Episiotomy: When will we cut it out? - PowerPoint PPT Presentation

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Episiotomy: When will we cut it out?

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PMH: asthma -no intubations or hospitalizations. Albuterol PRN PSH: D&C only Meds: PNV Allergies: NKDA SH: lives w mom. No tob/EtOH/drugs at all. – PowerPoint PPT presentation

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Title: Episiotomy: When will we cut it out?


1
Episiotomy When will we cut it out?
  • Alice Teich, PGY1
  • Dept of Family and Social Medicine
  • April 27, 2010

2
Case
  • 3/26/10
  • HPI 16yo G1P0010 _at_38w1d by LMP (7/5/09) EDD
    4/8/10 c/w 11w sono p/w CTX q5min since 3pm
    today. LOF en route to hospital (30min ago.)
    No VB, FM
  • PNI Intake BP 102/50 (102-132/50-90). Weight
    gain 31lbs (intake 158 --gt189)
  • Adolescent pregnancy saw SW, and nutritionist.
    Attended all prenatal appointments. Has WIC and
    Medicaid filled out.
  • PNL wnl/unremarkable
  • Sonos 9/20/09 dating sono _at_11w
  • 11/14/09 anatomy scan _at_ 19wks. No anat.
    Anomalies. Fetus 50tile
  • 2/17/10 no anat. Anomalies _at_31w. Fetus 55tile w
    adequate interval growth. AFI 14.
  • PObHx 2008 TOP 1st trim. DC. uncomplicated
  • PGynHx no cysts/fibroids/STIs/abnl pap.
  • 12/reg/5.

3
Case continued..
  • PMH asthma -no intubations or hospitalizations.
    Albuterol PRN
  • PSH DC only
  • Meds PNV
  • Allergies NKDA
  • SH lives w mom. No tob/EtOH/drugs at all. In
    high school. FOB involved.
  • FH non-contributory.
  • PE BP 112/60 HR 74 Tmax 36.6
  • FHT 140/mod/accels, -decels (EFM)
  • Toco CTX q2-3 min (monitored externally)
  • SVE 9/10/0 Vsono EFW 3100g (Leopolds)
  • A/P 16yo G1P0010 _at_38w1d in active labor
  • Admit to LD -- anticipate NSVD

4
Case continued..
  • Pt c/o pain and need to make bm. Found to be
    FD and ready to push.
  • SVE 10/100/1
  • Toco CTX q2-3min
  • Pt is in significant pain while pushing and
    requesting pain medication infants head has
    been crowning for approx 2 minutes/too late for
    epidural or IV analgesia.
  • Pt is screaming, thrashing around, and FHT begins
    to decel to 70s, 80s, then comes back up to 120s,
    then decels again. Pt repositioned to lateral
    decub on both sides, but unable to stay in these
    positions, given discomfort.
  • Episiotomy is cut midline, attempt made to
    deliver head for approx 30 seconds, then
    additional space cut, creating 2nd degree
    episiotomy. Infant is quickly delivered without
    instrumentation.
  • Delivery of vigorous female infant w apgars of
    9/9. Cord clamped, cut, and gases sent. 3 cord
    placenta delivered spontaneously and intact.
    Fundus firmed with fundal massage and pitocin
    administration. Lidocaine administered locally
    and 2nd degree episiotomy repaired with 2-0 and
    3-0 vicryl w/o further complication. No 3rd
    degree extension into rectal sphincter.
    Hemostasis achieved. EBL 500cc.

5
Episiotomy
  • Definition a surgical incision of the perineum
    usually performed at point when perineum is
    stretched and distended, just prior to crowning
    of the fetal head.
  • Median/Midline vertical incision from fourchette
    straight back towards anus
  • Easier to repair
  • Mediolateral episiotomy incision perpendicular
    to midline, with angle becoming smaller (45º)
    beyond fetal presenting part
  • Less extension to rectum
  • J incision hybrid

6
Episiotomy
The purpose is to increase the diameter of the
soft tissue pelvic outlet, thereby preventing
perineal lacerations, facilitating delivery, and
reducing the time for expulsion of the infant.
7
Episiotomy
  • One of the most common operations performed on
    women
  • Prevalence is decreasing

8
Indication for Episiotomy?
  • The only indication for episiotomy that cannot be
    categorically dismissed is for fetal concerns
    (non-reassuring tracing, etc) that arise urgently
    during advanced labor.
  • Other historical indications for episiotomy are
    not evidence-based and are proven to do more harm
    than good.
  • Nulliparity
  • Imminent tear
  • Shoulder dystocia
  • Need for vacuum or forceps delivery

9
Not an Indication for Episiotomy
  • Nulliparity

10
Not an Indication for Episiotomy
  • Tearing is imminent

11
Not an Indication for Episiotomy
  • Severe Shoulder dystocia

12
Not an Indication for Episiotomy
  • Using vacuum or forceps for delivery

13
Episiotomy
  • Other enduring myths about episiotomy
  • It prevents pelvic floor weakness
  • It is easier to repair than a tear
  • It heals better than a tear
  • It minimizes intraventricular hemorrhage in
    preterm infants

14
Evidence against routine use of episiotomy
  • Increases the following
  • Wound extension, dehiscence, infection, and
    healing time
  • Blood loss
  • Postpartum pain
  • Likelihood of leaking stool and gas (bowel
    incontinence)
  • Dyspareunia
  • /- urine incontinence

15
Episiotomy Why is it still performed?
  • High-intervention standards for childbirth
  • Practice style and values of individual providers
  • Practice style and values in specific birth
    settings
  • Influence of colleagues
  • Influence of medical education

16
Avoiding episiotomy
  • As early as possible in pregnancy
  • Encourage pts to learn about episiotomy as part
    of learning about pregnancy, labor and delivery
  • Encourage pts to create a birth plan that takes
    into account their values, preferences
  • Even if you have been the provider for a pt
    throughout their entire pregnancy and especially
    if you havent, ask pts about their birth plans
    again at the time of labor/admission.

17
Avoiding episiotomy
  • Kegel exercises
  • Perineal massage
  • Warm Compresses
  • Slowed, spontaneous pushing during second stage
    of labor
  • Upright birthing position

18
References
  • http//www.childbirthconnection.org
  • Hartmann K, Viswanathan M, Palmieri R, Gertlehner
    G, Thorp J, Lohr KN. Outcomes of routine
    episiotomy a systematic review. JAMA 2005
    2932141-8
  • UptoDate
  • ACOG PRACTICE BULLETIN. CLINICAL MANAGEMENT
    GUIDELINES FOR OBSTETRICIAN/GYNECOLOGISTS NUMBER
    71, APRIL 2006
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