Episiotomy, Bleeding In Pregnancy & Postpartum Hemorrhage

Episiotomy:
Episiotomy is a surgical incision given to a woman in late second stage of labour in order to widen or enlarge the vaginal opening. It must be applied at the correct time and positing as well as repaired properly and promptly (within a short time).

Types Of Episiotomy

• Mediolateral Episiotomy : this is the commonest type and it is given at 45 degrees angel from the mid line avoiding the anus as much as possible. 
• Midline Episiotomy : this is given at the centre of the perineum along the mid line. 
• J-Shaped EPisiotomy : here the incision is made in the shape of a "j" with the curve above and away from the anus.

Reasons For Episiotomy

• If the perineum threatens to tear such as occurs in women who has undergone female genital mutilation with extensive scaring
• Delay in the second stage due to soft tissue resistance (tight perineum) 
• Breech delivery 
• Fetal distress
• Forceps delivery 
• Fetal macrosomia (big baby) 4.2kg
• Preterm (premature) babies. 

Advantages Of The Midline Episiotomy

• It is easy to repair 
• Faulty healing is rare
• It is less painful 
• Dyspareunia is rare
• Blood loss is minimal.

Disadvantage Of Midline Episiotomy

• It can affect the anal sphincter by extension. 

Advantage Of Mediolateral Episiotomy

• Extension into the anal sphincter is less common. 

Disadvantages Of Mediolateral Episiotomy

• It is more difficult to repair 
• It usually has faulty healing 
• It is more painful 
• It involves greater bleeding 
• Dyspareunia occurs occasionally. 

How To Perform And Repair Episiotomy

• An incision is made just when the head of the fetus is distending the perineum associated with uterine contractions (a.k.a crowning) 
• If episiotomy is done earlier, it leads to more blood loss. 
• Adequate analgesia should be given before giving episiotomy and before the repair of episiotomy. 1% xylocaine is frequently used.

Note: As much as possible, reduce pain during this procedure.

• After delivery, carefully and promptly suture/close the episiotomy wounds in Anatomical Layers using absorbable suture material commonly chronic catgut either 2-0, or 0.
• The closure must start from the apex of the tear. Close the perineal muscle layer with interrupted or continuous sutures and then close the vaginal mucosa, sub mucosa and skin in continuous sutures.

Complications Of Episiotomy:
Maternal Complications :

• Bleeding 
• Episiotomy wound breakdown usually following infection 
• Infection 
• Painful coitus 
• Psychosexual problems. 

Fetal Complications :

• Laceration of the baby 
• Castration in breech baby
• Increased risk of vertical transmission of HIV infection.

Cervical Laceration /Tear
Cervical tear usually occurs following normal vaginal child birth. It occurs commonly at 3 O'clock and 6 O'clock positions. More severe laceration can extend far upwards affecting the uterus hence requiring extension repair.

Symptoms And Signs Of Cervical Laceration

• Excessive bleeding following delivery (post partum hemorrhage -PPH) 

Complications Of Cervical Laceration

• Bleeding 
• Anemia 
• Infection
• Cervical scarring leading to difficult labour in subsequent deliveries 
• Maternal death to excessive blood loss.

Bleeding In Pregnancy
There are several causes of bleeding in both early and late pregnancy. A good understanding of these will form the basis for adequate management.
Bleeding can occur either early or late in pregnancy

Causes Of Bleeding In Early pregnancy
The following are the causes in early pregnancy :

• Miscarriage
• Implantation bleeding 
• Ectopic pregnancy 
• Local genital tract injuries /trauma
• Molar pregnancy. 

Causes Of Bleeding In Late Pregnancy

• Placenta previa
• Abruption of placenta 
• Local causes eg, trauma, infection, cancer 
• Show of labour. 

NB: A woman never experiences her normal menstrual period after conception.


Abruptio Placenta
This is defined as the premature separation of properly located placenta before the delivery of the baby.

Causes Of Abruptio Placenta

• Hypertension in pregnancy
• Kidney disease in pregnancy 
• Trauma, blunt or forceful 
• Diabetes 
• Multiple pregnancy eg, twin pregnancy 
• Folic acid deficiency 
• Drug abuse in pregnancy. 

Symptoms And Signs Of Abruptio Placenta

• Abdominal pain 
• Vaginal bleeding 
• Hard uterus 
• Fetal death
• Back pain. 

Placenta Previa
This is defined as the abnormal location of the placenta at the lower segment /part of the uterus .

Symptoms And Signs Of Placenta Previa

• Bright red vaginal bleeding
• There is usually no abdominal pain 
• Most times the baby is still alive. 

Postpartum Hemorrhage :
Postpartum hemorrhage (PPH) is said to occur if bleeding of 500ml or more follows vaginal delivery or more than 1 liter following Caesarean operation. PPH is an obstetric emergency hence demands prompt diagnosis and treatment.

There are two categories of postpartum hemorrhage

• Primary PPH 
• Secondary PPH

Primary PPH : this is by far the more commonly seen and it is by far also the more severe in consequences. Primary PPH is when excessive bleeding occurs within 24 hours of delivery.

Secondary PPH : is when excessive bleeding occurs after 24 hours of delivery but before the end of 6 weeks after delivery.

Causes Of PPH

• Uterine atony: this is when the womb fail to contract following delivery of the baby due to several factors. This could be as a result of incomplete expulsion of placenta and membrane.
• Injury to the genital tract : this may include laceration injuries to the vagina, cervix, etc
• Blood coagulation abnormalities : the blood could not cloth as it should 
• Retained products of conception which may be some parts of the placenta or membranes
• Uterine inversion which may complicate fundal pressure application during difficult labour.

Management Of PPH

• Immediately call for help, meanwhile 
• Massage the uterus 
• Empty the urinary bladder 
• Secure an intravenous access/cannula
• Give oxytocics such at ergometrin, oxytocin injections or rectal 
• Collect blood sample for clotting profile analysis 
• If placenta is retained, you may attempt controlled umbilical cord traction or/and manual removal of the placenta if you are trained. You may undertake uterine mevacuation if there are retained products
• If the placenta is delivered completely and bleeding still continues, 
• Examine the vagina and cervix to check for laceration injuries. If these are found, repair them with absorbable sutures 
• If bleeding continues, do an ultrasound scan 
• If clotting profile is normal, the patient may need surgery.