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SUTURING EQUIPMENT & SUPPLIES
Although all that is needed to do a suturing job is suture, a needle, light and gloves. It is helpful to have some other items that can make the job easier.
- Gloves
- Needle Holders
- Scissors
- Allis Clamps
- Forceps
- Sutures
- Suturing Needles
- Sponge Forceps
- Lights
- An Assistant
- 4x4 Gauze Squares
- Firm Surfaces
- Local Anesthetic
GLOVES
Choosing gloves can be confusing since each glove has different features and benefits. To make it easier to decide, here are some characteristics to help make selection easier.
- Country of Origin: To determine where the glove is made.
- Beaded Cuff: Gloves that are beaded tend not to "roll up".
- Textured: The finish of the glove is not smooth. Preferred by some for tactility.
- Chlorinated: This refers to a chemical used to remove the powder from the glove to manufacture powder-free gloves. Water-washed (non-chlorinated gloves) do not possess these characteristics, but are white in color and more elastic in nature.
- Fitted: Gloves that are packed in pairs to fit the right and left hands. Anatomically correct.
- Powdered: Powdered gloves use two types of powder, 11either a mold-release agent (e.g. calcium carbonate) or a donning agent (USP absorbable dusting powder). Powdered gloves are the least expensive gloves available, but the market is moving toward powder-free gloves. The reason is that the powdered, while easier to put on, come with several disadvantages: powder is an airborne material that is an abrasive irritant; protein levels are highest in powdered gloves; powdered glove wearers are more likely to develop allergies; powder can inadvertently fall into wounds in a surgical procedure.
- Powder-free: These can be further processed to eliminate the need for lubricating powders. Some manufacturers coat their gloves with various surfactants and silicone. Others wash the powder off the gloves during the manufacturing. Powder-free gloves address the concerns of those who suffer from either Type IV hypersensitivity to chemical additives, or glove-related irritation. They also eliminate hazards of powder in operating rooms or medical procedures.
- Latex Gloves: Latex sterile powdered and powder-free gloves have similar qualities to latex non-sterile but are manufactured to be sterile. Latex is considered to be first choice for high-risk infectious situations. If allergies exist to latex, the health care practitioner can try using washable, reusable nylon or cotton glove linings as a barrier between sensitive skin and the latex gloves.
- Nitrile & Synthetic Gloves: These are powdered and powder-free gloves that do not contain natural rubber latex proteins and they do not cause Type I reactions to latex. Because they are compounded with chemicals, synthetic gloves still may cause irritation, as well as Type IV reactions. More and more people are turning to nitrile and synthetic gloves to meet their latex-sensitivity concerns.
- Vinyl Gloves: Vinyl gloves are becoming increasingly more popular for those healthcare practitioners with allergies to latex. They are a good choice for low risk protection situations and in circumstances not requiring contact with bodily cavities.
A good pair of form fitting, sterile surgeons gloves are ideal to use for suturing. Surgeons gloves may differ from regular medical exam gloves by having cuffs that cover more of the forearm (above the wrist) than regular medical exam gloves (which usually come to the wrist) and have higher tactile sensitivity. Gloves come in assorted sizes, either by numbers or by definition of ex-small (petite), small, medium, large and ex-large. The average size woman's hands would wear a small to medium, depending upon the manufacturer and type of glove (latex, non-latex, nitrile, etc.). It is good to try some different brands for fitting and tactile sensitivity before purchasing them, if possible. Gloves need to fit well, otherwise they can become a real nuisance to work with.
Gloves differ in price from inexpensive to very expensive per box cost. Shop around before buying. I prefer well fitted mid-price latex gloves (sterile about $25-35 and non-sterile about $7-10 per box). I also keep some not-latex gloves on hand for latex-sensitive clients. They can be obtained through a local medical supply resources or through nationally known medical supply outlets. Some drug stores/pharmacies have boxed gloves available if you need some right away and you are out. However, usually types and sizes are very limited when you buy them from your local drug store.
NEEDLE HOLDER
A Mayo-Hegar needle holder type 6" in length is a good, all-purpose tool to have. Do not get needle holders that are real long as they bump into the bed while suturing and are hard to use. For good quality get Miltex, Skylar, Snowden-Pencer or ask your local dealer what good brand they may carry.
A Baumgartner needle holder is smaller, has a smaller head and is ideal to have as a second needle-holder for going into tight places or doing sub-cutaneous suturing.
SCISSORS
A pair of ordinary operating scissors are fine to have. These are general medical scissors that can be purchased with a variety of blade styles from sharp-pointed to blunt-tip.
Spencer Delicate stitch scissors are a good size and type to obtain.
ALLIS CLAMPS
Allis clamps are an extra added benefit to suturing wounds. These are used to inspect tissue or remove blood clots of blood from the tear. It has teeth on each side to grasp tissue. A clamp with 4x5 teeth are good for this purpose.
FORCEPS
A pair of Halsted Mosquito forceps or tissue forceps can be nice to help to grasp the needle once it has been inserted it into one side of the tear (grasping the point of the needle with the forceps). Mosquito forceps are more versatile as they can be used to clamp off a torn blood vessel if necessary.
SUTURES
TYPES OF SUTURES
There are many different types of sutures for very different purposes. Wire, cotton, silk and nylon do not dissolve and cannot be used for vaginal repair. An absorbable suture is required for vaginal-perineal repair. The absorbable suture is used for the purpose of layering suture in tissue, which is often necessary, and have the added benefit of not needing to be removed later.
There are three kinds of absorbable suture:
- Dexon: This is a synthetic material which takes 3 or 4 weeks to dissolve and is therefore can be uncomfortable for the woman. However, it is easy to use and does not tangle like catgut.
- Catgut (plain): This is a natural material that takes 4 or 5 days to dissolve and is therefore no in place long enough for the healing of a vaginal repair.
- Chromic Catgut: This is a catgut that has been treated with chromic acid to keep it from rapidly dissolving. It is ideal for the repair of vaginal tears. It takes about 10 days to partially dissolve and by 20 days dissolution is complete. Catgut tends to kink and tangle if it is not watched.
SUTURE LENGTH & ATTACHMENT
The next consideration is suture length. The suture can be obtained on a spool or in pre-cut, pre-packaged lengths. Pre-cut is by far the optimal way to buy it as the spool must be kept sterile and protected from the environmental influences which may weaken the suturing material. The ideal length is 27 inches. Longer suturing lengths will tangle too much and it is more difficult to pull long lengths through the tissue. Most suturing jobs will not need more than one package of suture material to complete the job.
Another choice to make is having the suturing material attached to a needle or to thread them yourself. The most sterile and the easiest solution is to buy the suture already attached to a needle. This is less traumatic to the vaginal tissue since it is easier to pull a single strand through as compared to pulling a double strand through the tissue.
SUTURE THICKNESS
Finally, there are different thicknesses of suture thread which are used for the different jobs. They are numbered from 3 to 6-0, "3" being the heaviest and "5-0" being very fine. For most obstetrical repair 2-0 or 3-0 are the thicknesses to be used. Suturing material thicker than this will be hard to suture with, hard to tie knots and it also takes longer for the suturing material to dissolve. Smaller thicknesses than 2-0 or 3-0 are too fine and dissolve too quickly as well as breaking more easily.
The 3-0 is an ideal size for most of the repairing required for the vaginal mucosa and the perineum. The 2-0 size can be used for repair of muscular tissue, which tends to be rare unless an episiotomy was done. However, it never hurts to keep a few packages on hand just in case.
NEEDLE STYLES
NEEDLE SHAPE AND SIZE
Obtain the suture with a 1/2 circle needle attached. The needle needs to be rather large, as the stitches you will be taking are fairly big. The needle should be approximately an inch across from point to suture attachment.
NEEDLE POINTS
There are may kinds of needle points which can be found on suture needles. The two which are used for vaginal repair are:
- Cutting edge: This needle point has a knife-like blade-point. It is used to suture through delicate internal tissue and is likely to cut into blood vessels. It causes more tissue damage in general, but it can be good to have for tough sub-cutaneous suturing.
- Taper point: This needle point is ideal for most vaginal repair. This needle has a smooth, round tip and a sharp point. It will go right through delicate tissue while causing a minimum of trauma to surrounding tissue. It is much less likely to puncture vessels in the process.
Ethicon Surgical & Suturing Supplies - Catalog
SPONGE HOLDING FORCEPS
An extra instrument that is nice to have but may not ever be used in suturing is the Sponge Holding forceps. This instrument can be used to pull out and examine the cervix if it is needed in case of damage during the birth. This forceps can also be used to clamp off the cervix if it is torn (clamping over the torn area). This can be very painful and the only time that this may be done is if the woman was bleeding a lot and it seemed very likely that she had a cervical tear. Another helpful use for this instrument is for the removal of stuck membranes. The short version (6" or 7") is the preferred size and obtain the straight, Foerster Sponge forceps with serrated jaws.
LIGHT
A strong, bright light is essential for suturing. Suggestions have been made for using a miner's hat, however a small high intensity (halogen-type) desk lamp will work very well. The hat may work if you have to suture without an assistant, but it can be a nuisance on your head. The lamp can be placed on a table and is adjustable to fit your needs. A lamp can be purchased with a coil-like adjustable base that can be coiled onto a bed post or coiled to stand up on a table. Because the base is adjustable and can be collapsed into a coil, it is easily stored in a birth bag (don't forget to take a length of extension cord just in case it is needed). Another suggestion would be a good flashlight that could be held by an assistant.
AN ASSISTANT
An assistant should be enlisted to help with the suturing. This person can be a birth partner, apprentice or someone else at the birth. Their job will be to hold and adjust the light as needed, hand supplies to the suturer and to put on glove to assist with holding tissue open, if needed. If possible, try to keep the mother's partner with the mom while someone else less involved in the emotional support works as the assistant.
4x4 GAUZE SQUARES
These gauze squares are used to clean the vaginal area and blot up seeping blood as the repair is being done. Kleenex can be used in a pinch, but it will tend to shred and be a mess as well as a possible health hazard. Gauze squares can be rolled into a "tampon" to be placed inside the vaginal opening during suturing to soak up lochia discharge and keep the area clean and visible.
Gauze squares are inexpensive and can be purchased in bulk, put into packages and sterilized before hand or bought pre-sterilized in individual packages (which are more expensive). These squares are a common part of birth kits and birth bags and have an all purpose use throughout the labor and birth, as well as immediately postpartum.
AN EXTREMELY FIRM SURFACE
An extremely firm surface is needed. The more firm, the better. The couple can slip a board under their mattress on the birth bed for support. If suturing must be done, add an additional support with any of the following:
- A few large, flat, firm pillows.
- Piles of sheets or blankets which prop up another piece of board.
- A ready-made platform which collapses, which can be carried by the midwife for this purpose.
The purpose is to raise the mother's bottom up and off the bed enough so that there is a firm surface for support and a drop-off under her perineal area. This will substitute for the fact that there is no delivery table to suture on. This will help to make the job much easier for both the midwife and for the mother. It also provides the mother with a slight "shock position" and keeps the blood out of your suturing field. Although it is necessary to know that the mother is bleeding throughout the process, the bleeding referred to here is the slight, normal bleeding which occurs in the first 2-3 hours after the birth.
The distance to raise her is about 3-4 inches off the surface of the bed. This may not sound like much, but it will make a huge difference in the quality of repair work that needs to be done. The elevating object should be wedge shaped as much as possible so that it is not uncomfortable for the mother. Be sure to cover her if she becomes cold during the repair process.
LOCAL ANESTHETIC
It is entirely possible to suture without any anesthetic. I have never used one to this day and I also have had perineal suturing done on myself without anesthetic after the birth of my last son (I tore along an old episiotomy scar during pushing). I do know what it feels like. It has a "pinching feeling" as the needle goes through the tissue and a "pulling pressure" while the suturing material is being pulled through. I had no problem with working with the slight discomfort of being sutured.
Using anesthetic can have several disadvantages and advantages.
Disadvantages:
- The anesthetic itself can be painful when given.
- The anesthetic takes time to take effect. It may take as much time to inject the drug and have it take effect if she has not torn very badly. This takes away valuable "bonding time" with the baby and between the family.
- The injection will cause the tissue to swell which makes it more difficult to see what needs to be sutured.
- Allergic reactions do occur. If the woman is allergic to the drug, it could be serious and she could die.
- Although the drug is called a "local", it still goes into the bloodstream and gives the body just one more thing to have to deal with after the birth.
Advantages:
- When lacerations are superficial or mostly subcutaneous, they are the most painful to suture due to the number of nerve endings i the skin layers. Therefore, the anesthetic can make suturing more comfortable (again... it is painful to inject the anesthetic into the skin layers as well!).
- Anesthetic can be somewhat of a psychological reassurance to the mother.
- If there are labial lacerations then anesthetic is a MUST. These types of tears are too painful to suture without any pain relief.
Anesthetic is not necessary and the midwife should not feel that she cannot suture without it. It is only the top layers of tissue in the outermost third of the vagina which have nerve endings that can be felt readily by the mother. Most women cannot feel the needle deep in the vagina. It is the external sutures and the skin of the perineum which can be painful to suture.
If access to the anesthetic drugs is possible, offer the mother the choice of using it or not, but be sure to explain the pros and cons carefully and fully.
If anesthetic is used, then there are several more items that need to be carried and used:
- NEEDLES & SYRINGES: For suturing anesthetic, 1 1/2" needles are needed that are between 22 to 25 gauge. (Gauge refers to the size of the needle diameter. The larger the number the smaller the size.) Carry extra needles as the needle may need to reinserted several times during the injecting process. A long needle is needed to reach back into the vagina if necessary.
- ANESTHETIC: The type of anesthetic needed is 1% or 2% Xylocaine (Lidocaine or Novacaine) for suturing purposes. Get the plain anesthetic without Epinephrine. There is less chance the woman will have an allergic reaction to the plain variety. Be sure to question the woman again about any allergic reaction to ANY drugs and if she has ever had Novacaine at the dentist and then had a reaction to the medication. This drug usually comes in a vial which has several doses in it. Special care must be taken to clean the rubber top of the vial before use and to NEVER insert a used needle back into the vial (replace the needle with a new sterile needle before re-entering the vial to prevent contamination of the vial's contents).
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