OG35.{16-17,20} | ARM, Episiotomy Suturing and Urinary Catheterisation — Summary & Reflection

KEY TAKEAWAYS

ARM, episiotomy suturing, and urinary catheterisation are three core intrapartum procedural skills. ARM (amniotomy) is indicated for augmentation of slow labour or induction, requires an engaged fetal head (≤2/5 palpable abdominally, station 0 or below) as a safety prerequisite, is performed with an amnihook guided alongside two vaginal examining fingers, and mandates immediate post-procedure cord check and FHR auscultation. Episiotomy is now performed selectively (not routinely) per WHO 2018 and Cochrane evidence; the mediolateral technique at 45-60° from midline protects the external anal sphincter; repair is in three layers (vaginal mucosa with continuous locking suture, perineal muscles with interrupted sutures, skin with subcuticular stitch), starting the vaginal mucosal suture above the apex; a mandatory PR examination must follow repair to exclude suture penetration of the rectum. Urinary catheterisation uses strict aseptic non-touch technique (ANTT); the female urethra is 3-4 cm long; a catheter inserted without urine flow has likely entered the vagina and must be withdrawn and replaced; the Foley balloon must be inflated only after urine flows and after advancing 2-3 cm further. The most important complication of ARM is cord prolapse; of episiotomy repair, haematoma from missed apex or dead space; of catheterisation, CAUTI from broken asepsis.

REFLECT

Reflect on the principle that episiotomy should be selective rather than routine. In clinical practice you may observe senior colleagues performing episiotomies differently — some liberally, some rarely. How would you use the Cochrane evidence and WHO recommendation to guide your own decision-making when supervising a normal delivery in the future? Consider the ARM scenario at the start of this module — what clinical safety checks would you perform mentally before every ARM, and how would you respond if the FHR dropped to 60 bpm immediately after rupturing membranes? For urinary catheterisation, reflect on your own practice: have you identified the urethral meatus correctly each time, or have you had to make a second attempt? What strategies help you when anatomy is distorted in a postpartum patient?