineal or pelvic floor repair• Contracted pelvic outletB) Fetal:• Face to pubis delivery• Vaginal breech delivery• Shoulder dystocia• Oversized fetus• Forceps or ventouse delivery

Complications of Episiotomy

• Increased blood loss.

• Extension to anal sphincter or ischio-rectal

fossa

• Haematoma formation.

• Infection.

• Perineal pain and dyspareunia

Technique:

• A vertical incision is made in the perineal

body avoiding the fetal presenting part.

• The incision should be approximately

half the length of the perineal body.

• Mediolateral incisions should be made at

a 45 degree angle to the midline of the

perineum. The incision should extend

into the vagina approximately 2 to 3 cm.

Repair of Episiotomy:• There are many ways to close an Episiotomy

but the most common procedure is:• Vaginal mucosa and submucosa are closed by

chromic catgut up to and approximating the cut ends of the hymeneal ring.

• Interrupted chromic catgut sutures are used to approximate the muscles and fascia.

• Closure of the superficial fascia by continuous suture.

• Closure of the skin by interrupted simple or mattress sutures or alternatively by subcuticular continuous stitches.

THE ELDERLY PRIMIGRAVIDA

This term is applied to the primigravida whose age isabove 35 years. During pregnancy and labor these women are more liable to the following: Pregnancy induced hypertension with its complications especially accidental hemorrhage.Uterine inertia, premature rupture of membranes and prolonged labor.Rigid perineum and so low forceps may be needed more frequently.The fetus is usually very precious and the rate of cesarean section is increased for fetal safety.

THE GRAND MULTIPARA

This term is applied to the women who had 5 or more previous deliveries .

During pregnancy and labor they are more liable to the following:

• Anemia.• Pregnancy induced hypertension with its complications.• Placenta previa.• Diabetes with pregnancy.• Pendulous abdomen with malpresentations.• Uterine inertia, prolonged labor, premature rupture of

membranes and prolapsed cord.

• Obstructed labor and rupture uterus due to:• Malpresentations and large sized fetus.• Some osteomalacic changes in the bony

pelvis.• Pendulous abdomen.• Weak uterine muscles.• False sense of security.• Increased incidence of operative delivery

(forceps-C.S).• Post partum hemorrhage, puerperal sepsis

and sub involution.• Higher perinatal mortality.

BLOOD TRANSFUSION IN OBSTETRICS

INDICATIONSHemorrhage: during pregnancy or postpartum.Severe anemia (given very slowly to avoid overloading the circulation or better give packed RBCs).Puerperal sepsis and septic abortion: better fresh blood. Babies with erythroblastosis fetalis.Exchange transfusion after birth.Intrauterine transfusion in selected cases.Hypofibrinogenaemia (DIC)

Complications of blood transfusion Major anaphylactic reactions

due to incompatibility leading to dyspnea,

cyanosis, rigors, lumbar pain and anuria.

Febrile reactions due to presence of pyrogens as

blood or apparatus. Stop transfusion and give

antipyretics and antihistaminics.

Air embolism.

Circulatory overloading especially in cases of anemia.

Transmission of diseases: AIDS and infective hepatitis.

Precautions Cross matching

Rate of transfusion = rate of blood loss.

Blood should not be very cold.

For every 1-liter blood give 10 cc calcium gluconate.

Constant observation.

Monitoring CVP during transfusion in risky cases.

MATERNAL MORTALITY

Maternal mortality rate (MMR), is significantly increased in

developing countries, mostly due to inadequate health

services, low socioeconomic standards, lack of health

hygiene and education, and lastly deeply routed

inappropriate health habits.

Incidence: MMR in Egypt is 82/ 100000 deliveries

Causes of Maternal mortality : Post partum Hemorrhage (PPH): 34%Pregnancy induced hypertension (PIH): 22%Antepartum haemorrhage (APH): 9.0% Infection: post-partum and post-abortive: 8.0%.

Rupture of the uterus: 8.0%C.S. complications: 7.0%Pulmonary embolism and DIC.

Medical problems as heart disease with pregnancy.Complications of anaesthesia.

CAUSES OF FETAL / NEONATAL MORTALITY

ANTENATAL INTRAUTERINE FETAL DEATH

Hypertensive disorders of pregnancy

(due to placental insufficiency or separation)

Diabetes with pregnancy.

Rh incompatibility.

Placental insufficiency due to any cause as accidental hemorrhage,

multiple infarctions or abnormally small placenta.

Congenital anomalies of the fetus.

Knots of the cord.

Idiopathic.

II. INTRANATAL DEATH

Asphyxia.

Intracranial hemorrhage.

Intra-amniotic infection.

Birth trauma.

III. NEONATAL DEATHIt is infant death in the first month after deliveryThe highest neonatal mortality occurs during the first week after delivery and is due to:• Prematurity.• Asphyxia neonatorum.• Birth injuries.• Congenital anomalies.• Hemolytic and hemorrhagic diseases of the newly born.• Respiratory distress syndrome.• After the first week: death is mainly due to infection.

N.B: Perinatal mortality: includes antenatal and intranatal death and death during the first week after delivery