Suturing for Midwives

Deb Phillips, CPM

Know the Tissue

Know the Tissue

Know the tissue

Examine the Tear

Examine the Tear

FIRST DEGREE TEAR

• First degree tear involves the vaginal mucosa, the fourchette, and the skin of the perineum just below it.

SECOND DEGREE TEAR

A tear that extends into the muscles and fascia of the perineum but not the anal sphincter.

THIRD DEGREE TEAR

• A tear that involves the anal sphincter.

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FOURTH DEGREE TEAR

• A tear that extends through the anal sphincter and into the rectal mucosa.

First and Second Degree Tears

Third and Fourth Degree Tears

Labial tears

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Unusual Tears

Equipment

Equipment��Needle holders:�All purpose 6-8 inch Mayo-Hegar or similar tool. ��Scissors: To cut suture material when finished and vaginal skin tags��Sutures�27 inch is fine for most repair, 3-0 absorbable synthetic material is best, synthetic non-absorbable 4-0 for fine labial tears and rectal mucosa repair, 2-0 absorbable for perineal muscle repair and 2-0 synthetic for anal sphincter repair, non-synthetic can be used but may cause inflammatory reactions

Equipment��4x4 gauze pads: For drying area.�Sterile gloves�Sterile field drape: work space for clean tools and anything that will touch the midwife’s gloved hands or woman’s body��

���Numbing Agents - Anesthesia �1% or 2% “-caine” , lidocaine, xylocaine, novocain, procaine, etc. without epinephrine, topical or spray-on anesthesia is an option. ��Spray has alcohol in it.��Injected anesthesia can greatly inflate the tissue and make approximation of the tissues more challenging. The ability to properly tighten the stitches may also be compromised. Do not inject excessive amounts.��Injected anesthesia hurts being injected������

I use topical anesthesia with good results

Instruments��Tissue holders�Surgical scissors�Hemostats �Halsted mosquito forceps or similar tool�Tissue/dressing forceps (similar to tweezers)�Allis clamps�Sponge-holding (ring) forceps����

Topical wound care:

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Calendula or other herbs of choice that are hemostatic, astringent, and healing

�Herbal bath compresses: �Comfrey, shepherd’s purse, uva ursi, lavender

Before you begin� Gather equipment� Sutures� Flashlights� Trash bag� Stirrups� � Move mother to edge of bed� Pack if bleeding with gauze

Sterile technique ��Wash wound�Sterile field�Gloves on�Assistant opens sutures�Assistant opens instruments��

Instrument Knot

Instrument Knot

Square Knot

Anchor Stitch

Blanket Stitch

Blanket or Running Locking Stitch

Running mattress stitch�Subcuticular closure

Figure-eight Stitch

Three point Corner Stitch

Interrupted Stitch

Interrupted Stitch

Basting Stitch

Compound Tear Repair

1. Running Locking Stitch (Blanket Stitch)

2. Internal Basting Stitch

3. Subcuticular Stitch (Running Mattress Stitch)

4. Simple Interrupted Stitch (tie-off to finish)

Compound Tear Repair

Compound Tear Repair

Labial Repair

Skid Mark Repair

Checking the Repair

Hematoma