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THE BEST WAY OF DEALING WITH A LACERATION IS TO PREVENT IT TO BEGIN WITH! Unfortunately, even with the best techniques and care, midwives still get an occasional laceration that needs to be repaired. Fortunately, they rarely need more than a few stitches, if any at all. Many midwives prefer not to use any type of medical anesthetic for suturing for legal reasons and because the risk of anesthetic complications may occur. For those who feel the need or have a client that insists on some kind of anesthetic, here are some helpful suggestions and recommendations.
The information given below assumes knowledge of syringe use. For more information see links at the bottom of this article.
For minor lacerations or tears requiring only a stitch or two, anesthetic may not be required if repairs are performed on the perineum within a short time of placenta delivery. The perineal tissue will still be relatively numb from the birth and the suturing will feel like a slight "pinch" as the needle goes through the tissue. It may be repaired easily and quickly without the use of and the worries about anesthetic complications.
However, if the repair is going to require more than a few stitches, repair is delayed after the birth, and/or requires extra time to repair, anesthetic may be considered if you carry it in your birth bag. Keep in mind allergic reactions and tissue swelling associated with it's use. Be aware of any signs of adverse reactions with the use of any anesthetic and how to treat reactions before using any anesthetic product.
If anesthetic is to be administered, it should be injected prior to beginning suturing. It takes a few minutes to really take effect. 1% or 2% plain xylocaine (lidocaine) may be used. Epinephrine should not be included in with the xylocaine as it is more likely to cause allergic reactions and it is a vasoconstrictor. Ask the resource supplier about anesthetic product options.
The purpose of the anesthetic is to deaden the skin and just under the skin surface. Use only enough to achieve a result. There is no need to use anything further back as there are very few nerve endings in this region. Make sure you have noted any matching skin tags or other "land marks" prior to anesthetic injections since the injections may cause the tissues to swell and become slightly distorted. You will want to make sure the tissue is appropriately aligned for good repair and proper healing.
Begin by using 4 cc of 2% medication or 6 cc of 1% medication. This should be enough, however, up to 10 cc of 2% medication and 15 cc of 1% medication total amount can be administered. If the mother can still feel it with this amount, then it is important to simply get the sutures in as fast as can be done.
HELPFUL ANESTHETIC HINTS:
Keeping the mother occupied (distraction technique) with her new baby can help to distract her while repairs are being performed. This is helpful with or without anesthetic use.
Using a pre-frozen syringe needle will help to keep injection discomfort to a minimum. Freezing the needle while still in the package can be done during labor and the needle is removed from the freezer when repairs need to be performed.
Use small gauge needles (27 to 30 gauge, no larger than a 25 gauge needle should be used - the larger the gauge, the smaller the needle).
Infiltrate skin slowly.
Inject through wound edge if possible.
Warm xylocaine to body temperature.
Applying ice packs on the perineum can help cool the skin, numb the area, reduce swelling, slow bleeding and can be useful prior to repairs and for the discomfort after repairs.
Have the client/patient keep her eyes open during repairs (analogous to labor pain management).
Vibrate or pinch skin as you inject anesthetic.
Talk calmly to client/patient. Let her know what you are doing and what to expect. No surprises.
SUTURING ALTERNATIVES & REPAIR HINTS
Some midwives that are not able to obtain injectable anesthetic will often use a spray-on or gel local anesthetic that can be purchased at a local drug store or through a medical supply retailer. Keep in mind, it only works on the surface and there still may be some discomfort during suturing. Topical anesthetic can be used to help with injection discomfort when applied prior to injections. Spray-on lidocaine has alcohol in it and it does sting. But if you fan it, it is more tolerable than the injections. Cetacaine gel or Xylocaine spray applied and waiting about 3-4 minutes, gives about 50% numbness, which is usually sufficient for a normal 1st to small 2nd degree tear at a normal birth.
Tea tree oil put on the perineal wound before suturing to aid healing seems to help numb the area instead of or prior to injecting lidocaine may be helpful for one or two stitches. I have never tried this, but this is a suggestion from a midwife from the Midwife Archives (see link below).
Verbal anesthesia helps such as talking or singing (another form of distraction). Favorites may be "Leaving on A Jet Plane", "Hundred Bottles of Beer on the Wall" or some other well known, easy song can be used during repairs. The midwife can sing along with the mother and other people present at the birth.
"Suture" glue (similar to "Super Glue") may be used to "glue" the wound edges back together. It can be used alone or along with sutures by applying and holding the wound edges together until bonding occurs. Suturing may be done after the tissue edges have bonded. The ability to adhere properly is dependent on a dry surface. A midwife may have an extra person fanning the perineum after mom has been cleaned up and while glue is being applied. If you choose to suture, use a small suturing needle to reduce discomfort.
USING SUPER GLUE INSTEAD OF SUTURES:
The tear needs to be fresh, clean, and fairly shallow with straight edges that lie together on their own. The glue is applied to bridge over the closed edges, not inside on raw surfaces. (Covering the raw surfaces with Super Glue could actually PREVENT the surfaces from knitting together!) Insert a tampon first and insert your finger between the edges and pull it out to bring the edges forward slightly. This ensures that edges won't roll inward toward each other, but meet perfectly. You could also use a tissue forceps for this. Hold gauze below apex to catch any drips and apply tiny dots of glue sparingly where the edges meet. You can also apply a bead of tiny droplets to bridge the edges. Use a hair dryer or fan to dry, which takes about 30 seconds. The adhesive stiffens as it dries and prolonged soaking isn't too good for it. It will flake off by itself in usually less than a week. Some rare allergic reactions are inflammation and swelling. Be careful not to glue your glove or gauze pads to the mother during application. Some midwives prefer using a "gel super glue" over the liquid version since it has more control and less dripping. After all, you do not want to glue the mother's anus shut during the application process. Many midwives have had great success in using skin glue in place of sutures and the mothers like it too since needles are rarely used with the glue.
From Anne Frye's Healing Passage, 5th edition, p. 44.:
A Note About Tissue Adhesive: In 1959, a variety of cyanoacrylate adhesives were developed, some types of which are now used for wound closure in Canada and Europe. Some midwives have assumed that retail cyanoacrylate adhesives such as Super Glue are identical to medical adhesives. However, retail products contain methyl alcohol because it is much cheaper to produce, and are manufactured to industrial, not medical, standards. Cyanoacrylates cure by a chemical reaction called polymerization, which produces heat. Methyl ester has a pronounced heating action when it contacts tissue and may lead to tissue necrosis during metabolism.
Medical grade products contain either butyl, isobutyl or octyl esters. They are bacteriostatic and painless to apply, produce minimal thermal reaction when applied to dry skin and break down harmlessly in tissue. They are essentially inert once dry and have been shown not to be carcinogenic. Butyl products are rigid when dry, but provide a strong bond. Available octyl products are more flexible when dry, but produce a weaker bond. Ideally the wound to be closed is fresh, clean, fairly shallow, with straight edges that lie together on their own. The glue is applied to bridge over the closed edges; it should not be used within the wound, where it will impair epithelization. The only FDA approved adhesives suitable for use as suture alternatives are veterinary products; n-butyl-cyanoacrylate tissue adhesives Vetbond (3M) and Nexaband liquid and octyl-based Nexaband S/C (intended for topical skin closure when deep sutures have been placed). Histoacryl Blue (butyl based) (Davis & Geck) and Tissu-Glu (isobutyl based) (Medi-West Pharmaceuticals) are sold in Canada for human use. DMSO (dimethyl sulfoxide) or acetone serve as removers. (Helmstetter, 1995; Quinn & Kissick, 1994)
RELATED LINKS AND RESOURCES
FPNotebook.com: Local Skin Anesthesia
Midwife Archives: Suturing / Super Glue
SkinStitch.com: GluSeal Liquid Bandage
SUTURING LINKS
MoonDragon's How to Give Injections
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