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MoonDragon's Procedures: Suturing Equipment & Supplies
- 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
WHY SUTURE?
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.
Assessing Damage
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 doesn't 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. 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.
- Drink prune juice and avoid constipating foods.
- Do not strain on the toilet.
- Apply herbal ointment (such as comfrey) to the area GENTLY.
- Take every day for at least two weeks:
300 mg of zinc
vitamin B-complex tablets
400 IU of vitamin E
500 mg of vitamin C
Calcium (to relieve pain)
- Drink comfrey tea (to promote healing).
- Place an ice pack on it for 1 hour to reduce swelling.
- Use comfrey tea pericare after urination (washing the perineal area with a comfrey tea and apply comfrey tea soaked 4x4s to the perineal area to soothe injury.
- Kegel exercises - 150 daily.
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 caps from the bottle and place with suturing supplies.
- Sterile, form fitting gloves.
- 2 packages (minimum) of 27" 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.
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" to 1-3/8" needle.
- Extra needles.
- 1% or 2% 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.
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