The physician controls the progress of the head to effect a slow, safe delivery. Forceps are often used for delivery when maternal exhaustion prevents adequate pushing. Forceps are safe and may be required when epidural anesthesia precludes vigorous bearing down. Local anesthesia may not interfere with bearing-down efforts, so unless complications arise, forceps are usually not needed. If the 2nd stage of labor is likely to be prolonged because the patient is having difficulty bearing down, forceps or a vacuum extractor may be used.
Episiotomy is usually necessary only for first deliveries at term.
This procedure prevents excessive stretching and possible tearing of the perineal tissues. The incision is easier to repair properly than a tear and may decrease anterior tears. The most common type of episiotomy is a midline incision made with scissors from the midpoint of the fourchette directly backward toward the rectum. With this type, extension into the rectal sphincter or rectum is a risk, but if recognized promptly, the extension can be repaired successfully and heals well. Tears or extensions into the rectum can usually be prevented by keeping the baby's head well flexed until the occipital prominence passes the subpubic arch.