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SUTURING PREPARATION
Inserting A Tampon
SUTURE KNOT TYING
SUTURING TECHNIQUES
SPECIAL SITUATIONS
SUTURING PREPARATION
Clean out any blood and clots before beginning. Make sure the uterus is contracted and firm. Insert a tampon as follows before or after using anesthetic, if anesthetic is needed (most times it may not be needed).
Make a tampon out of sterile gauze squares, wrapping one inside the other and tying the whole bundle up with a strip of gauze to hold it together. Leave a pull string on the end for easy removal after the suturing is finished.
Lightly moisten the outer surface of the gauze tampon to minimize friction using a water-based lubricant (K-Y Jelly) or Vitamin E from a capsule.
Insert two fingers along the posterior vaginal wall, directing them toward the posterior fornix. Exert pressure slightly downward and toward the cervix.
The rolled tampon will slide against the fingers in a downward motion toward the posterior fornix and beyond the apex of the tear. Avoid any pressure on the anterior wall of the vagina. Hold the tail of the tampon so it does not touch the anal region.
This should be done just before suturing is started.
- Open the suture package and remove the suture.
- Straighten the strand with a gentle pull.
- Do not clamp on juncture of suture and needle or on any other part to be used in the actual repair.
Next, place the needle in the needle holder.
- Place the needle at the tip of the needle holder.
- For most repairs, the plane of the curve of the needle is to be at right angles to that of the needle holder.
- The needle holder grasps most securely the flattened part of the needle toward the end.
Manipulate the tissue as little as possible, but just enough to see what needs to be done and to do a good suturing job. The tissue may be sore to the touch and very sensitive to the mother if anesthetic has not been used.
Any area seen with a lot of oozing blood flow needs to be taken care of quickly. Get the tissue together and tie off the vessel, if necessary.
Blot the tissue with sterile gauze to remove blood, do not rub and disturb clotting.
Be sure about tissue landmarks before beginning and be sure any needle punctures are in the correct place the first time. Any new puncture is a new injury.
If instruments are used to part the tissue, be sure not to crush and devitalize the tissue. Be gentle, use only enough pressure to securely grasp the tissue.
A curved needle is used in a region where the point is difficult to see after the needle has been passed through the tissue. To use it properly, one grasps the needle holder by the shaft and the needle and wrist are curved backward. As soon as the tissue is entered, the turning of the wrist forward guides the depth and direction of the needle. In closing the wound edges, the point of the needle should always be brought up in the midline point before taking the tissue on the opposite side. The reasons why this is done this way is to, first, know where the needle is, and secondly, to match the sides more exactly. The mother, if no anesthetic was used, may feel a slight "stinging" or "pinprick" sensation as the needle goes through the tissue.
When the needle protrudes through the tissue after completing a particular suture, the fingers of the left hand hold the point, using either the finger tips or the small needle holder or tissue forceps (one instrument in each hand) while the right hand unclamps the needle holder. Never leave the needle free in the tissue!.
With the palm down, the needle holder grasps the point securely and by flicking the wrist, the needle is easily curved completely through the tissue. It is more traumatic to tissue to try and pull the needle through with the fingers. The mother may feel some "pulling" sensation during this time.
SUTURE KNOT TYING
Knots are used in suturing to either anchor one stitch or tie off a series of stitches. Each stitch should be tight enough to secure the tissue and secure enough so that slipping is impossible. At the same time, they must be loose enough to allow for reduction in tissue size due to swelling. Too-tight sutures will have the tendency to come out.
Knots should be as few and as small as possible to prevent tissue irritation. Suture whiskers should be cut short.
A "sawing action" with knot tying must be avoided as it weakens the integrity of the suture.
After the first loop is tied, it is necessary to maintain traction on one end of the strand to avoid loosening of the sutures. Each tied stitch needs three alternating knots.
The knots may be tied with the hands or by the square knot instrument method of tying sutures. This is done by pulling the suture through the tissue and leaving a three inch short end. The long end is held between the left thumb and index finger. The needle is cupped in that hand.
In this suture tying maneuver, hands cross over providing for a flat first knot of a square knot. Test the knot by applying light traction to the long end of the suture.
2. Loop the suture once around.
3. Again grasp the short end with the tip of the needle holder and pull it through the loop, separating hands to complete the square knot.
4. The third knot is done by placing the needle holder on top of the long strand and looping it around once. Grasp the short end of the suture with the tip of the needle holder and pull it through the loop crossing hands.
5. The short end should be cut not leaving more than a 0.5 cm whisker. If the whisker is made too short, the stitch is more likely to come out. Both ends are cut if it is an interrupted suture.
Do NOT become frustrated, this take lots of practice and is better learned by having someone show the method with hands on guidance. I still have problems figuring this one out!
If torn, bleeding blood vessels are found during examination, these need to be tied off. Torn blood vessels are rare unless an episiotomy was done. Always try to stop the bleeding by blotting the area with sterile gauze before doing this procedure.
2. Clamp it with a mosquito hemostat.
3. Elevate it from the surround tissue and run a thread around it.
4. Tie it off in the same fashion as the umbilical cord, using three alternating knots.
SUTURING TECHNIQUES
Remove any tags of skin from the tear. Do not bury any skin fragments, hair or clots of blood. This must be done carefully and correctly by first pushing the tear together and getting a "feel" for how it should look when it is finished.
Re-identify the apex in the vagina, the hymenal tags, the junction of the vaginal mucosa and the outside skin, the wound edges and the perineal apex of the tear. These are the landmarks for correct reconstruction.
Feel the depth of the tear throughout before beginning the suture repair. If the wound is very deep, two layers of muscle sutures may be required to close the space and properly join the tissue. It may be easier to do this type of repair with the vaginal mucosa only partially sewn up.
Muscle tears are rare occurrences and are most likely to be found in the perineum than in the vaginal wall. Muscle appears deep red, bleeds a great deal and is under the pink mucosa.
If the muscle tissue has been torn or cut and is bleeding a lot, it may be necessary to put in "figure of eight" stitches to control hemostasis prior to repairing the vaginal mucosa. This is done with 3-0 catgut in the following manner:
The "figure of eight" stitch is also used when repairing the rectal sphincter. It stops bleeding and has less tendency to pull out at the muscle tissue than regular sutures.
If torn blood vessels exist, tie these off.
To expose the vaginal apex, the tissue can be held open in either of the following ways by the midwife if she has no assistant available to help: 1. To view the vaginal apex, depress the posterior vaginal wall with the middle and index fingers of the left hand on either side of the tear. The right hand holds the needle holder, the extra suture lies across and to the right of the incision, tucked into the left palm with the ring and little fingers.
2. The vaginal apex can be exposed by spreading the labia from above with the thumb and index finger of the left hand. Suture is held partly to the right hand with the shaft of the needle holder and the rest is held upward over the tear by the middle finger.
If an assistant is available, she can hold the tissue open in whatever way is needed and both of the midwife's hands are free to work, manipulate suture and complete the repairs. Keeping the suture to the right of the incision and the needle point between the suture and the incision assures a locked stitch. If the suture is kept to the left, it can be dropped over the needle point with the hand or the needle holder can be inserted through the loop of suture to grasp the needle and pull it through, locking the stitch.
Repair of the mucosa first prevents seepage of lochia to the depth of the wound and lines up the edges so they can be better seen and repaired. A continuous locked (blanket) stitch will be used. It stops the bleeding and tends to shorten, therefore it is especially important not to put the stitches in too tight. During pregnancy there has been an increased blood supply to the vagina which is reduced after delivery. This is the reason the tissue shortens.
An anchoring stitch is placed about 1 cm above the vaginal apex so as to include any retracted blood vessels. Take a deep bite into the tissue with the needle and tie the stitch with three alternating knots. Cut the tail only. The stitching will continue with the suture attached to the needle. Check with fingers to see this first knot is secure against the tissue.
As each bite of stitch is taken, keep the needle holder parallel to the side of the tear that is being worked on. This will prevent a ripple-like line of stitches.
1. Locate the position for next suture. This is about 1 cm apart from the last suture.
Place each stitch about 1 to 1.5 cm from the last. By looking at the wound, an estimation can be made of about how many stitches will be needed to hold it together. The tendency is to put far too many stitches in the wound, especially when a midwife or assistant is just starting to learn about suturing. Remember that each suture has to be absorbed. Dark purple lines are blood vessels, void these!
Stitches should include the same amount of tissue from each side. If the edges roll, this means that too much tissue has been taken into that stitch or that the stitch is being pulled too tight. This can lead to a gaping scar if not corrected.
If a tear is present that goes off to one side, the inner side of the wound will tend to retract more than the side edge. Take care to place sutures slightly further apart on the outer side of the wound.
Place one suture just behind and one suture just in front of the hymenal ring to bring it together. Do not place a suture in the ring or tag itself. If muscular suturing needs to be completed, continue with the following section. If not, then go to the section on Suturing the Perineum.
Lay the suture and needle that was used for the repair of the vaginal mucosa aside. Either pin it to a sterile glove and put it on the mother's abdomen, or wrap it in a sterile gauze square.
Muscles and skin heal by the formation of scar tissue, so accurate reconstruction and elimination of "dead space" is very important. Textbooks recommend the use of 2-0 or 3-0 chromic catgut for muscular repair. If finances allow, obtain some 2-0 sutures to have on hand. In any case, a second package of suture is needed to do interrupted sutures with. Get it out and straighten the thread, etc..
Usually two or three interrupted sutures will be needed. They are placed at right angles to the muscle fibers to provide maximal strength. If one should come out, it will not effect the others.
The perineal muscles may be differentiated from the skin layers by feel. The muscles are tougher and more resistant to touch. The color of muscles are reddish hue. The depth will be greater, under the skin and mucosal layers of tissue.
Place the first muscular stitch close to the top of the vagina. At the level of the hymenal ring, the separated ends of the bulbocavernousus muscle are reunited. This muscle is rarely torn. It is almost always cut in giving an episiotomy. The "figure of eight" suture may be used to repair this if desired. If not done properly, the mouth of the vagina will gape. If it is sewn tight, intercourse may be painful (The "extra stitch for the husband" ritual so often performed by physicians has caused many women to have problems with resuming intercourse after the birth of a child with an episiotomy!).
Check to be sure the plane of the needle is at right angles to the plane of the holder. The needle holder must be held parallel with the wound edges, otherwise a puncture of the rectum may occur. After pregnancy and delivery, the perineum is thinned and VERY SOFT. Keep this in mind during the repair.
Gently pull these threads through and tie with three alternating knots, check to be sure the stitch is secure. With a side tear, there will be slightly more tissue to take up on the outer edge.
Often, as the suturing continues down toward the anus, these sutures will need to be more superficial. The midwife should only be placing 2 or 3 of these sutures, so the third one will be the most superficial.
When the muscular sutures have been completed, the repair job will resemble this drawing.
A rectal exam should be performed to check if any of these stitches have been accidentally put through into the rectum. If so, they must be removed. Removal will help prevent infection as well as a formation of an open sinus tract from perineum to rectum. Proceed as with the first rectal exam, with a cover glove, etc.
SUTURING THE PERINEUM
Suturing The Perineum is continued on next page...
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