MoonDragon's Women's Health Procedures Information
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Why Suture? Prenatal Perineal Examination During Labor & Birth After the Birth & Before Checking for Lacerations Checking for Lacerations Assessing Damage Suture or Not to Suture Preparing to Suture Medication For Postpartum Pain Diet & Nutrition Notify Your Midwife or Health Care Provider Wound (Episiotomy / Perineal Laceration) Healing Supplement Products
Wounds will usually heal, it is true. However the function of sutures is to hold tissue together which do not naturally lay together after an injury so as to promote healing between one side and another without leaving a big hole or gap in between. When a wound is deep, it is more likely to develop infection if the wound is left open which also causes delays in the healing process and may even produce toxic systemic issues (blood poisoning, etc.). If a person is unhealthy, the tissue is even less likely to heal well, so more artificial help may be needed.
PRENATAL PERINEAL EXAMINATION
During the initial prenatal pelvic exam is the ideal time to check the perineum and vagina for anatomy, scar tissue, etc. and to ask the woman questions about past tears or episiotomies she may have had. Take special note of the location of the hymenal ring, which in nulliparas may appear as a ring of tissue just inside the vaginal opening.
DURING LABOR & BIRTH
At some appropriate time during the birth, usually during second stage, re-check your prenatal notes and then the mother's perineum to refresh yourself as to what she looks like. Every woman looks different and it is important to see how she is made. Notice particularly if the scar tissue, if present, seems to be sewn up in a peculiar way, if it is and she does tear it will be important that a repeat of the same mistake is not made in repairing her. Re-check the location of the hymenal tags as well.
AFTER THE BIRTH & BEFORE CHECKING FOR LACERATIONS
A tear is not usually a life-threatening occasion, unless it is through a major blood vessel (which is rare in perineal tears). Therefore, be sure all the following items are taken care of before beginning to inspect for tears:
- Is the baby doing well?
- Is the mother doing well?
- Has the mother had at least a pint of fluids?
- Is the placenta out?
- Is bleeding normal and under control?
- Is the uterus low and very firm?
- Has the mother been cleaned up and made comfortable?
- Has the bed been cleaned up and arranged?
- Does the mother feel ready to be checked?
The answer to all of these questions should be "yes" before proceeding to laceration inspections. However, if bleeding is not controlled but the uterus is very firm and low, then the bleeding could be coming from a vaginal or cervical tear. If this is the case, then it is appropriate to go ahead and check to see if a vessel is bleeding in the vagina and causing the problem.
CHECKING FOR LACERATIONS
Checking for tears should be done in a systematic fashion so that nothing is left out. Even if it appears that a woman has not torn, checking for lacerations should still be done as they sometimes are "hiding". With a good light, clean sterile gloves, and an assistant standing nearby, proceed to examine in this fashion:
- Sit squarely between her legs and have the assistant to one side.
- With your fingers, gently open the outer lips of the vulva and check for lacerations. They will appear as dark, meaty lines or as if the surface of the skin were peeled back wit a roll of skin to one side.
- Continue to check the inner labia, if labial lacerations occur this is the most likely area where they will be. If lacerations are near the clitoris or urethra, do not suture them, as nerve damage can easily occur.
- Next check the outside of the vagina. Look and feel for lacerations. At first it may be difficult to distinguish lacerated tissue from bruised tissue, keep looking and it will be more plain to see the difference. Torn mucous membrane will appear bright pink-purple in color. Torn skin will appear bright pink on its inner surfaces. Torn muscle will appear deep red and will be deep, under the skin and mucous membrane.
- Check the inside of the vagina to see and feel how far the laceration goes back up inside. Again, this may be very hard to feel, as the tissues after the birth are so soft, but open the vagina and look to see where the tissue color changes. Then feel to see where it comes back together into a normal vaginal wall in the back. Identify the hymenal tags to help assess depth.
- Look at the entire laceration. How far in does it go? How far down does it go outside? While checking for lacerations, the woman will be bleeding some, so be sure to be checking the uterus to see that it is firm. Continue to blot up blood off of the vaginal tissue as necessary to clear your field of vision during the inspection. This should be done with sterile 4x4 gauze pads. White, unscented kleenex can be used, but keep in mind that kleenex tends to shred and may become an added problem. Be sure to check for deep holes, as they are sometimes present. Continue to assess the laceration in length, depth, and the extent of the damage. Be sure to check all the way back into the vagina, as rips can occur above the main tear back toward the cervix. This happens especially in unhealthy women. With these types of women, caution must be taken in feeling the laceration since lacerations can be easily ripped into the tissue, creating more problems. As observations are being made, keep in mind that usually lacerations of this nature do NOT extend deep enough to involve muscle tissue, but episiotomies almost always DO. The end of the laceration is called the "apex".
- Lastly, check the integrity of the recto-vaginal wall. Put on a clean, sterile glove on one hand and lubricate the little finger of that hand with either Olive Oil, K-Y Jelly, or Vitamin E Oil. Insert the little finger into the anus of the mother. Carefully insert the fore-finger of the other hand into the vagina, pressing with both hands as far back as can be reached and slowly, gently draw your fingers out simultaneously while pressing them toward each other, as if to cause them to meet through the tissue wall as they are withdrawn. If they DO meet, then there is a laceration into the rectum through the vagina.
- Before the rectal finger is withdrawn completely, ask the mother to tighten the anus around your finger. Look and feel to be sure the anal sphincter is not damaged. Ask the mother if it feels normal to her. Sometimes a laceration is so extensive that the sphincter is exposed. It will appear as a distinct band of firm muscle tissue. It is very rare, however, for the sphincter to be torn at a homebirth. Damage usually occurs when episiotomies are given.
- If this is a "first-time" mother, the hymenal ring will be torn during birth. This is often seen with a trickle of blood. DO NOT suture the hymenal ring if that is the only damage done. If there are more extensive lacerations, look for raw tags and not a ring.
- In multiparas, the hymenal tags will usually NOT be raw looking.
- Skid marks are small scrapes which may appear inside or outside the vagina or in the labia. These do not need sutures, only herbal compresses or something similar to help them to heal well.
Olive Oil Products Vitamin E Supplement Products
Upon completion of the examination for lacerations or episiotomy, decisions are made as to the degree of damage that has been done. Basically there are 3 degrees of damage that are recognized. Some practitioners now consider a 4th degree as well.
1st Degree: This laceration involves the area just below or just inside the opening of the vagina. It is very shallow.
2nd Degree: This laceration involves the skin below the vagina, the perineum and the muscles of the perineum. This is most often seen with episiotomies, but is possible with a tear as well.
3rd Degree: This laceration involves all of the above and the anal sphincter as well.
4th Degree: Some practitioners consider that a laceration extending through the anal sphincter is a fourth degree laceration.
SUTURE OR NOT TO SUTURE
Determination of whether to suture or not is the next consideration. Some situations have been mentioned as things that should NOT be sutured: labia tears close to the urinary meatus or clitoris, skid marks which are like scrapes. Beyond this, assessment and decisions to suture or not to suture need to be made. The woman has the right to say if she does not want to be sutured, but she will also be depending on the experience of the midwife to help her make that decision. Some things which would make the decision to suture more likely might be:
- The woman wants them.
- The laceration is ragged and does not close together when legs are placed together.
- The laceration is extensive, externally or internally.
- The woman needs more than 2 stitches to close the laceration.
- A new laceration probably needs sutures for best healing.
Some things which might help decisions against sutures might be:
- The woman does not want them.
- The laceration edges are straight and close together well when legs are closed.
- The laceration is shallow and not extensive.
- The laceration is along an old episiotomy scar (where it will probably be very straight and close well).
- She needs less than 2 stitches to close her up.
- She has been closed up during a former birth in what turned out to be an uncomfortable way (that infamous "extra stitch" commonly given by male physicians for the pleasure of the woman's husband), in such cases healing is often better with no sutures at all, as long as the damage is not extensive. (Ask the woman.)
Ultimately, the midwife and the woman must come to a decision based upon the midwife's knowledge and the woman's desires.
If a woman does not get sutures and has torn, she needs to follow the same rules that someone who has had sutures does.
RULES FOR WOUND CARE WITH OR WITHOUT SUTURES
If a woman does not get sutures and has torn, she needs to follow the same rules that someone who has had sutures does. These rules are as follows:
Stay in bed with legs together as much as possible for 2 weeks.
Keep legs together at all times.
Sit very gently when urinating or having a bowel movement.
Kegel exercises - 150 daily.
Drink plenty of prune juice, drink lots of water and juices, and avoid constipating foods. Include fiber, such as bran, in the diet. Constipation is not a desired situation while the perineum is healing. I would describe the first bowel movement under the best of conditions as "passing a roll of barbed wire". Keep the stool as loose as possible to prevent straining.
Do not strain on the toilet. Not only is this painful, but it puts undesired pressure on the healing perineum.
Place an ice pack on the perineum for 1 hour to reduce swelling. Make sure you have a barrier between the ice pack and skin tissue. You do not want to freeze the tissue. A wash cloth, hand towel or thick layer of gauze will work. You can try soaking gauze pads with Witch Hazel and stick them in the freezer to the point of freezing (very cold and pliable but not frozen solid). Apply the cold Witch Hazel pads to the sore perineum.
Use Comfrey Infusion (Tea) pericare after urination (washing the perineal area with a comfrey tea and apply comfrey tea soaked 4x4 gauze pad compresses to the perineal area to soothe injury. Urine may cause a stinging sensation in sensitive perineal tissues. Pouring warm water over the perineum while urinating will help prevent stinging and helps to wash away the urine at the same time. Blot dry with gauze pads (do not flush, put in a trash barrel instead). Do not rub or wipe perineal area. This may open tissues that are repairing.
Apply herbal ointment (such as Comfrey Ointment, Aloe Vera Gel, or Calendula Ointment) to the area GENTLY. Warm comfrey infusion sitz baths can ease a sore bottom and promote healing. Drink Comfrey Leaf tea (to promote healing) - This can be added to Red Raspberry leaf tea to help with flavor. Red Raspberry leaf is a good woman's uterine tonic herb for pregnancy and postpartum. It helps to balance out hormonal shifts following childbirth.
Take the following supplements every day for at least two weeks:
- Zinc (300 mg)
- Vitamin B-Complex
- Vitamin B-6
- Vitamin B-12
- Vitamin E (400 IU)
- Calcium (500 mg - To Relieve Pain)
MoonDragon's Pregnancy Information: Postpartum Care - Perineum
MoonDragon's Health Therapy: Sitz Bath Therapy
MoonDragon's Womens Health Information: Hemorrhoids
MoonDragon's Womens Health Information: Incontinence, Urge
MoonDragon's Womens Health Information: Incontinence, Stress
RECOMMENDED HERBAL & SUPPLEMENT PRODUCTS
Aloe Vera Herbal Products Calcium Supplement Products Calendula Herbal Products Comfrey Herbal Products Fiber Complex Supplement Products Prenatal Multivitamin & Mineral Psyllium Fiber Herbal Products Red Raspberry Herbal Products Vitamin B-6 Supplement Products Vitamin B-12 Supplement Products Vitamin B-Complex Supplement Products Vitamin E Supplement Products Witch Hazel Herbal Products Zinc Supplement Products
PREPARING TO SUTURE
If the decision is made to suture the wound, first the materials need to be set up. Have a chair or a section of the foot of the bed arranged where the equipment and supplies can be placed within easy reach.
- Open the suture pack and arrange the instruments.
- Open some 4x4 gauze squares and set them with the instruments. These will be used for blotting up blood.
- Some midwives like to lubricate the tip of the needle with Vitamin E from a capsule before inserting the needle into the skin. If this is to be done, remove some Vitamin E capules from the bottle and place with suturing supplies.
- Sterile, form fitting gloves.
- 2 packages (minimum) of 27-inch Ethicon 810 H 3-0, chromic catgut suture with taper point CT-1 needle attached (or similar suturing brand)
- High intensity lamp.
- An assistant who is familiar with all the above equipment and supplies.
After the initial postpartum check for mother and baby has been completed and everything has been cleaned up and the mother is comfortable, suturing may be done up to 6 hours after the birth. However, sooner the better is the optimal choice.
ASSESSMENT OF THE MOTHER
Check the mother's condition next. Continuing assessment is important for the mother's well being.
- Is the uterus firm and low?
- How is her bleeding?
The mother should be occupied with the baby if possible while being sutured, otherwise her partner should be helping her to deal with it.
The uterine checks must not be forgotten in the process of suturing, especially if a gauze tampon is used to clear the working field of blood. The assistant will be the best person to do periodic uterine checks to make sure the uterus is staying hard and low in the pelvis.
The assistant should record when suturing starts and all the uterine checks in the mother's birthing records while it is proceeding.
The mother may take sips of juice between stitches.
If the mother and the midwife feel that she would do better with anesthetic, set out the equipment & supplies for this as well.
- 10 cc syringe with a 1-1/2 inch to 1-3/8 inch needle.
- Extra needles.
- 1 or 2 percent xylocaine.
After the equipment is set up and ready, put on your sterile form fitting gloves (be sure to pull them on by the edge of the cuff and not to touch the hands of the gloves against anything that is non-sterile except the mother. Have the assistant put on gloves, too. Prop up the mother where she is comfortable and at a position to easily suture.
Next, recheck the laceration/episiotomy. Really look at it in good light and figure out what goes where and exactly how it will be put back together. This is where the hymenal tags become great landmarks. Big mistakes are often made when midwives just start to suture, hoping to finish the task as quickly as possible. Take the time and get a good look at the tissue and get a feeling about what is going on (with the hands) and this will help immensely. If time is taken to look long enough, the tissue layers will become clear to see. Notice especially any dark purple lines in the laceration. These are blood vessels. This should not be stitched into while making repairs if it can be helped.
MOONDRAGON'S SUTURING LINKS
MoonDragon's Procedures: Suturing Supplies
MoonDragon's Procedures: Suturing Techniques & Knot Tying
MoonDragon's Procedures: Administering Anesthesia
MoonDragon's Procedures: Episiotomy
You may use non-prescription drugs, such as acetaminophen or ibuprofen for minor pain. Stool softener laxative (or lots of prune juice! A much safer and tastier remedy) to prevent constipation if needed. Antibiotics, if required to fight infection.
ACTIVITY RECOMMENDATIONS & RESTRICTIONS
Follow your midwife's or health care provider's advice on resuming, or beginning, a postpartum exercise program. Resume driving 10 days after the birth. Resume sexual relations as directed by your midwife or health care provider or when a follow-up postpartum examination determines that healing is completed (usually 3 to 6 weeks).
SEXUAL ACTIVITY AFTER AN EPISIOTOMY
Your perineum should be completely healed around four to six weeks after delivery, so if your caregiver gives the okay and you are up to it, you can try having sex then. You might feel some initial tenderness and tightness.
Try having a glass of wine, taking a warm bath, and leaving plenty of time for foreplay. You might prefer to be on top so that you can control the degree of penetration, or you may find that lying on your side is most comfortable.
Relaxing as much as possible and using a good water-soluble lubricant will help make sex more comfortable. This may be especially helpful if you are breastfeeding, because lactation lowers your estrogen levels, which reduces the amount of lubrication your vagina can produce. Many women continue to use a lubricant during sex until they stop nursing.
MoonDragon's Pregnancy Information: Postpartum Care - Elimination
DIET & NUTRITION
Eating a high fiber diet will help prevent constipation which is common after childbirth. Increase your fluid intake as you increase your fiber intake. Continue taking your Prenatal Multinutrient Supplements after your baby is born while you are breastfeeding your baby. The nutrients in your prenatal supplement will help in your healing process and recovery from an episiotomy and from childbirth in general.
MoonDragon's Pregnancy Information: Postpartum Care - Elimination
MoonDragon's ObGyn Womens Health Information: Constipation
MoonDragon's Nutrition Information: Fiber Diet
MoonDragon's Nutrition Information: Nutrition Index
NOTIFY YOUR MIDWIFE OR HEALTH CARE PROVIDER
Pain, swelling, redness, drainage or bleeding increases in the surgical area. You develop signs of infections: general ill feeling and fever, headache, muscle aches, dizziness. You experience nausea, vomiting, constipation or abdominal swelling. New, unexplained symptoms develop. Drugs used in treatment may produce side effects. Pass uncontrolled urine through the vagina. Pass gas (flatus) or stool from the vagina.
MoonDragon's Pregnancy Information: Episiotomies - What You Should Know
Postpartum Care: Index Postpartum Care: Weight Postpartum Care: Diet Postpartum Care: Bowel Movements & Urination Postpartum Care: Bathing Postpartum Care: Breasts & Breastfeeding Postpartum Care: Perineal Care Postpartum Care: Vaginal Bleeding (Lochia) & Menstruation Postpartum Care: Exercise & Back Care Postpartum Care: Sexual Intercourse Postpartum Care: Contraception PostPartum Visit: Day One PostPartum Visit: Day Three PostPartum Visit: Day Seven PostPartum Visit: 4 to 6 Week Visit Baby Care & Concerns Fatigue & Exhaustion Postpartum Depression (The "Baby Blues")
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WOUND (EPISIOTOMY / PERINEAL LACERATION) HEALING SUPPLEMENT PRODUCTS
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Allspice Leaf Oil Angelica Oil Anise Oil Baobab Oil Basil Oil Bay Laurel Oil Bay Oil Benzoin Oil Bergamot Oil Black Pepper Oil Chamomile (German) Oil Cajuput Oil Calamus Oil Camphor (White) Oil Caraway Oil Cardamom Oil Carrot Seed Oil Catnip Oil Cedarwood Oil Chamomile Oil Cinnamon Oil Citronella Oil Clary-Sage Oil Clove Oil Coriander Oil Cypress Oil Dill Oil Eucalyptus Oil Fennel Oil Fir Needle Oil Frankincense Oil Geranium Oil German Chamomile Oil Ginger Oil Grapefruit Oil Helichrysum Oil Hyssop Oil Iris-Root Oil Jasmine Oil Juniper Oil Labdanum Oil Lavender Oil Lemon-Balm Oil Lemongrass Oil Lemon Oil Lime Oil Longleaf-Pine Oil Mandarin Oil Marjoram Oil Mimosa Oil Myrrh Oil Myrtle Oil Neroli Oil Niaouli Oil Nutmeg Oil Orange Oil Oregano Oil Palmarosa Oil Patchouli Oil Peppermint Oil Peru-Balsam Oil Petitgrain Oil Pine-Long Leaf Oil Pine-Needle Oil Pine-Swiss Oil Rosemary Oil Rose Oil Rosewood Oil Sage Oil Sandalwood Oil Savory Oil Spearmint Oil Spikenard Oil Swiss-Pine Oil Tangerine Oil Tea-Tree Oil Thyme Oil Vanilla Oil Verbena Oil Vetiver Oil Violet Oil White-Camphor Oil Yarrow Oil Ylang-Ylang Oil Aromatherapy
Healing Baths For Colds
Using Essential Oils
AROMATHERAPY: HERBAL & CARRIER OILS DESCRIPTIONS & USES
Almond, Sweet Oil Apricot Kernel Oil Argan Oil Arnica Oil Avocado Oil Baobab Oil Black Cumin Oil Black Currant Oil Black Seed Oil Borage Seed Oil Calendula Oil Camelina Oil Castor Oil Coconut Oil Comfrey Oil Evening Primrose Oil Flaxseed Oil Grapeseed Oil Hazelnut Oil Hemp Seed Oil Jojoba Oil Kukui Nut Oil Macadamia Nut Oil Meadowfoam Seed Oil Mullein Oil Neem Oil Olive Oil Palm Oil Plantain Oil Plum Kernel Oil Poke Root Oil Pomegranate Seed Oil Pumpkin Seed Oil Rosehip Seed Oil Safflower Oil Sea Buckthorn Oil Sesame Seed Oil Shea Nut Oil Soybean Oil St. Johns Wort Oil Sunflower Oil Tamanu Oil Vitamin E Oil Wheat Germ Oil
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