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.
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.
Sterile equipment needed:
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:
Steps to performing an amniotomy are as follows:
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...
My approach to a normal (without complicating features) vaginal delivery is as follows:
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.