Episiorrhaphy: Technique, Types And Care

The episiotomy is performed suture to repair an episiotomy. The episiotomy is a surgical incision that is made in the woman’s perineum area in order to facilitate the expulsion of the fetus without tearing.

Episiotomy can be done with special scissors or with a scalpel. This incision includes several planes such as the skin, fasciae, muscle, and vaginal mucosa. When episiorrhaphy is performed, each plane must be sutured with the appropriate type of suture (generally absorbable sutures are used) and with a particular technique.

The words episiotomy and episiorrhaphy have a common Greek root: “epision” or “episeion”, which refers to the pubis. These procedures involve an incision and suturing of an area called the perineum. The perineum has a superficial area and a deep area, diamond-shaped and located in the genital area.

If an imaginary horizontal line is drawn that passes through the ischial tuberosities, the rhombus that forms the perineum is divided into two triangles, an upper one where the urogenital area is located and a lower one where the anal area is located.

The perineum contains skin, muscle, and fasciae, which are cut at the episiotomy along with the vaginal wall and which must be sutured at the episiorrhaphy. Three main muscles are found in the perineal area of ​​women: the ischiocavernosus, the superficial transverse perineum and the bulbocavernosus.

Episiotomy and, therefore, episiorrhaphy are indicated for maternal causes due to the imminence of a vulvo-vagino-perineal tear, to shorten the expulsive period and the intensity of the push or for fetal causes such as acute fetal distress, macrocephaly, position breech, etc.

Techniques

According to the American College of Gynecology and Obstetrics, episiotomies – and consequently episiorrhaphies – should not be routinely indicated and their use should be restricted to indications for maternal or fetal causes.

Before starting episiorrhaphy, local anesthesia with lidocaine is applied. Even, sometimes, in patients who have undergone epidural anesthesia for delivery, it must be reinforced with local anesthesia to finish the suture.

The techniques used for episiorrhaphy depend on the type of episiotomy. There are basically two types of episiotomies: one medial and one mediolateral. The latter, depending on the obstetric school referred to, has different cutting inclinations with respect to the midline.

In cases where there are extensions or there is a need to repair tears, the technique will vary according to the degree of tear and the extension of the extension.

Episiorrhaphy is done with absorbable sutures. In addition, chrome-plated “catgut” (a kind of nylon) is used to suture the muscle and the same type of suture can be used for the other planes. Some obstetricians prefer polyglycol sutures, as they are more resistant to tension and are hypoallergenic, reducing the frequency of dehiscence.

Episiorrhaphy is performed once the delivery of the placenta is complete and after ensuring the hemodynamic recovery of the patient. It allows restoring the anatomy and controlling bleeding, favoring hemostasis.

Episiorrhaphy of a medial and mediolateral episiotomy

The suture begins with the vaginal mucosa, beginning approximately one centimeter behind the apex of the vagina with a deep anchor point. A continuous cross suture is made to the immediate posterior area of ​​the caruncles of the hymen.

Once the vagina has been sutured, the compromised portion of the transverse muscle and the joint tendon in the perineal wedge is sutured with continuous and uncrossed suture. The suture is continued up to the lower vertex of the perineum and from there the skin is sutured.

For the skin suture, both the subcutaneous cell and the skin are addressed. This last suture can be done with running sutures or with separate stitches.

Episiorrhaphy for episiotomies with extensions or to repair tears

Tears of the birth canal are classified into four grades.

First degree : affects the hairpin, the skin of the perineal area and the vagina without affecting fascia or muscles.

Second degree : it involves the fascia and the muscle.

Third degree : includes the skin, mucosa, perineum, muscles and anal sphincter.

Fourth degree : it extends, compromising the rectal mucosa and may include tears in the urethra.

First degree tears do not always require suturing. When necessary, a very fine “catgut” or adhesive suture glue is used.

Second-degree tears are sutured following the steps described for episiorrhaphies of medial and mediolateral episiotomies. The third degree include anal sphincter repair, for which there are two techniques: one called the “ end to-end technique ” and the other “ overlapping technique ” (overlapping).

The fourth degree involves a repair in order, first of the rectum, then the sphincter of the anus, and then the steps similar to those described for the suture of the medial or mediolateral episiotomy are followed.

When an episiotomy prolongation is sutured, the sphincter of the anus is repaired first and then proceeded as previously mentioned. Anatomic repair must be done without leaving “dead” spaces that can fill with blood.

Types

There are several types of episiorrhaphy:

– Those that correspond to the sutures of the medial and medial-lateral episiotomies.

– Those used to correct or suture tears and extensions.

Care

– Patients who have undergone this procedure should avoid the use of tampons and vaginal douches in the postpartum period, in order to ensure adequate healing and avoid new injuries.

– Patients should be informed about the need to abstain from sexual intercourse until they have been re-evaluated by the treating physician and are fully recovered.

– They should not perform physical activities that could cause dehiscence of the sutures, at least during the first 6 weeks.

– Sanitary pads should be changed every 2-4 hours. Daily cleaning of the genital area with soap and water should be maintained at least once a day and whenever necessary; for example, after urinating or having a bowel movement. They should dry the area using clean towels or baby wipes.

– The minimum time necessary for the healing and absorption of the sutures ranges between 3 and 6 weeks.

– In cases where the anal sphincter and rectum are involved, antibiotic treatment is indicated.

– A diet rich in fiber should be maintained to avoid constipation and pain to evacuate. Regarding the use of pain medications, those that do not affect the child (breast milk) and only if the pain is very intense can be indicated.

– Patients should see a doctor if pain increases, if they have vaginal secretions with a bad smell, if blood loss increases, if they observe areas where the wound opens or they have not evacuated in 4 or 5 days.

References

  1. Crisp, WE, & McDonald, R. (1953). Control of Pain Following Episiorrhaphy. Obstetrics & Gynecology , 1 (3), 289-293.
  2. Dashe, JS, Bloom, SL, Spong, CY, & Hoffman, BL (2018). Williams obstetrics . McGraw Hill Professional.
  3. Moreira, C., & Torres, A. (2013). Didactic guide for the workshop: Episiotomy, episiorrhaphy, perineal tears and their repair. Ecuador: Private Technical University of Loja. Department of Health Sciences .
  4. Phelan, JP (2018). Critical care obstetrics . John Wiley & Sons.
  5. Trujillo, A. (2012). Protocol of indications and technique of episiotomy and episiorrhaphy. New Granada .
  6. Woodman, PJ, & Graney, DO (2002). Anatomy and physiology of the female perineal body with relevance to obstetrical injury and repair. Clinical Anatomy: The Official Journal of the American Association of Clinical Anatomists and the British Association of Clinical Anatomists , 15 (5), 321-334.

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