LEARNING GUIDE 7.2: EPISIOTOMY AND REPAIR

(To be completed by Learners)

Note: This learning guide should be used in conjunction with Learning Guide for Conducting a Delivery.

Rate the performance of each step or task observed using the following rating scale:
1Needs Improvement: Step or task not performed correctly or out of sequence (if necessary) or is omitted
2Competently Performed: Step or task performed correctly in proper sequence (if necessary) but learner does not progress from step to step efficiently
3Proficiently Performed: Step or task efficiently and precisely performed in the proper sequence (if necessary)
LEARNING GUIDE FOR EPISIOTOMY AND REPAIR
(Many of the following steps/tasks should be performed simultaneously.)
STEP/TASK / CASES
GETTING READY
  1. Prepare the necessary equipment.

  1. Tell the woman (and her support person) what is going to be done, listen to her and respond attentively to her questions and concerns.

  1. Provide continual emotional support and reassurance, as feasible.

  1. Ask about allergies to antiseptics and anesthetics.

  1. Put on personal protective barriers.

ADMINISTERING LOCAL ANESTHETIC
Note: As the birth attendant, you should already have protective clothing and gloves on.
  1. Wash hands thoroughly with soap and water and dry with a clean, dry cloth or air dry.

  1. Put high-level disinfected or sterile surgical gloves on both hands.

  1. Clean the perineum with antiseptic solution.

  1. Draw 10 mL of 0.5% lignocaine into a syringe.

  1. Place two fingers into the vagina along the proposed incision line.

  1. Insert the needle beneath the skin for 4–5 cm following the same line and aspirate by drawing the plunger back slightly to make certain the needle is not penetrating a blood vessel.

  1. Inject the lignocaine solution into the vaginal mucosa, beneath the skin of the perineum and into the perineal muscle.

  1. Wait 2 minutes and then pinch the incision site with forceps. (If the woman feels the pinch, wait 2 more minutes and then retest.)

MAKING THE EPISIOTOMY
  1. Wait to perform episiotomy until:
The perineum is thinned out.
3–4 cm of the baby’s head is visible during a contraction.
  1. Insert two fingers into the vagina, palmar side downward, between the baby’s head and the perineum.

  1. Insert the open blade of the scissors between the perineum and the two fingers.

  1. Make a single cut 3–4 cm long in a mediolateral direction (45º angle to the midline toward a point midway between the ischial tuberosity and the anus).

  1. If delivery of the head does not follow immediately, apply pressure to the episiotomy site between contractions, using a piece of gauze, to minimize bleeding.

  1. Control delivery of the head to avoid extension of the episiotomy.

REPAIRING THE EPISIOTOMY
  1. Ask the woman to position her buttocks toward the lower end of the bed or table (use stirrups if available).

  1. Ask an assistant to direct a strong light onto the woman’s perineum.

  1. Clean the woman’s perineum with antiseptic solution.

  1. If it is necessary to repeat local anesthetic, draw 10 mL of 0.5% lignocaine into a syringe.

  1. Insert the needle along one side of the vaginal incision and inject the lignocaine solution while slowly withdrawing the needle.

  1. Repeat on the other side of the vaginal incision and on each side of the perineal incision.

  1. Wait 2 minutes to allow the lignocaine solution to take effect.

  1. Using 2/0 chromic catgut, insert the suture needle just above (1 cm) the vaginal incision.

  1. Use a continuous suture from the apex downward to repair the vaginal incision.

  1. Continue the suture to the level of the vaginal opening.

  1. At the opening of the vagina, bring together the cut edges.

  1. Bring the needle under the vaginal opening and out through the incision and tie.

  1. Use interrupted sutures to repair the perineal muscle, working from the top of the perineal incision downward.

  1. Use interrupted or subcuticular sutures to bring the skin edges together.

  1. Place a clean pad on the woman’s perineum.

POSTPROCEDURE TASKS
  1. Before removing gloves, dispose of waste materials in a leakproof container or plastic bag.

  1. Place all instruments in 0.5% chlorine solution for 10 minutes for decontamination.

  1. Decontaminate or dispose of syringe and needle:
If reusing needle or syringe, fill syringe (with needle attached) with 0.5% chlorine solution and submerge in solution for 10 minutes for decontamination.
If disposing of needle and syringe, flush needle and syringe with 0.5% chlorine solution three times, then place in a puncture-proof container.
  1. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning them inside out.
If disposing of gloves, place them in a leakproof container or plastic bag.
If reusing surgical gloves, submerge them in 0.5% chlorine solution for 10 minutes for decontamination.
  1. Wash hands thoroughly with soap and water and dry with a clean, dry cloth or air dry.

  1. Record the procedure on woman’s record.

CHECKLIST 7.2: EPISIOTOMY AND REPAIR

(To be used by the Learner for practice and by the Teacher at the end of the module)

Place a “” in case box if step/task is performed satisfactorily, an “X” if it is not performed satisfactorily, or N/O if not observed.
Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines
Not Observed: Step or task not performed by learner during evaluation by teacher

LEARNER______Date Observed ______

CHECKLIST FOR EPISIOTOMY AND REPAIR
(Many of the following steps/tasks should be performed simultaneously.)
STEP/TASK /

CASES

GETTING READY
  1. Prepare the necessary equipment.

  1. Tell the woman (and her support person) what is going to be done and encourage them to ask questions.

  1. Provide continual emotional support and reassurance, as feasible.

  1. Ask about allergies to antiseptics and anesthetics.

  1. Put on personal protective barriers.

SKILL/ACTIVITY PERFORMED SATISFACTORILY
MAKING THE EPISIOTOMY
  1. Wash hands thoroughly and put on high-level disinfected or sterile surgical gloves.

  1. Clean the perineum with antiseptic solution.

  1. Administer local anesthetic.

  1. Perform episiotomy when perineum is thinned out and baby’s head is visible during a contraction.

  1. Insert two fingers into the vagina between the baby’s head and the perineum.

  1. Insert the open blade of the scissors between the perineum and the fingers. Make a single cut in a mediolateral direction.

  1. If delivery of the head does not follow immediately, apply pressure to the episiotomy site between contractions.

  1. Control delivery of the head to avoid extension of the episiotomy.

SKILL/ACTIVITY PERFORMED SATISFACTORILY
REPAIRING THE EPISIOTOMY
  1. Clean the woman’s perineum with antiseptic solution.

  1. Repeat local anesthetic, if necessary.

  1. Use a continuous suture from the apex downward to repair the vaginal incision.

  1. At the vaginal opening, bring the cut edges together.

  1. Bring the needle under the vaginal opening and out through the incision and tie.

  1. Use interrupted sutures to repair the perineal muscle, working from the top of the perineal incision downward and to bring the skin edges together.

  1. Place a clean pad on the woman’s perineum.

POSTPROCEDURE TASKS

  1. Before removing gloves, dispose of waste materials in a leakproof container or plastic bag.

  1. Place all instruments in 0.5% chlorine solution for decontamination.

  1. If reusing needle or syringe, fill syringe (with needle attached) with 0.5% chlorine solution and submerge in solution for decontamination. If disposing of needle and syringe, place in puncture-proof container.

  1. Remove gloves and discard them in a leakproof container or plastic bag if disposing of or decontaminate them in 0.5% chlorine solution if reusing.

  1. Wash hands thoroughly.

  1. Record procedure on woman’s record.

SKILL/ACTIVITY PERFORMED SATISFACTORILY

MCPC Learning Resource PackageModule 7, Malpositions and Malpresentations – Page 1