1. Maternal or fetal compromise to expedite delivery.
   
   
2. Clinical indication such as instrumental delivery, breech delivery or shoulder dystocia
   
   
3. Minimise the risk of severe perineal trauma
   
   
4. Women with FGM should be informed of the need for anterior episiotomy and possible need for deinfibulation in labour.

Perineal infiltration should be carried out timeously allowing adequate time for analgesia to be effective prior to performing episiotomy.

• Gain informed consent and document in the patient’s labour record.
  
  
• Clean the vulva with sterile water.
  
  
• Using a 10ml syringe and 21g needle draw up 5-10mls Lidocaine as per unit protocol checking dosage and expiration date with colleague.
  
  
• Insert 2 fingers into the vagina, behind the perineum to protect the presenting part
  
  
• Insert the full depth of the needle (4-5cm) centrally at the introitus, draw back plunger prior to infiltration to ensure not in a vein and inject 1/3 of the lidocaine.
  
  
• Reposition without removing the needle into a lateral position and inject 1/3 of the lidocaine
  
  
• Repeat the process for a third time to infiltrate a fan shaped area of the perineum
  
  
• Lidocaine takes approximately 3-4minutes to take effect

Diagram: illustrating perineal infiltration

Diagram illustrating correct angle of Right medio-lateral episiotomy

• Verbal consent and documenting in the patient’s labour record.
  
  
• Insert 2 fingers into the vagina gently push the Presenting Part (PP) back for protection (see diagram).
  
  
• Using straight mayo scissors out with uterine activity place scissors at the midpoint of the fourchette
  
  
• At the height of a contraction, make an incision 4-5cm directed towards the ischial tuberosity, at a 60-degree angle (8 o’clock)
  
  
• Immediately remove scissors and apply pressure to control bleeding and facilitate delivery of the fetal head and continue with delivery

P  -  Predisposing Perineal Risk factors:

• Induction of labour
• Primiparous women
• History of OASIS injury
• Indian / Asian women
• Short perineum <2cm
• Large BMI
• Fetal macrosomia

O  -  Observe Perineum during 2^nd stage:

• Length
• Friable tissues
• Button holes
• Scarring

P  -  Prevention:

• Consider early infiltration
• Lubricate with gel
• Warm / cool compress
• Consider RML episiotomy

T  -  Technique – delivery:

• Maternal position
• Perineal support technique
• Perineal repair / labial repair required – repair ASAP