Once a routine procedure, the episiotomy has almost fallen into extinction. It used to be done because it decreases the risk of developing a severe perineal tear into the anal sphincter or rectal mucosa (3rd or 4th degree perineal tear, respectively), but it is now understand to be a procedure that, when done routinely, increases the overall degree of trauma to the perineum and increases the risk of complications as a result. So why has it not completely died out? There is one indication for performing an episiotomy, and that is to facilitate certain maneuvers when a shoulder dystocia has been encountered. Other than that, it is not indicated. Episiotomy repair, like episiotomies, are then too also a rare skill to need to know, but not so much, because it follows the same principles as the repair of perineal lacerations, which are extremely common in the delivery process. Here I will provide an overview to the very brief procedure that is performing an episiotomy, and I will spend a bit more time on how to repair perineal lacerations, be they be from the rare episiotomy or from the common laceration. I will review only the repair of first and second degree lacerations here, which is as nasty of a laceration as a low-risk obstetrician would be expected to be able to do. Third and fourth degree tears tend to be done by skilled obstetricians, often in an OR setting.

Episiotomy
Equipment needed: A scalpel and bravery. That is all.
​Anatomy: An episiotomy is an incision through the mucosa and perineal body. The mediolateral approach is the preferred flavour.

Procedure:

1. Consent: Ideally the woman has discussed the possibility of various interventions prior to the onset of labour with the physician providing her prenatal care and/or the attending physician, when there is sufficient time to address any questions. In the setting of emergent episiotomy, it is important in any case to obtain consent prior to performing the procedure.
2. With consent obtained, proceed to placing one or two fingers inside the posterior vaginal wall to prevent nicking the fetal scalp when making the cut. 
3. Make the incision, mediolaterally. Incise from the posterior fourchette and laterally in an almost horizontal direction (when the fetal head is no longer stretching the tissue, this will end up being about 45 degrees from the horizontal or vertical plane). The incision is usually made to be about 3-5 cm long.
4. Deliver the infant

Perineal repair
Sterile equipment needed: 

1. Gauze sponges
2. Vaginal retractor
3. 10 mL syringe filled with 1% lidocaine with epinephrine
4. Tissue forceps
5. Needle driver
6. Nontraumatic forceps
7. 2-0 or 3-0 Vicryl sutures

Anatomy: There are a lot of muscles in the area, and we need to bring them back together so they can be functional once again. 

Procedure: 

1. Perform a thorough inspection for tears after delivery of the placenta, which is part of the standard process of managing labour and delivery. This includes a rectal exam to look for any tears that may involve the rectal mucosa ("buttonhole" tears). Don a second sterile glove for the rectal exam, so that it can be removed and disposed of to reveal a sterile glove underneath, and the procedure does not need to be interrupted to re-glove. 
2. If tears are identified, prepare for the sterile procedure with the needed supplies, and be generous (within reason) with local anesthesia. Check for sufficient freezing by gently pinching the perineum with the tissue forceps.
3. Begin suturing by placing the first suture at the apex (see diagram below) and then run the suture down to the introitus using nonlocking continuous suturing to reapproximate the hymenal ring, with the last stitch to reapproximate the ring being just outside the hymenal ring itself.
4. Now take the suture and bury the stitch by passing it through the repaired vaginal layer above through to the deep perineal layer. This is known as the "transition stitch." 
5. The suture is then placed through the superficial bulbocavernosus muscle on each side in a "V" configuration. This is known as the "crown stitch."
6. The suture is then passed through the deep perineal tissue from side to side in a vertical direction until the apex of the perineal tear is reached.
7. The suture is then brought superficially toward the introitus from the apex of the perineum in a subcuticular closure and the know is tied below the epithelium.
8. For a much better demonstration than I could do or explain in 8 steps, check out this video demonstrating how to perform a second degree perineal laceration repair from the Department of Family Medicine at Western University in London, Ontario.
9. Reassess situation and repeat the rectal exam to ensure no stitches have penetrated the rectal mucosa. If so, you must remove the entire thing and start again. Bleep!

Artificial rupture of membranes (aka amniotomy) may be done in order to perform certain interventions in labour (such as insertion of an intrauterine pressure catheter or placement of a fetal scalp electrode) or as a way of inducing/augmenting labour in conjunction with an oxytocin infusion. The fetus must be engaged with normal cephalic presentation, and it cannot be done if the clinician can palpate a cord on vaginal exam. It is also contraindicated if the mom has untreated HIV or active hepatitis B or C infections.

Equipment needed to complete the procedure:

• Sterile gloves, as well as a gown, mask, and eye protection
• Drapes for mom
• Amniotomy hook
• Absorbent towels/pads
• Electronic fetal monitor

Steps to performing an amniotomy are as follows:

1. Obtain consent: The procedure should be explained to the patient, as well as its possible benefits and risks and any alternatives. Specifically, the patient should be informed about the risk for cord prolapse and the precautions that the clinician will take to avoid this (making sure the head is well applied and the absence of a palpable cord). The possible increased risks for infection (and need for antibiotics) and bleeding should also be explained. Rupture of membranes commits the patient to delivery, usually within 24 hours. After 24 hours, the risk for chorioamnionitis is increased significantly, so cesarean delivery may be indicated or necessary. As well, rarely, the infant's head could be scratched or cut, but this is unlikely with an experienced clinician.
2. Fetal heart rate assessment: This must be done before, during, and after the procedure (for at least 30 minutes)
3. Gown up! Ensure you protect yourself with standard blood and body fluid precautionary measures.
4. Positioning: The patient should be in a recumbent position, with legs in the frog-legged position or else in stirrups. 
5. Perform a vaginal exam to ensure that the cervix is sufficiently dilated (to properly assess the following features but also to be able to actually perform the procedure), that the amniotic membrane is still intact, that the fetal head is well-applied, and that there is no palpable umbilical cord. 
6. With the index and middle fingers of your nondominant hand, palm up, insert the fingertips into the uterus and against the membranes. Be confident of what you are feeling before proceeding to avoid inadvertently damaging maternal tissue. 
7. With your dominant hand, insert the amniotomy hook between the two fingers of your other hand that are applied against the membranes. At this point, the hook should be pointed downward and away from the membranes.
8. Have an assistant apply gentle suprapubic pressure (which should increase the amount of fluid between the fetal membranes and fetal head, then rotate the hook 180 degrees to bring the sharp part into contact with the membranes and rupture them. When the membranes are ruptured, fluid will leak from the vagina.
   
9. Keeping the fingers of your nondominant hand in place, remove the hook and note the volume and colour of the fluid that has leaked out. Be sure to confirm the umbilical cord has not prolapsed, and then remove these fingers now adjacent to the infant's head. 
10. Monitor fetal heart rate to ensure it remains normal, and document the procedure.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Demonstrate ability to interact appropriately with other members of the obstetrical team
• Assess and manage normal labour and delivery
  
• Consult obstetricians appropriately
  

My approach to a normal (without complicating features) vaginal delivery is as follows:

1. Complete admission history and physical examination if the women is in active labour (cervical dilation of 4 or more cm) or if there is another reason warranting admission (rupture of membranes, complications identified)
   • If the woman is still only in latent first stage of labour (regular contractions but cervix not yet dilated to 4 cm), we want to avoid early admission to hospital as evidence shows this increases risk of intervention that overall causes more harm than good. If the patient is being discharged home to continue early labour but is in significant pain (she is in labour, after all), provide her with injections of morphine and dimenhydrinate (because opioids can cause nausea). If latent labour is prolonged (>20 hours in a nulliparous woman or >14 hours in a multiparous woman), consider augmentation as there is increased risk of complications when latent labour is significantly prolonged. Once the woman is admitted, give antibiotics for GBS prophylaxis, if indicated.
2. Once admitted, regularly reassess maternal and fetal status. Nursing 1:1 support is standard of care if a woman is admitted in labour. 
   1. Frequency of reassessment 
      1. If the woman is in active first stage of labour, I reassess every 2-4 hours
      2. If the woman is in the passive second stage of labour, I reassess every 1 hour
      3. Also reassess whenever the patient feels the urge to push, prior to augmentation or anesthesia, of if there are any concerns regarding fetal or maternal status. 
   2. Components of maternal assessment
      1. How she is coping (ex: pain control, hydration, fatigue, emotional support)
      2. Physical exam includes reassessing vital signs and contractions (frequency, duration, intensity, and resting tone), along with vaginal exam (cervical dilation and effacement, fetal station and position)
   3. Components of fetal assessment
      1. FHR interpretation (unless there is an indication for continuous electronic fetal monitoring, fetal heart rate monitoring is preferably done by intermittent auscultation)
3. Once the woman has transitioned to stage 2 of labour (complete cervical dilation), she may begin pushing if she has the urge to push. If there is no urge to push and the fetal station is still high, then it is advised to delay pushing up to 2 hours to allow passive fetal descent (evidence shows that this lengthens the overall time in labour but shortens the time when the woman is actively pushing, which promotes better outcomes). If there is no urge to push and there is no passive descent at one hour from onset of 2nd stage, consider initiating directed pushing.
4. Active stage 2 begins with active pushing. There is no evidence that coaching women on how to push makes a difference, except if there is an epidural (because they just can't feel what's going on down there as well).
   1. Prepare for delivery
      1. Ready equipment and place sterile drapes under patient. Be sure to have 2 clamps and a pair of blunt scissors close by in case there is a irreducible nuchal cord. 
   2. Controlled delivery of the head
      1. Protect the perineum by performing perineal massage, and when crowning, applying midline pressure with a warm compress, can help to prevent tears. With the hand that isn't protecting the perineum, use it to control rate of extension of the fetal head when crowning. Just enough pressure is applied so as to prevent rapid extension and associated perineal tears, and pressure should be applied to the infant's occiput to maintain the head in a flexed position. Never take your eyes off the perineum once crowning has begun. Once crowning, encourage the woman to pant as opposed to push the baby out. Preferably, the head is delivered between contractions when the force of propulsion is decreased.
   3. Restitution and checking for a nuchal cord
      1. After delivery of the fetal head, all the head to naturally restitute (watch for the turtle sign, which could signify shoulder dystocia). While allowing the head to restitute, check for a nuchal cord by sliding your fingers around the fetal neck. If there is a lot of thick mucus covering the infants nose and mouth, wipe gently with a sterile towel or sponge. If a nuchal cord is present (up to 25% of deliveries), attempt to reduce it by slipping it over the fetal head. If this is difficult to do but the cord is not tight, you can instead try to slip it over the fetal shoulder, which will essentially mean that baby is delivered through the cord, otherwise known as the somersault maneuver. If the cord is unable to be displaced, it will need to be clamped and cut, followed by prompt delivery of the infant 
   4. Deliver anterior shoulder and body
      1. Apply gentle downward pressure on infant toward sacrum with flat fingers while mom pushes with the next contraction. Following delivery of the anterior shoulder, the posterior shoulder is immediately delivered with gentle upward traction. Standard of care is to give mom an injection of oxytocin at this time to prevent postpartum hemorrhage.
   5. Delayed cord clamping
      1. Baby is placed skin-to-skin with mom, and delayed cord clamping for at least one minute in a full term infant is instituted. Once the cord is cut, blood is taken from the cord for cord blood gases. 
5. Third stage of labour is from the time the infant is delivered until delivery of the placenta. Generally it takes about 5-10 minutes, but can last up to 30 minutes. The placenta is delivered with gentle cord traction while providing suprapubic support, and after delivery it is immediately inspected for completeness and for whether the umbilical cord has 3 vessels (normal). Assess uterine tone and apply gentle uterine massage as indicated to promote tonicity, which prevents postpartum bleeding. Then inspect the perineum for tears and repair as indicated.

Note that in my above outline of the delivery process I have focused specifically on my actions in direct relation to the labouring mother. However, there are many key team players in the delivery process, including the nursing team, the obstetrical team (who may be consulted at any time for more support), the patient's social supports who may attend the labour and delivery, and oftentimes the anesthesiologist who provides epidural analgesia. The labour and delivery process is an incredible team feat, and having a strong mode of functioning that depends on effective communication and understanding others' roles is an irreplaceable asset for a smooth delivery.