Tillvägagångssätt episiotomi

  1. Informera kvinnan och inhämta samtycke.

  2. Säkerställ adekvat bedövning innan klippet läggs, antingen inre PDB eller infiltration med t ex 5-10 ml Xylocain på planerad plats för klippet.

  3. Lägg klippet när huvudet kronar (vid sugklocka är då hela klockan synlig i introitus), då vävnaderna är uttänjda och mindre blodfyllda.

  4. Lägg klippet i början av en värk. Blödningsmängden ökar om klippet läggs för tidigt.

  5. Episiotomi lateralt eller mediolateralt. Klippets vinkel är viktigast och bör vara 60° från medellinjen.

  6. För att åstadkomma rätt vinkel, stå gärna med vänster sida mot patienten och för in vänster pek- och långfinger innanför slidöppningen mellan föregående fosterdel och slidväggen. För in den halvöppna saxen mellan pek- och långfinger och rikta den mot sittbensknölen, klockan 4 i denna position. Om du är vänsterhänt kan du stå med höger sida mot patienten och rikta saxen mot kl 8.

  7. Klipp 3-5 cm långt för att avlasta muskelvävnaden. Saxen bör vara vass. Sträva efter att åstadkomma klipplängden med ett (ej flera) saxtag.

  8. När klippet lagts måste framfödandet kontrolleras så att det inte går för fort. Fortsatt god kommunikation med kvinnan och perinealskydd är av största vikt.

 

Infiltration inför klipp.png

Figur Lateral infiltration inför klipp

Klippvinkel.png

Figur Klippvinkel

Bilden ovan visar korrekt vinkel för att åstadkomma mediolateral episiotomi med 60 graders vinkel.

 

Komplikationer av episiotomi

Även vid episiotomi finns en risk för skada på sfinktermuskulaturen trots att klippet utförts för att skydda denna. Det finns inga belägg för att lateral episiotomi skadar levatormuskulaturen eller skyddar mot levatorskada.

Episiotomi kan vara associerat med ökad användning av analgetika och blödning postpartum, men det vetenskapliga underlaget för det är svagt. Hos förstföderskor som fött med sugklocka och lateral episiotomi eller ingen episiotomi var det ingen skillnad i blödningsmängd eller smärtskattning första dagarna på BB eller vid 2 månader, men fler kvinnor använde smärtstillande efter förlossningen i klippgruppen. Det var ingen skillnad i hur länge smärtlindring behövdes.

Lateral episiotomi kan innebära en ökad risk för sårinfektion och sårruptur. Se avsnittet om uppföljning och komplikationer.

 

Referenser

  • Baghestan E, Irgens LM, Bordahl PE, Rasmussen S. Trends in risk factors for obstetric anal sphincter injuries in Norway. Obstet Gynecol 2010; 116: 25–34.
  • Raisanen S, Vehvilainen-Julkunen K, Cartwright R, Gissler M, Heinonen S. A prior cesarean section and incidence of obstetric anal sphincter injury. Int Urogynecol J 2013; 24: 1331–39
  • Pergialiotis V, Bellos I, Fanaki M, Vrachnis N, Doumouchtsis SK. Risk factors for severe perineal trauma during childbirth: an updated metaanalysis. Eur J Obstet Gynecol Reprod Biol 2020;247:94–100.
  • Rygh AB, Skjeldestad FE, Körner H, Eggebø TM. Assessing the association of oxytocin augmentation with obstetric anal sphincter injury in nulliparous women: a population-based, case-control study. BMJ Open. 2014 Jul 24;4(7):e004592. 
  • Aasheim V, Nilsen AB, Lukasse M, Reinar LM. Perineal techniques during the second stage of labour for reducing perineal trauma. The Cochrane database of systematic reviews. 2011(12):Cd006672.
  • Edqvist, Malin, et al. "The effect of two midwives during the second stage of labour to reduce severe perineal trauma (Oneplus): a multicentre, randomised controlled trial in Sweden." The Lancet10331 (2022): 1242-1253.
  • Albers LL, Sedler KD, Bedrick EJ, Teaf D, Peralta P. Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: a randomized trial. Journal of midwifery & women's health. 2005;50(5):365-72.
  • Samuelsson E, Ladfors L, Wennerholm UB, Gareberg B, Nyberg K, Hagberg H. Anal sphincter tears: prospective study of obstetric risk factors. BJOG : an international journal of obstetrics and gynaecology. 2000;107(7):926-31.
  • Kotaska A, Campbell K. Two-step delivery may avoid shoulder dystocia: head-to-body delivery interval is less important than we think. Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC. 2014;36(8):716-20.
  • Tern, H., Rubertsson, C., Ekelin, M., Dahlen, H. G., Häggsgård, C., & Edqvist, M. (2024). Women’s experiences of being assisted by two midwives during the active second stage of labour: Secondary outcomes from the Oneplus trial. Sexual & Reproductive Healthcare, 39, 100926.
  • Tern H., Rubertsson C., Edqvist M., Ekelin M. Midwives’ experiences of professional learning when practicing collegial midwifery assistance during the active second stage of labour: Data from the Oneplus trial. BMC Pregnancy and Childbirth, 2024 24:287
  • Laine K, Rotvold W, Staff AC. Are obstetric anal sphincter ruptures preventable?-- large and consistent rupture rate variations between the Nordic countries and between delivery units in Norway. Acta obstetricia et gynecologica Scandinavica. 2013;92(1):94-100.
  • Basu M, Smith D, Edwards R. Can the incidence of obstetric anal sphincter injury be reduced? The STOMP experience. European journal of obstetrics, gynecology, and reproductive biology. 2016;202:55-9.
  • Edqvist M, Hildingsson I, Mollberg M, et al. Midwives' Management during the Second Stage of Labor in Relation to Second-Degree Tears-An Experimental Study. Birth (Berkeley, Calif). 2016.
  • Basu M, Smith D. Long-term outcomes of the Stop Traumatic OASI Morbidity Project (STOMP). International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2018;142(3):295-9.
  • Kopas, Mary Lou. "A review of evidence‐based practices for management of the second stage of labor."Journal of midwifery & women's health3 (2014): 264-276.
  • Lemos A, Amorim MM, Dornelas de Andrade A, de Souza AI, Cabral Filho JE, Correia JB. Pushing/bearing down methods for the second stage of labour. The Cochrane database of systematic reviews 2017;3:Cd009124.
  • Prins M, Boxem J, Lucas C, Hutton E. Effect of spontaneous pushing versus Valsalva pushing in the second stage of labour on mother and fetus: a systematic review of randomised trials. BJOG : an international journal of obstetrics and gynaecology. 2011;118(6):662-70.
  • Smith LA, Price N, Simonite V, Burns EE. Incidence of and risk factors for perineal trauma: a prospective observational study. BMC pregnancy and childbirth. 2013;13:59.
  • Beckmann, M. M., & Stock, O. M. (2014). Antenatal perineal massage for reducing perineal trauma-Cochrane Database of Systematic Reviews-ISBN: 1465-1858.
  • Häggsgård, C., Nilsson, C., Teleman, P., Rubertsson, C., & Edqvist, M. (2022). Women’s experiences of the second stage of labour. Women and Birth, 35(5), e464-e470.
  • Samuelsson E, Ladfors L, Lindblom BG, Hagberg H. A prospective observational study on tears during vaginal delivery: occurrences and risk factors. Acta obstetricia et gynecologica Scandinavica. 2002;81(1):44-9.
  • Pirhonen JP, Grenman SE, Haadem K, Gudmundsson S, Lindqvist P, Siihola S, et al. Frequency of anal sphincter rupture at delivery in Sweden and Finland--result of difference in manual help to the baby's head. Acta obstetricia et gynecologica Scandinavica. 1998;77(10):974-7.
  • Jonsson ER, Elfaghi I, Rydhstrom H, et al. Modified Ritgen's maneuver for anal sphincter injury at delivery: a randomized controlled trial. Obstetrics and gynecology. 2008;112(2 Pt 1):212-7
  • Aasheim V, Nilsen ABV, Reinar LM, Lukasse M. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev. 2017 Jun 13;6(6):CD006672.
  • Aabakke AJ, Willer H, Krebs L. The effect of maneuvers for shoulder delivery on perineal trauma: a randomized controlled trial. Acta obstetricia et gynecologica Scandinavica. 2016;95(9):1070-7.
  • Locatelli A, Incerti M, Ghidini A, Longoni A, Casarico G, Ferrini S, Strobelt N. Head-to-body delivery interval using 'two-step' approach in vaginal deliveries: effect on umbilical artery pH. J Matern Fetal Neonatal Med. 2011 Jun;24(6):799-803.
  • Elvander C, Ahlberg M, Thies-Lagergren L, et al. Birth position and obstetric anal sphincter injury: a population-based study of 113 000 spontaneous births. BMC pregnancy and childbirth. 2015;15:252.
  • Gottvall K, Allebeck P, Ekeus C. Risk factors for anal sphincter tears: the importance of maternal position at birth. BJOG : an international journal of obstetrics and gynaecology. 2007;114(10):1266-72.
  • Gupta, J. K., Sood, A., Hofmeyr, G. J., & Vogel, J. P. (2017). Position in the second stage of labour for women without epidural anaesthesia. Cochrane database of systematic reviews, (5).
  • Lindgren, H., Rehn, M. & Wiklund, I. (2019). Barnmorskans handläggning vid normal förlossning: forskning och erfarenhet. (Andra upplagan), Barnets framfödande(s. 71-80). Lund: Studentlitteratur.
  • Nieuwenhuijze MJ, de Jonge A, Korstjens I, et al. Influence on birthing positions affects women's sense of control in second stage of labour. Midwifery. 2013;29(11):e107-14.
  • Thies-Lagergren L, Kvist LJ, Christensson K, et al. No reduction in instrumental vaginal births and no increased risk for adverse perineal outcome in nulliparous women giving birth on a birth seat: results of a Swedish randomized controlled trial. BMC Pregnancy Childbirth 2011, 11:22.
  • Thies-Lagergren L, Kvist LJ, Sandin-Bojö AK, et al. Labour augmentation and fetal outcomes in relation to birth positions: a secondary analysis of an RCT evaluating birth seat births. Midwifery 2013, 29(4):344-350.
  • Lindgren, H., Rehn, M. & Wiklund, I. (2019). Barnmorskans handläggning vid normal förlossning: forskning och erfarenhet. (Andra upplagan). Lund: Studentlitteratur AB.
  • https://lof.se/filer/Instrumentell-forlossning-med-sugklocka.pdf
  • Bergendahl S, Lindberg P, Brismar Wendel S. Operator experience affects the risk of obstetric anal sphincter injury in vacuum extraction deliveries. Acta Obstet Gynecol Scand. 2019 Jun;98(6):787-794. doi: 10.1111/aogs.13538. Epub 2019 Feb 7. PMID: 30659578.
  • Lund NS, et al. Episiotomy in vacuum-assisted delivery affects the risk of obstetric anal sphincter injury: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2016;207:193-9.
  • Okeahialam NA, Wong KW, Jha S, Sultan AH, Thakar R. Mediolateral/lateral episiotomy with operative vaginal delivery and the risk reduction of obstetric anal sphincter injury (OASI): A systematic review and meta-analysis. Int Urogynecol J. 2022 Jun;33(6):1393-1405. doi: 10.1007/s00192-022-05145-1. Epub 2022 Apr 15. PMID: 35426490; PMCID: PMC9206628.
  • Bergendahl S, Jonsson M, Hesselman S, Ankarcrona V, Leijonhufvud Å, Wihlbäck AC, Wallström T, Rydström E, Friberg H, Kopp Kallner H, Brismar Wendel S. Lateral episiotomy or no episiotomy in vacuum assisted delivery in nulliparous women (EVA): multicentre, open label, randomised controlled trial. BMJ. 2024 Jun 17;385:e079014. doi: 10.1136/bmj-2023-079014. PMID: 38886011.
  • Liabsuetrakul T, Choobun T, Peeyananjarassri K, et al. Antibiotic prophylaxis for operative vaginal delivery. Cochrane Database Syst Rev. 2020 Mar 26;3(3):CD004455. doi: 10.1002/14651858.CD004455.pub5. PMID: 32215906; PMCID: PMC7096725.
  • Knight M, Chiocchia V, Partlett C, Rivero-Arias O, Hua X, Hinshaw K, Tuffnell D, Linsell L, Juszczak E; ANODE collaborative group. Prophylactic antibiotics in the prevention of infection after operative vaginal delivery (ANODE): a multicentre randomised controlled trial. Lancet. 2019 Jun 15;393(10189):2395-2403. doi: 10.1016/S0140-6736(19)30773-1. Epub 2019 May 13. Erratum in: Lancet. 2019 Jun 15;393(10189):2394. PMID: 31097213; PMCID: PMC6584562
  • Heitmann JA, Benrubi GI. Efficacy of prophylactic antibiotics for the prevention of endomyometritis after forceps delivery. Southern Medical Journal 1989;82:960‐
  • Bonet M, Ota E, Chibueze CE, Oladapo OT. Antibiotic prophylaxis for episiotomy repair following vaginal birth. Cochrane Database Syst Rev. 2017 Nov 2;11(11):CD012136. doi: 10.1002/14651858.CD012136.pub2. PMID: 29096053; PMCID: PMC6485970.
  • Bonet M, Ota E, Chibueze CE, Oladapo OT. Routine antibiotic prophylaxis after normal vaginal birth for reducing maternal infectious morbidity. Cochrane Database Syst Rev. 2017 Nov 13;11(11):CD012137. doi: 10.1002/14651858.CD012137.pub2. PMID: 29190037; PMCID: PMC6486135.
  • Humphreys ABC, Linsell L, Knight M. Factors associated with infection after operative vaginal birth-a secondary analysis of a randomized controlled trial of prophylactic antibiotics for the prevention of infection following operative vaginal birth. Am J Obstet Gynecol. 2023 Mar;228(3):328.e1-328.e11. doi: 10.1016/j.ajog.2022.08.037. Epub 2022 Aug 24. PMID: 36027955.
  • Buppasiri P, Lumbiganon P, Thinkhamrop J, Thinkhamrop B. Antibiotic prophylaxis for third- and fourth-degree perineal tear during vaginal birth. Cochrane Database Syst Rev. 2014 Oct 7;2014(10):CD005125. doi: 10.1002/14651858.CD005125.pub4. PMID: 25289960; PMCID: PMC10542915.
  • Rotem R, Mastrolia SA, Rottenstreich M, Yohay D, Weintraub AY. The use of metronidazole in women undergoing obstetric anal sphincter injuries: a systematic review of the literature. Arch Gynecol Obstet. 2020 Aug;302(2):321-328. doi: 10.1007/s00404-020-05651-x. Epub 2020 Jun 20. PMID: 32564129.
  • Kok M, Pechère J. Nature and pathogenicity of micro‐ In: Armstrong D, Cohen J editor(s).Infectious Diseases. London: Mosby, 2000:1‐26. 
  • Ankarcrona V, Karlstrom S, Sylvan S, et al.Episiotomy in vacuum extraction, do we cut the levator ani muscle? A prospective cohort study. Int Urogynecol J, Apr 25 2022.
  • Coats PM, Chan KK, Wilkins M, et al. A comparison between midline and mediolateral episiotomies. Br J Obstet Gynaecol, 87, n. 5, p. 408-412, May 1980.
  • Fodstad K, Staff AC, Laine K. Effect of different episiotomy techniques on perineal pain and sexual activity 3 months after delivery. Int Urogynecol J, 25, n. 12, p. 1629-1637, Dec 2014.
  • Fodstad K, Staff AC, Laine K. Episiotomy preferences, indication, and classification--a survey among Nordic doctors. Acta Obstet Gynecol Scand, 95, n. 5, p. 587-595, May 2016a.
  • Fodstad K, Staff AC, Laine K. Sexual activity and dyspareunia the first year postpartum in relation to degree of perineal trauma. Int Urogynecol J, 27, n. 10, p. 1513-1523, Oct 2016b.
  • Ginath S, Elyashiv O, Weiner E, et al.The optimal angle of the mediolateral episiotomy at crowning of the head during labor. Int Urogynecol J, 28, n. 12, p. 1795-1799, Dec 2017.
  • Gonzales-Dias E, Fernandez Fernandes C, Gonzalo Orden JM, et al. Which characteristics of the episiotomy and perineum are associated with a lower risk of obstetric anal sphincter injury in instrumental deliveries. Eur J Obstet Gynecol Reprod Biol, 233, p. 127-133, Feb 2019.
  • Annual report 2021 of the Swedish Pregnancy Register. Stockholm, Sweden 2022. Disponível em: https://www.medscinet.com/GR/uploads/hemsida/dokumentarkiv/Graviditetsregistrets%20Årsrapport%202021_1.0.pdf.
  • Jiang H, Qian X, Carroli G, et al. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev, 2, p. CD000081, Feb 8 2017.
  • Kalis V, Laine K, de Leeuw JW, et al. Classification of episiotomy: towards a standardisation of terminology. BJOG, 119, n. 5, p. 522-526, Apr 2012.
  • Karbanova J, Rusavy Z, Betincova L, et al.Clinical evaluation of peripartum outcomes of mediolateral versus lateral episiotomy. Int J Gynaecol Obstet, 124, n. 1, p. 72-76, Jan 2014.
  • Lund NS, Persson LK, Jango H, et al. Episiotomy in vacuum-assisted delivery affects the risk of obstetric anal sphincter injury: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol, 207, p. 193-199, Dec 2016.
  • Martin DL. The Protection of the Perineum by Episiotomy in Delivery at Term. Cal State J Med, 19, n. 6, p. 229-231, Jun 1921.
  • Necesalova P, Karbanova J, Rusavy Z, et al.Mediolateral versus lateral episiotomy and their effect on postpartum coital activity and dyspareunia rate 3 and 6 months postpartum. Sex Reprod Healthc, 8, p. 25-30, Jun 2016.
  • Ould F. A Treatise on Midwifry: In Three Parts.  Buckland, 1748.
  • Rockner G, Fianu-Jonasson A. Changed pattern in the use of episiotomy in Sweden. Br J Obstet Gynaecol, 106, n. 2, p. 95-101, Feb 1999.
  • Sagi-Dian L, Sagi S. Morbidity associated with episiotomy in vacuum delivery: a systematic review and meta-analysis. BJOG, 122, n. 8, p. 1073-1081, Jul 2015.
  • Analsfinkterskador vid förlossning. Mölnlycke, Sweden: Statens beredning för social och medicinsk utvärdering, 2016. Disponível em: http://www.sbu.se/sv/publikationer/SBU-utvarderar/analsfinkterskador-vid-forlossning/. Acesso em: 27 sept 2017.
  • Stedenfeldt M, Pirhonen J, Blix E, et al.Episiotomy characteristics and risks for obstetric anal sphincter injuries: a case-control study. BJOG, 119, n. 6, p. 724-730, May 2012.

Nu är det här avsnittet slut. Klicka på länken nedan eller använd menyn för att fortsätta: