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    Intern ACOG Bulletin Episiotomy and Repair3

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    sharu4291
    This document describes the anatomy involved in an episiotomy procedure. It discusses the external and internal structures of the female perineal region, including muscles, fascia, arteries and nerves. A midline episiotomy incision extends from the vaginal opening toward the anus, cutting through the superficial and deep transverse perineal muscles. The main muscle incised in a mediolateral episiotomy is the bulbospongiosus muscle. Adequate pain relief is needed before performing an episiotomy to protect the fetal head.

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    Intern ACOG Bulletin Episiotomy and Repair3

    Uploaded by

    sharu4291
    144 views3 pages
    This document describes the anatomy involved in an episiotomy procedure. It discusses the external and internal structures of the female perineal region, including muscles, fascia, arteries and nerves. A midline episiotomy incision extends from the vaginal opening toward the anus, cutting through the superficial and deep transverse perineal muscles. The main muscle incised in a mediolateral episiotomy is the bulbospongiosus muscle. Adequate pain relief is needed before performing an episiotomy to protect the fetal head.

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    Intern ACOG Bulletin Episiotomy and Repair3

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    This document describes the anatomy involved in an episiotomy procedure. It discusses the external and internal structures of the female perineal region, including muscles, fascia, arteries and nerves. A midline episiotomy incision extends from the vaginal opening toward the anus, cutting through the superficial and deep transverse perineal muscles. The main muscle incised in a mediolateral episiotomy is the bulbospongiosus muscle. Adequate pain relief is needed before performing an episiotomy to protect the fetal head.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    144 views3 pages

    Intern ACOG Bulletin Episiotomy and Repair3

    Uploaded by

    sharu4291
    This document describes the anatomy involved in an episiotomy procedure. It discusses the external and internal structures of the female perineal region, including muscles, fascia, arteries and nerves. A midline episiotomy incision extends from the vaginal opening toward the anus, cutting through the superficial and deep transverse perineal muscles. The main muscle incised in a mediolateral episiotomy is the bulbospongiosus muscle. Adequate pain relief is needed before performing an episiotomy to protect the fetal head.

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    © All Rights Reserved
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    of 3

    6 Episiotomy

    Mons pubis
    Anterior commissure of
    labia majora
    Prepuce of clitoris
    Pudendal cleft (groove or
    space between the
    labia majora)
    Glans of clitoris
    Frenulum of clitoris
    External urethral orice
    Labium minus
    Labium majus
    Openings of paraurethral
    (Skenes) ducts
    Vestibule of vagina
    (cleft or space surrounded
    by labia minora)
    Vaginal orice
    Opening of greater
    vestibular (Bartholins) gland
    Hymenal caruncle
    Vestibular fossa
    Frenulum of labia minora
    Posterior commissure of
    labia majora
    Perineal raphe
    (over perineal body)
    Anus
    Fig. 2. External genitalia. (Netter RH. Atlas of human anatomy. 4th
    ed. Philadelphia [PA]: Saunders Elsevier; 2006. Netter illus-
    trations used with permission of Elsevier Inc. All rights
    reserved.)
    Internal
    Underlying the skin are the muscle and fascial supports of the per-
    ineum ( Fig. 3) . A midline episiotomy will extend from the vaginal ori-
    fice caudad toward the anus. The incision will be in the central point
    of the perineum and usually extends to the transverse perineal mus-
    cles, of which there are two: superficial and deep. The two muscles are
    in such close approximation that they usually are not identifiable as
    two separate entities. Because they also intertwine with the anal
    Suspensory ligament of clitoris
    Bulb of vestibule
    Perineal membrane
    Greater vestibular
    (Bartholins) gland
    Bulbospongiosus
    muscle
    (cut away)
    Supercial
    transverse
    perineal
    muscle
    Perineal
    body
    Clitoris
    Bulbospongiosus muscle
    with deep perineal (investing
    or Gallaudets) fascia
    partially removed
    Supercial perineal space
    (pouch or compartment)
    Ischiopubic ramus
    with cut edge of
    supercial
    perineal (Colles)
    fascia
    Perineal
    membrane
    Ischial
    tuberosity
    Sacro-
    tuberous
    ligament
    Gluteus
    maximus
    muscle
    Obturator
    fascia
    Tendinous arch of
    levator ani muscle
    Inferior fascia of
    pelvic diaphragm (cut)
    Levator ani muscle
    External anal sphincter muscle
    Anococcygeal (ligament) body
    Coccyx
    Ischioanal fossa
    Crus of
    clitoris
    Ischio-
    pubic
    ramus
    Bulb of
    vestibule
    Greater vestibular
    (Bartholins) gland
    Perineal membrane
    Urethra
    Sphincter urethrae
    muscle
    Perineal membrane
    (cut and reected)
    Compressor urethrae
    muscle
    Sphincter urethrovaginalis
    muscle
    Vagina
    Deep transverse
    perineal muscle
    Ischiocavernosus muscle
    Fig. 3. Muscle and fascial supports of the perineum. (Netter
    RH. Atlas of human anatomy. 4th ed. Philadelphia [PA]:
    Saunders Elsevier; 2006. Netter illustrations used with
    permission of Elsevier Inc. All rights reserved.)
    Episiotomy 7
    8 Episiotomy
    sphincter, they often are mistaken for the sphincter itself. They extend
    laterally from the midline to the ischial tuberosity, and near the lateral
    vaginal edge their fascial covering is also next to the bulbospongiosus
    muscle.
    The bulbospongiosus is the main muscle that is incised when mak-
    ing a mediolateral episiotomy. This muscle extends from the pubic
    rami, circumscribes the vaginal opening, and then spreads slightly as it
    terminates just above the transverse perineal muscles. Lateral to the
    bulbospongiosus muscle is the superficial perineal compartment,
    which is usually filled with fatty tissue. The Bartholins gland, vestibu-
    lar bulb, and multiple veins are also in this compartment.
    The blood supply to this area is seen in Figure 4. The internal
    pudendal artery, a branch of the anterior trunk of the internal iliac
    artery, is the main supplier of the perineum. Its branches are the per-
    ineal, labial, and hemorrhoidal arteries. The venous drainage follows
    essentially the same patterns as the arteries. However, in the paravagi-
    nal area, varicosities are not uncommon during pregnancy.
    The area is innervated by the pudendal nerve and its branches as
    seen in Figure 5. The pudendal nerve is a branch of sacral 2, 3, and 4.
    Occasionally, a cutaneous branch of the inferior anal nerve can inner-
    vate the area around the anus. When this occurs, the traditional pu-
    dendal block anesthesia will not be adequate for performance of an
    episiotomy, and local infiltration will be needed.
    Midline Episiotomy
    Procedure
    Before performance of the episiotomy, adequate pain relief is needed.
    This can be obtained by use of local infiltration, pudendal nerve block,
    or conduction analgesia, such as an epidural or saddle block. Once
    pain relief is ensured, the procedure can commence. It is important to
    make certain that the fetal head is protected during the episiotomy. For
    that reason, a scalpel or other blade should be used only if scissors are
    not available.
    Initially, the index and middle finger should be inserted into the
    vagina between the perineum and the fetal head. The perineum is then

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