: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.
 Types of Episiotomy
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
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 outlet
B) 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 is
above 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

INDICATIONS
Hemorrhage: 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 DEATH
It is infant death in the first month after delivery
The 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