OG15.2 | Episiotomy and Operative Obstetric Assistance — Summary & Reflection

KEY TAKEAWAYS

Episiotomy is a selective, not routine, procedure — WHO 2018 guidance reserves it for operative delivery, fetal distress, shoulder dystocia, and rigid perineum. The mediolateral episiotomy (45–60° from midline) is preferred over midline for its lower extension risk. Repair is performed layer by layer: vaginal mucosa → deep perineal muscles (perineal body) → superficial muscles → subcuticular skin, using 2/0 or 3/0 absorbable suture. A rectal examination after every repair is mandatory to exclude inadvertent rectal suturing.

Operative vaginal delivery requires ALL six prerequisites to be satisfied (full dilatation, ruptured membranes, engaged head, known position, adequate analgesia, empty bladder). Neville-Barnes forceps provide outlet traction; Kielland's are rotational. Vacuum cup placement on the flexion point (3 cm anterior to the posterior fontanelle) optimises traction. Abandon OVD after three failed pulls or instrument-on-time exceeding 20 minutes.

At Caesarean section, your assistant duties include: bladder retraction, cord clamping, oxytocin 5 IU IV slowly after delivery, swab counts, and operation documentation. Perineal tear classification (1st–4th degree) determines repair setting: 3rd and 4th degree tears are repaired in OT under regional/general anaesthesia. Post-procedure, check for haematoma formation, wound integrity, and neonatal scalp injury (subgaleal haematoma is the most dangerous vacuum complication).

REFLECT

Kolb reflection — think back to a delivery (real or simulated) where you observed the perineum being repaired or an operative delivery being performed. What did you observe that matched what you have learned in this module? What surprised you? What would you do differently as the operator or assistant, having now studied the anatomy and technique in depth? Write 3–4 sentences in your learning portfolio. Consider: Was the rectal examination performed? Was the episiotomy timing optimal? Was the consent discussion adequate for the urgency? Reflect on how clinical time pressure influences procedural decision-making, and how you will maintain standards under pressure as an intern.