College of Midwives ~
Technical Bulletin #4
and Procedures in the Repair of Second Degree
Perineal Lacerations by Licensed Midwives
The Use of Medical Grade Super Glue ~ URLs regarding Skin Repair in Perineal Lacerations
First degree lacerations don’t usually profit from being sutured unless there is great asymmetry or bleeding. Second degree lacerations, by definition, include the rendering of the perineal muscle (bulbocavernosus). In the absence of asymmetry or uncontrolled bleeding and presence of informed consent for an “experimental” treatment ~ non-suturing of these lacerations is an acceptable option (see HOOP study done in UK).
Should suturing be desired by the mother (a conclusion arrived at only after suitable informed consent) or required by the severity of perineal trauma (ditto informed consent, including the option of medical transfere), the following is a list of general steps for repairing a second degree laceration or midline episiotomy.
Its purpose is to refresh the memory of those who already know how to classify lacerations and assess their seriousness, are skilled in the principles of sterile technique and knowledgeable of the basic techniques (methods of placing sutures, how to tie effective knots, how to anesthetized the wound, etc.) but suture so rarely that they would benefit from this review. These instructions are not meant to take the place of formal instruction in the art and science of perineal laceration repair.
----------------------------- Preparation -----------------------------------
1. Set up instruments and materials, including 1 pair of sterile gloves and at least 1 additional sterile vag exam glove to “double” glove when checking rectum to be certain no stitches accidentally went through rectal wall. Arrange for good light (and/or head lamp), position mother with hips slightly elevated on underpads. Be sure she is hydrated, keep her warm and holding baby if she is willing.
2. After gloving, inspect laceration well, looking for bleeding, bruising and deep hematomas. See how things fit back together, cut off any skin tags and remove any blood clots.
3. Roll two gauze 4x4s into a slightly off-center tampon, creating a “tail” for easy removal and lubricate it with sterile KY jelly. Use your gloved fingers to press down on the posterior vaginal wall (actually the “floor”), sliding the tampon down the ramp made by your fingers. Leave a tail of the 4x4 hanging out and off to the side or top so that it doesn’t touch the anus. A small Kelly clamp is a convenient way to do this.
---------------------- Suturing Principles & Techniques------------------
In order of placement, you will be using about 6 running locked stitches in the vaginal mucosa, 2-4 interrupted sutures in the deep perineal muscle, followed by 4-5 continuous basting stitches in the subcutaneous fascia of the perineum and finally, 5-6 subcuticular or continuous mattress stitches to bring the edges of the skin together. Total number of stitches placed is about 20.
Healing happens by the joining of the two surfaces so avoid all “dead spaces” and avoid sewing up blood clots, hair or skin tags into the healing surfaces of the wound. All suturing must begin by bringing together the intact portion of tissue and then continuing to approximate the wound edges as one moves forward (as one would close a zipper).
Should the perineal muscle be bleeding heavily and need to be repaired in two layers, you will need to place a single deep figure-8 stitch in the perineum with 2-0 chromic to control the bleeding before beginning to suture the vaginal mucosa.
4. Normally one begins by repairing the mucosa of vaginal floor with 3-0 chromic on an atraumatic (tapered) needle. The first stitch is an anchoring suture about 1/2 centimeter above the apex (upper most v-cleft) of the laceration. If you are right-handed, lock the stitch on the left. Each stitch is a new source of trauma to the tissues so make each one count -- inexperienced practitioners tend to err on the side of too many sutures.
Be sure not to go through vaginal mucosa into rectum. This is assured by taking each stitch in two steps -- through the outside, upper surface of the vaginal mucosa with the needle coming out on the torn inner surface and pulled through. Then the needle is inserted to the opposite torn inner surface and aimed upward to the outside, upper surface of vaginal mucosa on the opposite side. Only then is it brought together and “locked”. This avoids a single big “blind” bite through all tissue a once which may go too deep and enter the upper wall of the rectum.
After the initial anchoring stitch, proceed to run a continuous locked stitch (also known as a “blanket stitch”), 1 to 1 1/2 cm apart, down to just before the hymenal ring or junction of mucosa and skin of perineum. At this point you will have to take one extra “bite” and then pull up some of that suture into a loop to use as the opposing side to lock the last stitch. Do NOT cut needle side of the suture as you will be using it to close the perineum. Cut ONLY the doubled sided loop of the suture about 1/2 cm long - not so close that the knot comes undone or so long that it pokes out of the mouth of the vagina. Then lay the needle and suture on sterile drape on mom’s belly for later use.
5. Open a second package of suture and repair perineal muscle using 2-0 chromic on cutting needle (CT1) with 2 - 4 interrupted sutures. Begin suturing at the top of the tear with the same “two-step” process as used in the vaginal mucosa (to avoid accidentally suturing into the rectum) and tie off each one. As you go down towards the anus, take smaller and shallower bites. Interrupted stitches provide the extra assurance that if a suture does come out, the others will still hold the musculature together for good healing.
Double glove one hand and check through the rectum to be sure that no stitches have gone through. If so, remove and replace them, then check again. Were they allowed to remain, the mother could develop a fistula (tract between vagina and rectum), which would mean that liquid stool would come out her vagina -- something to be avoided at all costs. If it turns out that she has a third degree laceration (serious involvement of rectal mucosa and/or sphincter), call for or transport her to an experienced medical care provider for completion of suturing. There is no shame in knowing when you are in over your head and great, long-term benefit to the mother by having this delicate work done by a well-experienced person.
6. Using the 3-0 chromic suture from the vaginal mucosa, close the subcutaneous fascia with about 5 basting stitches, again starting at the top of the tear and working down towards the rectum. As you get closer to the bottom, takes smaller and shallower ‘bites’. The suture is kept to the right side and not locked except for the last stitch. Don’t cut it however, as you are going to continue to use this suture.
7. Continue on with the same 3-0 chromic and using a subcuticular stitch, begin to suture the skin by starting at the bottom (closest to anus) with smaller, shallow bites and working your way up with this continuous mattress stitch. A 1 cm bite is taken on the first side, slightly below the level of the skin and parallel to the wound edge, repeated on the opposite side and then pulled together so that it makes an “invisible” stitch (no suture is seem from the outside). Hold this taunt and repeat until the entire length of the perineal wound is closed, much like an invisible zipper. Do not overlap or roll edges. The last stitch is taken at the junction of the skin and vaginal mucosa. The vagina is brought together loosely and then the needle is brought through to the inside of the vaginal mucosa (behind the hymenal ring) and a square knot is made with this loop of suture without bring the long end through (left buried in tissue). Finish last two ties (total of three) and your done.
Dispose of all sharps properly, and give the mother appropriate instructions on healing, her activity level (bedrest) and what signs and symptions should prompt her to call you.
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