First degree
lacerations don’t usually profit from being sutured unless there is great
asymmetry or bleeding. Second degree lacerations, by definition, include the
rendering of the perineal muscle (bulbocavernosus). In the absence of
asymmetry or uncontrolled bleeding and presence of informed consent for
an “experimental” treatment ~ non-suturing of these lacerations
is an acceptable option (see HOOP study done in UK).
Should suturing be
desired by the mother (a conclusion arrived at only after suitable informed
consent) or required by the severity of perineal trauma (ditto informed
consent, including the option of medical transfere), the following is a list
of general steps for repairing a second degree laceration or midline
episiotomy.
Its purpose is to
refresh the memory of those who already know how to classify lacerations and
assess their seriousness, are skilled in the principles of sterile technique
and knowledgeable of the basic techniques (methods of placing sutures, how to
tie effective knots, how to anesthetized the wound, etc.) but suture so
rarely that they would benefit from this review. These instructions are not
meant to take the place of formal instruction
in the art and science of perineal laceration repair.
-----------------------------
Preparation -----------------------------------
1. Set up
instruments and materials, including 1 pair of sterile gloves and at least 1
additional sterile vag exam glove to “double” glove when checking rectum
to be certain no stitches accidentally went through rectal wall. Arrange for
good light (and/or head lamp), position mother with hips slightly elevated on
underpads. Be sure she is hydrated, keep her warm and holding baby if she is
willing.
2. After gloving,
inspect laceration well, looking for bleeding, bruising and deep hematomas.
See how things fit back together, cut off any skin tags and remove any blood
clots.
3. Roll two gauze
4x4s into a slightly off-center tampon, creating a “tail” for easy removal
and lubricate it with sterile KY jelly. Use your gloved fingers to press down
on the posterior vaginal wall (actually the “floor”), sliding the tampon
down the ramp made by your fingers. Leave a tail of the 4x4 hanging out and
off to the side or top so that it doesn’t touch the anus. A small Kelly
clamp is a convenient way to do this.
----------------------
Suturing Principles & Techniques------------------
In order of
placement, you will be using about 6 running locked stitches in the
vaginal mucosa, 2-4 interrupted sutures in the deep perineal muscle,
followed by 4-5 continuous basting stitches in the subcutaneous fascia
of the perineum and finally, 5-6 subcuticular
or continuous mattress stitches to bring the edges of the skin together. Total
number of stitches placed is about 20.
Healing happens by
the joining of the two surfaces so avoid all “dead spaces” and avoid
sewing up blood clots, hair or skin tags into the healing surfaces of the
wound. All suturing must begin by bringing together the intact portion of
tissue and then continuing to approximate the wound edges as one moves forward
(as one would close a zipper).
Should the perineal
muscle be bleeding heavily and need to be repaired in two layers, you
will need to place a single deep figure-8 stitch in the perineum with 2-0
chromic to control the bleeding before beginning to suture the vaginal
mucosa.
4. Normally one
begins by repairing the mucosa of vaginal floor with 3-0 chromic on an
atraumatic (tapered) needle. The first stitch is an anchoring suture about
1/2 centimeter above the apex (upper most v-cleft) of the laceration. If you
are right-handed, lock the stitch on the left. Each stitch is a new source of
trauma to the tissues so make each one count -- inexperienced practitioners
tend to err on the side of too many sutures.
Be sure not to go
through vaginal mucosa into rectum. This is assured by taking each stitch in two
steps -- through the outside, upper surface of the vaginal mucosa with the
needle coming out on the torn inner surface and pulled through. Then the
needle is inserted to the opposite torn inner surface and aimed upward to the
outside, upper surface of vaginal mucosa on the opposite side. Only then is it
brought together and “locked”. This
avoids a single big “blind” bite through all tissue a once which may go
too deep and enter the upper wall of the rectum.
After the initial
anchoring stitch, proceed to run a continuous locked stitch (also known as a
“blanket stitch”), 1 to 1 1/2 cm apart, down to just before the hymenal
ring or junction of mucosa and skin of perineum. At this point you will have
to take one extra “bite” and
then pull up some of that suture into a loop to use as the opposing side to
lock the last stitch. Do NOT cut needle side of the suture as you will be
using it to close the perineum. Cut ONLY the doubled sided loop of the suture
about 1/2 cm long - not so close that the knot comes undone or so long that it
pokes out of the mouth of the vagina. Then
lay the needle and suture on sterile drape on mom’s belly for later use.
5. Open a second
package of suture and repair perineal muscle using 2-0 chromic on cutting
needle (CT1) with 2 - 4 interrupted sutures. Begin suturing at the top
of the tear with the same “two-step” process as used in the vaginal mucosa
(to avoid accidentally suturing into the rectum) and tie off each one. As you go
down towards the anus, take smaller and shallower bites. Interrupted
stitches provide the extra assurance that if a suture does come out, the
others will still hold the musculature together for good healing.
Double glove one
hand and check through the rectum to be sure that no stitches have gone
through. If so, remove and replace them, then check again. Were they
allowed to remain, the mother could develop a fistula (tract between vagina
and rectum), which would mean that liquid stool would come out her vagina --
something to be avoided at all costs. If it turns out that she has a third
degree laceration (serious involvement of rectal mucosa and/or sphincter), call
for or transport her to an experienced medical care provider for completion of
suturing. There is no shame in knowing when you are in over your head and
great, long-term benefit to the mother by having this delicate work done by a
well-experienced person.
6. Using the 3-0
chromic suture from the vaginal mucosa, close the subcutaneous fascia with
about 5 basting stitches, again starting at the top of the tear
and working down towards the rectum. As you get closer to the bottom,
takes smaller and shallower ‘bites’. The suture is kept to the right side
and not locked except for the last stitch. Don’t cut it however, as
you are going to continue to use this suture.
7. Continue on with
the same 3-0 chromic and using a subcuticular stitch, begin to suture
the skin by starting at the bottom (closest to anus) with smaller,
shallow bites and working your way up with this continuous mattress stitch. A
1 cm bite is taken on the first side, slightly below the level of the skin and
parallel to the wound edge, repeated on the opposite side and then pulled
together so that it makes an “invisible” stitch (no suture is seem from
the outside). Hold this taunt and repeat until the entire length of the
perineal wound is closed, much like an invisible zipper. Do not overlap or
roll edges. The last stitch is taken at the junction of the skin and
vaginal mucosa. The vagina is brought together loosely and then the
needle is brought through to the inside of the vaginal mucosa (behind the
hymenal ring) and a square knot is made with this loop of suture without
bring the long end through (left buried in tissue). Finish last two ties
(total of three) and your done.
Dispose of all
sharps properly, and give the mother appropriate instructions on healing, her
activity level (bedrest) and what signs and symptions should prompt her to
call you.
Click
the Picture to
Return to the home page
The
Use of Medical Grade Super Glue
~ URLs regarding Skin Repair in Perineal Lacerations