Caesarean section and episiotomy

• A caesarean birth is a laparotomy performed to deliver a baby through incisions in the abdominal wall and uterus; for most women it is performed under regional (spinal or epidural) anaesthesia.
• Roughly one in three women (25% to 30%) in the United Kingdom currently give birth by caesarean. ^[1][4]
• The most common single indication is delay in labour or concern about the fetal condition, but a planned caesarean becomes the safer route when vaginal birth would put mother or baby at disproportionate risk.
• An uncomplicated vaginal birth after a single previous lower-segment caesarean (VBAC) succeeds in three out of four women whose labour starts naturally. ^[7]
• Episiotomy is a controlled cut of the perineum made at vaginal birth; restricting its use rather than making it routine reduces severe perineal trauma and is recommended by current guidelines. ^[2][5][8]

By the end of this page you should be able to:

1. List the common indications and the contraindications for caesarean birth, and explain the difference between an elective and an emergency procedure.
2. Counsel a woman about the benefits and risks of caesarean versus vaginal birth, including for a future pregnancy.
3. Describe the standard surgical steps in order, and explain the purpose of each action (skin preparation, catheter, anaesthesia, incision, delivery, uterotonic, repair).
4. Recognise postoperative complications (haemorrhage, infection, thrombosis, uterine rupture) from their early warning signs.
5. Advise women with a previous caesarean on the relative merits of planned VBAC and planned repeat caesarean, and state when VBAC is not advisable.
6. Classify perineal tears (first to fourth degree), list when episiotomy is justified, and describe how to repair an episiotomy.
7. Compare the recommendations of RCOG, ACOG, NICE and WHO, and state the edition of each you are using.

Every major guideline cited here uses the language of informed shared decision-making. A woman may decline any operation, and a request for caesarean without a medical indication is a valid starting point for discussion, not a problem to be refused. ^[1]

There is no single comprehensive list that applies to every hospital. NICE organises indications into maternal, fetal and combined; the most frequently encountered are below. ^[1]

Fetal indications. Suspected fetal compromise (abnormal fetal monitoring, cord prolapse, major placental abruption), a persistent abnormal presentation that cannot be corrected (transverse lie, footling breech, brow), and multiple pregnancy where the first twin is not cephalic or delivery is premature and complicated. For an uncomplicated singleton breech at term, whether to offer a planned vaginal birth or a planned caesarean depends on discussion of risks, benefits and external cephalic version. ^[1]

Maternal or combined indications. Placenta praevia (minor or major), placenta accreta spectrum, obstructed labour or true cephalopelvic disproportion, severe hypertensive disorders requiring delivery, active genital herpes simplex virus infection in the third trimester, HIV co-infection with hepatitis C virus (to reduce mother-to-baby transmission), and an inability to achieve safe vaginal birth because of a severe medical or obstetric condition. ^[1]

Planned (elective) versus emergency. A planned caesarean is booked before labour, usually at or after 39 completed weeks. An emergency (unplanned) caesarean is one performed after labour has started or because the clinical situation has changed. The urgency classification below is common to both, but the preoperative pathway differs: in an emergency there is less time for consent, antibiotics, counselling and neonatal preparation. ^[1]

Some situations that used to be assumed to require caesarean are no longer indications on their own. A body mass index (BMI) over 50 kg/m2 is not, by itself, an indication. ^[1] Estimated fetal weight, maternal height, shoe size and shoe size should not be used to decide between caesarean and vaginal birth. ^[1] Pelvimetry is not recommended for mode-of-birth decisions. ^[1] Where a woman requests caesarean birth without a medical indication, the professional should explore the request, offer balanced information and a birth options clinic, and support the woman's final choice. ^[1]

A caesarean is the safer route, and in some situations the only sensible route, when:

• there is a major placenta praevia or a suspected placenta accreta spectrum;
• a previous uterine scar is (or becomes) dangerous, such as a classical (vertical upper-segment) incision or a previous rupture;
• the fetus is in an uncorrectable transverse lie or an entrapped breech at term;
• there is an absolute fetomaternal emergency (cord prolapse, catastrophic abruption, unreassuring fetal status not resolved by expedite vaginal delivery); or
• vaginal birth is physically obstructed (fibroid blocking the birth canal, severe cervical cancer, or contracted pelvis in a context where instrumental delivery is unsafe).

Relative situations (coagulopathy, severe cardiac or pulmonary disease, placental abruption with a live fetus, severe pre-eclampsia or eclampsia needing imminent delivery) need individual multidisciplinary decisions and are addressed under those topics.

The surgeon must know the layers from skin to uterine cavity: skin, subcutaneous fat, rectus sheath, rectus abdominis, peritoneum, lower uterine segment, and the bladder (which overlies the lower segment). The lower segment is thin, poorly contractile and relatively a vascular compared with the upper segment, which is why it is chosen for incision and why it must be gently dissected free of the bladder. ^[1] The position of the placenta matters: an anterior placenta over the lower segment forces a different incision and careful cutting under vision.

A standard laparotomy tray with Deaver retractors, curved forceps for the baby's head, atraumatic uterine forceps for the placenta and sutures, plus neonatal resuscitation equipment, cross-matched blood, an anaesthetic machine with drugs for failed intubation, and a warmer. A maternity unit performing caesarean needs on-site blood transfusion services whenever the woman is already at high risk of bleeding (for example, antepartum haemorrhage, abruption or placenta praevia). ^[1]

Do not routinely carry out a planned caesarean before 39 completed weeks, because doing so increases the risk of respiratory morbidity in the newborn. ^[1] If a woman books earlier for a medical reason, the decision and its rationale should be documented. ^[1]

Offer women having caesarean birth the following before the operation: a full blood count (to identify anaemia), antibody screening and blood grouping with saving of serum; NICE does not recommend routine cross-matching of blood, a clotting screen, or preoperative ultrasound for localisation of the placenta. ^[1] Units should risk-stratify those who may need transfusion (placenta praevia, abruption, antepartum haemorrhage) and ensure on-site blood. ^[1]

Regional anaesthesia (spinal or combined spinal-epidural) is preferred to general anaesthesia for almost all women having caesarean birth, including those with placenta praevia. ^[1] Perform induction of either regional or general anaesthesia in theatre. ^[1] Reduce the risk of aspiration with antacids and H2-receptor antagonists or proton pump inhibitors, and include pre-oxygenation, cricoid pressure and rapid-sequence induction if general anaesthesia is used. ^[1]

To prevent maternal hypotension with regional block: place a left lateral tilt of up to 15 degrees or displace the uterus to the left once the woman is supine, and offer a prophylactic intravenous infusion of phenylephrine after the spinal injection, titrated to keep blood pressure at 90% or more of baseline and never below 80%. ^[1] Intravenous crystalloid co-loading in addition to vasopressors further reduces hypotension. ^[1] Give ephedrine boluses if the heart rate is low. ^[1]

Consent for caesarean should be taken only after providing evidence-based information, with dignity, privacy, views and culture respected, and the woman told clearly that she is entitled to decline the operation even when it would benefit her or her baby's health. ^[1] Factors important to the woman must be documented. ^[1] When a medical condition is not present and a woman requests caesarean birth (for example, because of fear of birth), explore and record the reasons, offer birth options discussion, perinatal mental health support for tokophobia, and honour the request if, after that discussion, she still wants it. ^[1]

Women having caesarean under regional anaesthesia are given an indwelling urinary catheter to prevent bladder over-distension. ^[1] Offer thromboprophylaxis, choosing between graduated stockings, hydration, early mobilisation and low-molecular-weight heparin by thrombosis risk. ^[1] Prophylactic antibiotics are offered before skin incision, choosing agents effective against endometritis, urinary tract and wound infection, but co-amoxiclav is not used for this purpose. ^[1] Infectious morbidity (endometritis, urinary tract and wound infection) occurs in about 8% of women having caesarean birth, and antibiotics before incision reduce maternal infection more than antibiotics given after incision, with no known effect on the baby. ^[1]

Aqueous povidone-iodine vaginal preparation before caesarean reduces endometritis in women with ruptured membranes; alcohol-based chlorhexidine is the preferred skin preparation. ^[1] Both reduce the risk of wound infection. ^[1]

Warm intravenous fluids of 500 ml or more, and all blood products, to 37 degrees Celsius with a fluid warmer; warm irrigation fluids to 38 to 40 degrees Celsius, and consider forced-air warming for women who shiver, feel cold, or have a temperature under 36 degrees Celsius. ^[1]

1. Position and access. The woman lies supine with up to 15 degrees left tilt. Skin is prepared with alcohol-based chlorhexidine; a urine catheter is in place; regional block is on. The bladder is not usually drained by suprapubic catheter.
2. Abdominal incision. Make a low, transverse, straight skin incision, opening subsequent tissue layers bluntly and extending with sharp dissection if needed. Modify with a higher incision in class 3 obesity (BMI 40 kg/m2), and use a vertical midline incision for some clinical indications. ^[1] Do not use separate knives for skin and deeper tissue: it does not reduce wound infection. ^[1]
3. Bladder reflection. The loose peritoneal fold over the lower uterine segment is opened bluntly and the bladder displaced downward. A standard manual or Kelly-type displacement of the bladder is used; gentle dissection protects against bladder trauma.
4. Uterine incision. Incise the lower segment (Kerr incision). When the lower segment is well formed, use blunt rather than sharp extension of the uterine incision: this reduces blood loss, postpartum haemorrhage and transfusion. ^[1]
5. Delivery of the baby. Deliver through the incision by fundal pressure by the assistant, with forceps used only if difficulty arises. Amniotic fluid is sucked if the sac is intact. Warn the woman and warn staff that a baby can be slippery. Avoid routine fundal pressure in the second stage of labour during vaginal birth, but here fundal assistance is part of the surgical delivery. ^[2]
6. Cord clamping and warming. Clamp the cord; dry and warm the baby; ensure airway and breathing; start skin-to-skin contact when both are stable. ^[1]
7. Placental removal. Remove the placenta by controlled cord traction, not manual removal, to reduce endometritis. ^[1]
8. Uterine repair. Repair the uterus in the peritoneal cavity; routine exteriorisation of the uterus is not recommended because it increases pain without improving haemorrhage or infection. ^[1] Single-layer or double-layer closure is acceptable, depending on clinical circumstances; single-layer closure does not increase the risk of bleeding or uterine rupture in a subsequent pregnancy. ^[1]
9. Peritoneal and abdominal closure. Do not close the visceral or parietal peritoneum. ^[1] Close the rectus sheath and skin: use mass closure with slowly absorbable continuous sutures for midline incisions; close subcutaneous tissue only when fat is more than 2 cm. ^[1] Consider sutures rather than staples to reduce superficial wound dehiscence. ^[1] Do not use superficial wound drains routinely. ^[1]
10. Uterotonic after delivery. Follow the third-stage-of-labour recommendation on intrapartum care for oxytocin after cord clamping, rather than older practice. ^[1] This is particularly important after caesarean birth, because uterine atony causes postpartum haemorrhage.

Impacted head. When the head is deeply engaged, delivery can be obstructed. NICE directs readers to the RCOG scientific impact paper on management of impacted fetal head at caesarean birth. ^[1] Options discussed there include reversing the station with a hand, using the "push" method from below, and a large inverted "T" or "J" extension of the incision; each must be prepared for before starting. ^[1]

NICE's four-category scheme is widely used: ^[1]

• Category 1: immediate threat to the life of the woman or fetus (for example, suspected uterine rupture, major abruption, cord prolapse, fetal hypoxia, persistent bradycardia). Perform as soon as possible; in most situations within 30 minutes. ^[1]
• Category 2: maternal or fetal compromise that is not immediately life-threatening. Perform as soon as possible; in most situations within 75 minutes. ^[1]
• Category 3: no maternal or fetal compromise, but needs early birth.
• Category 4: birth timed to suit the woman or the provider (elective).

After general anaesthesia, a healthcare professional with airway skills observes the woman continuously, one-to-one, until airway control returns, haemodynamic stability is achieved, and she can communicate. Observations (oxygen saturation, respiratory rate, heart rate, blood pressure, temperature, pain, sedation) are then half-hourly for 2 hours, then according to local protocol; if unstable, or if risk factors such as hypertension, infection or sepsis are present, a medical review and longer, more frequent observations are needed. ^[1] After regional anaesthesia, continuous one-to-one observation continues until cardiovascular stability. ^[1]

Use intrathecal or epidural diamorphine (up to 300 micrograms intrathecal, 3 mg epidural) to reduce the need for supplemental analgesia, or intrathecal morphine (up to 100 micrograms) plus fentanyl (up to 15 micrograms) if diamorphine is unavailable. ^[1] Add paracetamol and an NSAID when not contraindicated, using immediate-release preparations taken regularly rather than just when needed, to reduce opioid need. ^[1] Do not use codeine or co-codamol in breastfeeding women; use dihydrocodeine, tramadol or oxycodone at the lowest effective dose for the shortest time if stronger analgesia is needed. ^[1] Remove the urinary catheter once the woman is mobile, but no sooner than 12 hours after the last top-up dose of regional anaesthetic. ^[1] Offer removal of dressings 6 to 24 hours after birth, and plan suture or clip removal. ^[1] The woman may eat and drink as normal once recovering well. ^[1] Avoid routine respiratory physiotherapy after general anaesthesia, as it does not improve respiratory outcomes. ^[1] For well women who are apyrexial and free of complications, discharge from hospital after 24 hours with home follow-up is not associated with more readmissions. ^[1] Activities such as driving, carrying heavy items and sexual intercourse can be resumed when she feels fully recovered. ^[1] NICE informs women that, after caesarean birth, they are not at increased risk of depression, post-traumatic stress symptoms, pain on intercourse, faecal incontinence or breastfeeding difficulties. Women not recovering well, or with urinary symptoms, heavy or irregular bleeding, or respiratory or leg symptoms should be assessed for urinary tract infection, stress incontinence (which occurs in about 4% of women after caesarean birth), urinary tract injury (about 1 per 1,000 caesarean births), endometritis or venous thromboembolism. ^[1]

Offer early skin-to-skin contact and help to start breastfeeding. ^[1] Ensure thermal care is appropriate, and an appropriately trained practitioner skilled in newborn resuscitation is present if there is evidence of fetal compromise or if the caesarean is under general anaesthesia. ^[1] Perform paired umbilical artery and vein cord blood gas measurement after caesarean for suspected fetal compromise. ^[1]

Assess the wound for increasing pain, redness, discharge or dehiscence; encourage loose, comfortable clothes and cotton underwear; clean and dry gently; remove standard dressings 6 to 24 hours after birth. ^[1] Consider negative-pressure wound therapy after caesarean for women with BMI 35 kg/m2 or more. ^[1] No dressing type is superior, and removal at 6 hours is as safe as removal at 24 hours. ^[1]

Haemorrhage. Blood loss of more than 1,000 ml is more likely after caesarean when there is antepartum haemorrhage, abruption or placenta praevia, which is why those women should be delivered in a unit with on-site blood transfusion. ^[1] Atony is the most common cause; deal with retained placenta, trauma and coagulopathy early. Warm fluids, adequate intravenous access and early uterotonic use all matter. ^[1]

Thromboembolic disease. Pay particular attention to women with respiratory or leg symptoms after caesarean birth, because they are at increased risk of deep vein thrombosis and pulmonary embolism. ^[1] Thromboprophylaxis (graduated stockings, mobilisation, hydration, heparin) should be routine. ^[1]

Infection. Risk factors sit in the endometrial cavity, wound and urinary tract. Watch for fever from day two, rising white cell count, offensive lochia, wound erythema or discharge, and dysuria.

Fetal laceration. The risk of a fetal laceration is about 2% at caesarean birth. ^[1] Usually these are superficial and heal without long-term problems, but they must be documented and treated.

Bladder or bowel injury. Occurs in about 1 per 1,000 caesarean births for bladder injury. ^[1] Risk rises with scarring, a transverse lie, very preterm delivery and an atonic uterus. Intraoperative injury is usually repaired immediately.

Hypotension, nausea and shivering in theatre. Anticipate spinal hypotension with phenylephrine and fluid co-loading, and use acupressure or anti-emetics for nausea. ^[1]

Uterine rupture (future risk). Women who reach 4 cm or more and push after previous caesarean are at risk of rupture, and rupture risk is higher for planned VBAC than for planned repeat caesarean: up to 1 in 200 women in planned VBAC compared with less than 1 in 4,000 for planned repeat caesarean. ^[7] Uterine rupture presents with pain (often "tearing"), vaginal bleeding, loss of fetal station, fetal heart-rate abnormality (especially prolonged bradycardia), uterine hypertonus or loss of contractions. Use continuous electronic fetal monitoring during labour. ^[1][4]

Massive haemorrhage. Occur after emergency or elective caesarean for placenta praevia and placenta accreta in particular. Multidisciplinary preparation, cell salvage where available, and specialist centres for suspected accreta reduce harm. ^[1]

Three out of four women who have had one caesarean whose labour starts naturally go on to achieve a vaginal birth. ^[7] Previous vaginal birth (before or after the caesarean) raises the chance to 8-9 in 10; spontaneous onset of labour and a BMI under 30 at booking also improve success. ^[7]

Benefits of VBAC over elective repeat caesarean include a lower maternal death rate (4 compared with 25 in 100,000 women), quicker recovery, shorter hospital stay, fewer breathing admissions for the baby (1 in 24 versus 1 in 56), no surgical complications and no scar tissue. ^{[7] [6]}

Risks. Among women attempting VBAC, about 1 in 4 will need an emergency caesarean in labour (only slightly more than the 1 in 5 chance for a first-time birth). Blood transfusion is slightly more likely (about 4 per 1,000 compared with 3 per 1,000 for repeat caesarean). Uterine rupture (up to 1 in 200) can require hysterectomy (up to 1 in 3 of those who rupture) and slightly increases serious risk to the baby (an extra 10 in 10,000 babies; risk of baby death around 4 in 10,000 births). Induction increases the emergency caesarean rate and raises uterine rupture risk two- to three-fold. ^[7]

Planned repeat caesarean (elective) advantages and disadvantages. A uterine rupture risk under 1 in 4,000; 1 in 10 women go into labour before the booked date, so elective sometimes becomes emergency. Disadvantages of repeat surgery: longer duration with more scar tissue (risk of bladder or bowel injury, around 1 in 1,000), infection (2-7 in 100 women), recovery about 6 weeks, and a higher long-term risk of abnormal placental invasion (placenta accreta or percreta three times more common after one previous caesarean, around 1 in 1,000 women). Babies born by caesarean before 39 weeks are more likely to need neonatal unit admission for breathing support. ^[7]

When VBAC is not advised. Three or more previous caesarean births; previous uterine rupture; a previous classical (upper-segment) incision; other pregnancy complications requiring planned caesarean. ^[7]

Who may be offered a trial in most cases? ACOG states that TOLAC is suitable for many women, but should be accompanied by an assessment of the likelihood of success and of individual risks, because a failed labour increases maternal and perinatal morbidity compared with successful VBAC and elective repeat caesarean. ^[3] NICE advises electronic fetal monitoring throughout labour, and delivery in a unit with immediate access to caesarean birth and on-site blood. ^[1] RCOG advises continuous electronic fetal monitoring from the onset of regular contractions. ^[4] Women with up to 4 previous caesareans have similar risks of fever, bladder and surgical injury with planned VBAC and elective repeat caesarean, but a higher risk of uterine rupture with vaginal birth. ^[1]

Routine or liberal use of episiotomy is not recommended for spontaneous vaginal birth. ^[2] ACOG likewise recommends restrictive over routine use. ^[5] In the Cochrane review of selective versus routine episiotomy, restrictive use meant an episiotomy rate of about 28% rather than 75%, and was associated with less severe perineal trauma (relative risk 0.67, 95% confidence interval 0.49 to 0.91). ^[8]

Reasonable indications, made by clinical judgement rather than by fixed rules, include:

• Operative or instrumental vaginal birth, especially a forceps or vacuum delivery in a nulliparous woman, where a mediolateral incision is often used. ^[6]
• Fetal distress in the second stage, where one more strong push would be too slow.
• Shoulder dystocia, to make room, recognising that there are insufficient randomised data clearly showing benefit or harm from episiotomy in this setting (ACOG). ^[5]
• A very short perineum where a spontaneous tear would reach the anal sphincter.
• Prevention of severe (third- or fourth-degree) tears in selected women at high risk, although the evidence is mixed and clinical judgement remains the best guide. ^[5]
• A very large baby or a face presentation at the end of a long second stage.

Mediolateral episiotomy is preferred to midline when an incision is needed, because midline is associated with increased risk of injury to the anal sphincter; mediolateral incision is associated with more perineal pain and dyspareunia. ^[5] Warm compresses applied to the perineum during pushing reduce the risk of third- and fourth-degree lacerations (ACOG, Level A). ^[5] Perineal massage in the second stage may help reduce lacerations. ^[5]

WHO also recommends restricting episiotomy: "routine or liberal use of episiotomy is not recommended for women undergoing spontaneous vaginal birth". ^[2] Warm compresses applied to the perineum during pushing reduce the risk of third- and fourth-degree lacerations (ACOG, Level A). ^[5] Perineal massage in the second stage may help reduce lacerations. ^[5]

Episiotomy is usually performed under local anaesthetic or an existing epidural. After positioning and sterile cleaning, the incision is made from the vaginal fourchette toward the posterolateral perineum at 60 degrees (mediolateral), cutting skin, subcutaneous tissue, perineal muscles and posterior vaginal epithelium. The baby is allowed to deliver through the enlarged opening; once the head and shoulders are out, repair is performed. Repair includes haemostasis, layered closure of muscle and vaginal mucosa, and subcuticular skin closure, with good light and systematic examination of the anal sphincter and rectal mucosa to avoid missing an occult fourth-degree tear.

About 53% to 79% of women who deliver vaginally sustain some perineal trauma of any degree; the majority are first- and second-degree tears that heal well. ^[5] Severe tears (OASI, third- and fourth-degree) occur in about 3 to 4 in 100 vaginal births, more commonly with first vaginal birth, babies over 4 kg, a long second stage, shoulder dystocia, or instrumental delivery. ^[6][7]

A Cochrane review of selective versus routine episiotomy found less severe perineal trauma with selective use; with third- and fourth-degree tears, a single dose of antibiotic is recommended at repair (ACOG, Level A) and prophylactic antibiotics are used after OASIS. ^[5][6][8] Repair of OASIS should be performed at once in theatre beneath adequate anaesthesia, with end-to-end or overlap repair of the external anal sphincter both acceptable, and endoanal imaging or manometry where available to guide later care. ^[5][6]

• NICE (NG192, 2021, last updated 10 June 2025) recommends planning caesarean at or after 39 weeks, category-based decision-to-birth intervals (30 and 75 minutes), regional anaesthesia, alcohol-based chlorhexidine skin prep, povidone-iodine vaginal prep with ruptured membranes, blunt extension of the uterine incision, controlled cord traction for the placenta, single or double layer uterine closure, no peritoneal suture, no routine subcutaneous closure unless fat exceeds 2 cm, sutures over staples, antibiotics before skin incision, and thromboprophylaxis. ^[1]
• WHO (intrapartum care for a positive childbirth experience, 2018) recommends restrictive episiotomy, no routine antibiotics for uncomplicated vaginal birth or episiotomy, uterotonics for all births during the third stage, and postnatal uterine tone and regular assessment of bleeding in the first 24 hours. ^[2]
• ACOG (PB 205, 2019, reaffirmed 2024; PB 165, 2016) advises restrictive episiotomy (Level A), warm compresses (Level A), and selective episiotomy with clinical judgement as the strongest guide. For VBAC, TOLAC is suitable for many women with individualised risk assessment. ^[3][5]
• RCOG (GTG 45, 2015; GTG 29, 2015) supports planned VBAC as safe for most women with one previous lower-segment caesarean, gives the uterine-ruptiture risk comparisons quoted above, recommends continuous electronic fetal monitoring during labour, and grades perineal tears and OASIS repair as described. ^[4][6]

These guidelines differ in small details (for example, ACOG defines the active phase from 6 cm whereas WHO uses 5 to 6 cm and NICE uses 4 cm, as discussed in labour-stages topics), and should be referenced by edition in any examination or clinical protocol. ^[1]

• Where uterotonics are scarce, the cheapest measures that avert death are oxytocin 10 IU intramuscularly for the third stage and uterine massage, combined with timely transfer to a facility. ^[2]
• Prenatal and intrapartum "caesarean on request" practices may strain local resources; weigh maternal request against available beds, blood and anaesthetic cover. ^[1]
• Sterile technique, alcohol-based chlorhexidine (or povidone-iodine) for skin preparation, and a single dose of antibiotic before incision are the interventions that most reduce postoperative infection. ^[1]
• Continuous postnatal observation, with prompt recognition of rising bleeding, fever and leg pain, will save more lives than technology. ^[1][2]
• Episiotomy rates fall, and outcome improves, when staff are trained in perineal protection: hands-on perineum, controlled delivery of the head, and selective rather than routine cutting. ^[5][6]

Postpartum haemorrhage; shoulder dystocia; third- and fourth-degree perineal tears; assisted (instrumental) vaginal birth; labour stages and failure to progress; antepartum haemorrhage; placenta praevia and placenta accreta spectrum; thromboprophylaxis in obstetrics; perineal care and wound healing.