Perineal massage is a proven method to decrease perineal lacerations and the need for episiotomy. Patients can begin massage at about 34 weeks. The goal of perineal massage it to stretch the perineal tissue before delivery.
Patients with abdominal striae have been shown to have an increased risk of tearing during delivery - be sure to offer these patients information on perineal massage (Wahman, 2000).
Mediolateral Episiotomy (Wikimedia 2005)
Episiotomy is rarely required!
If episiotomy cannot be avoided (ie room for shoulder maneuvers or impending tear), wait for the fetal head to distend the perineum. Use local anesthesia. Insert two fingers between fetal head and perineum. Cut 1-2 cm through perineum and then extend 1cm into the vaginal floor.
The RML episiotomy (illustrated above) is less likely to extend to a fourth degree tear but causes more pain and is harder to repair.
The midline episiotomy is less painful during healing, easier to repair but more likely to extend into rectum.
Perineal Laceration Repair
Over the course of your rotation in obstetrics you will become skilled in delivering a baby with the perineum intact. Unfortunately lacerations happen and you should be ready to do the repair.
But if you are unable or struggle to tie the first knot, don't expect to do the repair.
Review the Knot Tying Manual from the Ethicon suture company. The manual provides information on types of knots, diagrams on knot tying, instruction on suture selection and needle types.
This video from Cine' Med reviews how to grasp a needle holder, the one-hand tie and a locking running stitch (scroll to page bottom to view "sample video").
Know the difference between 1st - 4th Lacerations.
Take a look at this article by Drs. Leeman, Spearman and Rogers from the University of New Mexico at Albuquerque.
Questions: Knots, Needles & Sutures
What type of suture is best?
How many 00s?
What size needle?
Taper or cutting?