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SUTURING PREPARATION
Inserting A Tampon
KNOT TYING
SUTURING TECHNIQUES
SPECIAL SITUATIONS
The subcutaneous fascia must be closed first in order to control bleeding and close the space which would be caused by pulling the skin over a subcutaneous defect.
The suture used to close the vaginal mucosa is now brought down to begin closure of the external part of the tear.
A continuous basting stitch to close the tissue will be used. Stitches are about 1 cm apart and parallel to each other. Keep the flat side of the needle holder parallel to the plane of the wound edges.
If an assistant is not available, the midwife may hold the edges apart with her thumb and middle finger of her left hand, held from above. The suture is kept to the right side and is NOT locked.
It is especially important to keep the distance from the skin edges slight and yet equal on both sides. It is also especially hard to do so.
With a lateral tear there will be much more tissue to take up on the outer edge.
This continuous stitch is carried down to the inferior apex of the tear (the external apex). Stitches near this end will be more superficial.
This subcuticular stitching will now need to be done which will bring the skin edges together.
1. A subcuticular stitch is placed beneath the skin to hold the edges close together. This type of stitch cannot be seen when finished. It gives the same appearance as a "hidden zipper". This type of suture is good for several reasons:
- It does not dissolve as fast as external interrupted sutures.
- It is much more comfortable for the mother.
- There is much less chance of rolling the wound edges as it is sewn together.
- It helps to prevent or eliminate infection issues.
2. The suture used is the same suturing used to close the vaginal mucosa and subcuticular area. After the last subcutaneous stitch, the suture is brought out into the subcuticular space at the external apex of the tear.
3. The stitch is a continuous mattress suture whereby stitches are taken alternately from side to side. Each one is started at or slightly below the point where the last suture came out on the opposite side. Some points to remember are:
- Bring the suture across to see where the next bite will go.
- Smaller stitches would be placed near the apex.
- Go in and out subcuticularly, however, the needle will penetrate into deeper tissue as it makes the stitch.
- DO NOT pull too tightly, allow for some swelling that may occur.
- Edges should NOT overlap, but lie side by side.
- To help make the stitch, stretch the skin taunt with a finger.
- The needle may be held on the holder in the middle of the curve at an obtuse angle, the needle holder may then be held as if it were a pencil, or the needle may be reversed at a right angle, or held as usual. See which best suits the situation.
4. In withdrawing the needle after the stitch, the midwife's palm should be pointed upward to help bring the curve of the needle through the tough subcuticular space. Often the needle must be pushed quite hard to get through.
5. Stitches are taken up to the junction of the skin and vaginal mucosa. At this point, a stitch is taken to close the mouth of the vagina LOOSELY and then the needle and thread is brought UNDER from the outer perineum up behind the hymenal ring. This is the last stitch. The long end is not drawn completely through. A square knot is made with this loop and what is left attached to the needle.
SPECIAL SITUATIONS
A third degree tear is rare, but can happen with a huge baby and a uncontrolled delivery, previous rectal damage, and an unhealthy mother. Repair must be right or she may have bowel incontinence. If the midwife has never seen rectal repair it may be best to take her to the hospital for suturing. However, it is possible to do a good job having never done it before.
As the mother is checked for tears and discovery of a third degree tear into or through her anal sphincter is found, first see how far it goes. If it is only part-way through the sphincter muscle, the midwife may need only one or two interrupted sutures through the tear to close it up. Be careful as these stitches in because, with this type of muscle, it is very easy to pull the thread right through it. A "figure of eight" suture may be used to prevent this. Proceed to sew the rest of the tear as described. The midwife will probably have muscle repair to do with this deep a tear.
In dealing with a third degree tear through the anal sphincter, be sure to examine carefully for tears through the vagina into the rectal mucosa. This should always be done, especially in this case. First the rectal mucosa needs to be repaired (which is the lowest layer in the vagina and the "roof" of the rectal cavity). This must be done before anything else. If the midwife does a poor job of repairing this layer, feces may forever escape through the woman's vagina, so good closure is essential. This is another case where hospital transport may be the best solution.
However, here is what needs to be done: 1. First repair the rectal mucosa, being sure to keep tissue layers where they belong. Be careful not to contaminate the vagina with fecal matter as it is sewn. Also be sure the tear has been examined all the way back to catch the apex of the tear, or poor repair will create a fistula (hole between the vagina and rectum).
2. Stick your finger in the finished repair by inserting a forefinger into the rectum and looking at the tear. Sew it exactly as would be done with the vaginal mucosa, using locked stitches. The mother may find the rectal experience unpleasant, but it is necessary for proper repair.
3. The midwife needs to grab the ends of the sphincter muscle with hemostats (Allis clamps are really the best thing to use). The muscle will tend to retract into the tissue like a piece of round elastic which may require some fishing around for it and pulling it out once found. While someone else is holding the pieces together (it is always nice to have an assistant to help out in these cases!), the midwife must put in her sutures. Use the "figure of eight" style to help insure that the sutures don't rip out while the sphincter is being repaired.
4. After the midwife is finished sewing the sphincter, she should be able to insert her finger into the anus with no trouble.
5. This woman needs COMPLETE bedrest, a low residue diet and prune juice for at least five days!
This occurs when a blood vessel has broken beneath the surface of the skin or mucosa and is bleeding into the tissue. They usually occur in conjunction with difficult forceps births or some other operative procedure, but can happen at home as well. When checking a woman, look for swellings, usually they will be dark purple (bruised looking), sometimes they will be bleeding slowly and not immediately noticeable. Symptoms are primarily pain and swelling or a feeling of increasing pressure. Checking should be done with hands for a fluctuant mass in the wall of the vagina or between the vagina and rectum. It will be tense and tender to touch.
Small hematomas often resolve themselves. They re-absorb and only need to be watched to be sure they are doing so. Bigger ones sometimes keep getting bigger and need to be lanced and the area packed to stop the bleeding. Women can go into shock from this kind of blood loss. Symptoms can be delayed until hours after the birth and the labia may become swollen with blood, usually only on one side.
If a woman has pain in the vaginal area after a difficult birth, be sure to check for a hematoma. If she continues to complain of pain and the midwife can't find one, she should not rule out the possibility of one being hidden. The midwife should watch her closely for signs of blood loss and keep checking to see what is going on. If a hematoma seems likely to be deep in the tissue, take her to the hospital for a check.
These usually occur due to difficult operative deliveries, however they can happen at home. If there is bleeding that the midwife cannot locate the source of, it may be coming from the cervix. Gently inspect with a hand. If the midwife can't tell (and probably can't because everything will be so soft) the midwife will need to pull the cervix out with a ring forceps enough to look at it. Have a good light, an assistant is needed to hold the vagina open, and a coach for mom nearby... Don't pull the cervix out any more than is needed in order to see it. If the midwife finds a tear, clamp it with your ring forceps and take her to the hospital to get it sutured.
Sometimes women tear in very weird ways and it looks very much like nothing goes anywhere. If this is the case, the best help in this instance would be to find the apex of each part of the tear and start sewing from the hind-most apex down toward the perineum. As the midwife gets to the level of another apex, sew it up and bring it into the biggest line of the tear and so on.
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