The generic process is very complex and largely unpredictable. Therefore, during the birth of a baby, doctors are always ready to provide a woman with any help. One of the methods of active obstetric protection is perineotomy. About what it is and why this procedure can be carried out in childbirth, we will tell you in this article.
Features:
The birth of the fetal head is an important and crucial moment, which can sometimes be overshadowed by purely physical difficulties - a discrepancy between the size of the outlet from the vagina and the diameter of the head, as a result of which there is a possibility of spontaneous rupture of the perineum. If such a rupture occurs, the consequences can be very serious - sometimes not only the genitals, but also the intestines are injured, severe bleeding, vaginal-rectal fistula develops.
If such a delicate situation arises, during childbirth, obstetricians can use perineotomy - a surgical dissection of the perineum of the median type. In an episiotomy, an incision is made from the center to the right or left, diagonally.
A perineotomy involves a straight, vertical incision from the center of the perineum down to the anus. The length of the incision is 2-3 centimeters. This is the main difference from episiotomy. The rest of the methods are no different, and therefore perineotomy is considered one of the types of episiotomy, allocating it an honorable second place in the classification of dissection types.
This artificial expansion of the perineum allows the baby to quickly leave the birth canal, if the situation requires it, moreover, the incision prevents tears, which has a positive effect on recovery from childbirth.
The difference between episiotomy and perineotomy is almost imperceptible in the rehabilitation process, because the rules for processing sutures and basic recommendations for women with a mid-lateral (diagonal) incision and a straight (median) incision are almost the same.
The name of manipulation comes from the Greek perineotomia (in turn, this word consists of perineos - "female perineum" and tome - "dissection"). It is used along with an episiotomy and is a free choice of a doctor or obstetrician taking part in childbirth. That is, how to make the dissection is decided by the situation. Although some studies show that with a vertical midline incision, there is a higher risk of continuing the rupture along the incision down to the rectum. Therefore, a mid-lateral dissection is considered more appropriate. But there are no clear indications on this score.
Until recently, manipulation was widespread in obstetrics. Almost every woman in labor was “cut”. Today, on the recommendation of the WHO and the Ministry of Health of Russia, perineotomy is used less often and only if there are certain indications.
Indications
As already mentioned, earlier the dissection was done for preventive purposes - to prevent perineal tears. Today the view of perineotomy and episiotomy has changed. The Ministry of Health recommends the tactics of observation and waiting. The medical staff can resort to surgical dissection only when there is a high probability of rupture during pathological childbirth.
A midline incision may be necessary at the birth of a large baby, with a large head diameter or born with legs forward. Usually, under such circumstances, a caesarean section is recommended, but a woman has every right to write a refusal and insist on natural childbirth.
If doctors need to apply forceps or a vacuum extractor, there is also a need to expand the perineal region surgically. Colloidal and thinned, patchy scars from previous tears or incisions can also be the basis for a midline incision.
High perineum and rigidity for some time now are not considered grounds for indispensable perineotomy.
The method can be used if a woman is forbidden for medical reasons to push hard (for example, with diseases of the organs of vision). Great hopes are pinned on manipulation also in the case of detecting a state of hypoxia in a child whose head is already at the exit from the vagina.
Execution technique
The incision is made exclusively during the period of pushing, neither earlier nor later. The head should already be cut through and peek out about 3-4 centimeters at the peak of the next push. Take blunt-pointed surgical scissors. In the interval between attempts, one end is inserted inside, the other remains outside. At the peak of the push, an incision is made in one motion. Only the skin is cut.
To exclude further rupture of the incision, it is recommended to manually control the rate of head birth. If the baby is in a hurry, he is slightly restrained with the palm.
The perineotomy itself can be anesthetized locally with lidocaine, or it can be performed without the use of anesthesia, since at the peak of the pushing when the skin is pulled, the incision is almost not felt. If there is a catheter in the spinal canal and the woman is given an epidural during labor, some additional anesthetic may be given if necessary.
After the birth of the placenta, the condition of the cervix is checked, if necessary, it is sutured, and only then the labor is completed by suturing the cut perineum. The algorithm is pretty simple:
the perineum is treated with an antiseptic;
take measures for pain relief (locally);
the incision site is sutured with catgut threads, and silk surgical sutures are applied to the skin;
antiseptic treatment is carried out again.
Subsequently, antiseptic treatments are repeated daily.
Complications
It is very difficult to process the seams yourself. The crotch area is not the most convenient place for this. But while the woman is in the hospital, she has nothing to worry about - the treatment is carried out by the medical staff. At home, the husband can help in this matter. It is desirable to treat the wound using hydrogen peroxide and brilliant green. This will help dry it out and avoid bacterial contamination.
Considering that the wound in the perineum cannot be constantly ventilated, and is also in direct contact with postpartum bleeding, handling and care should be given increased attention, because inflammation is the most common complication of perineotomy.
Normally, silk threads are removed in 6-7 days, and complete healing in the absence of complications takes place within 3-4 weeks. With a longer healing time, when the seam is compacted, bumps appear on it, the ichor or pus is released from it, you should immediately consult a doctor and get the necessary treatment.
Suture divergence is also a common complication. It can occur due to excessive tension of the perineum, due to violations of the requirements of the motor regime, due to obstetric flaws - mistakes made in the suturing technique or an incorrectly selected suture set. This is manifested by the renewal of bloody or bloody discharge from the scar, gaping of the wound at the site of the discrepancy, increased pain and swelling.
A discrepancy may require re-suturing only when no fusion has occurred over most of the incision length. In other cases, doctors wash the wound, disinfect it and recommend local anti-inflammatory or antibacterial agents (Levomekol, for example). Healing occurs by secondary intention.
Inflammation and suppuration require antibiotic treatment, and the formation of hernias, fistulas, and internal hematomas requires surgical assistance.
Complaints of a woman that at first it hurts to stand and walk are not considered a complication - while the restoration of nerve endings and the integrity of the skin is underway, discomfort and pulling pain are considered normal.
When can I sit down? Care of seams
The first thing that usually interests women after a perineotomy is whether it is possible to sit. You can't sit. If, after a mid-lateral incision, it is possible to sit with support on one thigh to relieve tension on the perineum, it is not recommended to sit at all after a mid-vertical incision. You should walk with caution, without making any sudden movements. Feed the newborn while standing or lying down, and eat and drink tea while standing.
If the stitches heal without significant problems and complications, then the woman will be able to sit down in about three weeks. If there are complications, then the period of prohibition on such a pose can be individually increased in time.
During discharge home, a woman needs to sit in the back seat of the car lying on her side so as not to accidentally damage the stitches in the crotch on the way.
The following recommendations will help to avoid unpleasant consequences and speed up healing:
change the gaskets as often as possible;
after visiting the toilet, you need to wash yourself;
wiping the crotch is not worth it, you should only gently and gently blot it with a soft napkin or a separate diaper;
once a day, the perineum should be left open for half an hour for ventilation and drying;
take a bath before the wound heals after a perineotomy, you can only wash in the shower;
if problems are found, you need to contact a gynecologist.
After healing, that is, in the second month after childbirth, a woman can start using a remedy that increases the elasticity of scars by increasing the amount of collagen - "Contractubex".
Sexual life is recommended no earlier than the completion of postpartum discharge. In the first six months after childbirth, due to the presence of a scar, a woman may experience discomfort during intimacy. Gradually, they will pass, this phenomenon does not need treatment.
