It is estimated that 350,000 women each year who have a vaginal birth will sustain perineal trauma that requires suturing (Kettle et al, 2002). Midwives are the attending lead practitioner for the majority of normal births and are responsible for the systematic assessment of the external genital and perineum (even if it looks intact) in order to identify the full extent of the trauma sustained. When assessing the perineum, a rectal examination* should also be included, with consent, to eliminate anal sphincter damage (NICE, 2007; RCOG, 2007a).
Classification of trauma
► First degree – injury to skin only
► Second degree – injury to the perineal muscles but not the anal sphincter
► Third degree – injury to the perineum involving the anal sphincter complex:
› 3a – less than 50% of external anal sphincter thickness torn
› 3b – more than 50% of external anal sphincter thickness torn
› 3c – internal anal sphincter torn.
► Fourth degree – injury to the perineum involving the anal sphincter complex (external and internal anal sphincter) and anal epithelium.
In the UK, midwives who have been appropriately trained usually carry out the repair of uncomplicated perineal tears (first and second degree) and episiotomies. Current national evidence-based guidelines and Cochrane reviews recommend that second-degree perineal tears and episiotomies are repaired using the continuous, non-locking suture technique and vicryl rapide suture material (gauge 2-0 on 36mm tapercut needle) (NICE, 2007; Kettle et al, 2007; 2010). Despite these guidelines, there continues to be a variation in the suturing techniques used by individual midwives. Furthermore, a recent survey of 323 midwives found that only 6% (n=20) were using the recommended suturing technique for the repair of perineal trauma (Bick et al, 2012). Currently, it is also recommended that all second-degree tears are sutured and not left to heal naturally.
Midwives must be appropriately trained to ensure that they provide a consistently high standard of evidence-based perineal care and minimise the short- and long-term problems encountered by women following childbirth (NICE, 2007; Kettle, 2009). They must also be able to recognise their own limitations and seek appropriate assistance when required. Once competence is gained, midwives have a duty to maintain their skills and keep up to date with new techniques and research evidence (NMC, 2012; RCOG, 2007b).
There are also increasing legal implications and rising negligence claims associated with inadequately or incorrectly repaired perineal trauma (NHSLA, 2011). Failure to recognise the degree of injury and carry out a satisfactory repair, according to recommended guidelines, may now result in litigation. It is important that midwives are aware of the employing authority’s policies and guidelines and the NMC’s Midwives rules and standards relating to perineal assessment, repair and postnatal management (NMC, 2012).
The main principles on which the practice of suturing is based is to control bleeding, minimise the risk of infection, assist the wound to heal by primary intention and achieve correct anatomical alignment. It is an aseptic procedure that should be carried out as soon as possible after birth. The procedure needs to be explained to the woman and carried out with her consent. All equipment used should be checked and counted before and after repair. The woman should be in a comfortable position, so that the trauma can be easily visualised. The wound should be adequately anaesthetised by either topping up a working epidural or by injecting the wound with 20ml of local anaesthetic (Lidocaine 1%). Maternal observations should be checked before and after the procedure.
Basic surgical skills should be carried out during repair: holding the suture needle in the correct position with needle holder (see below illustration), correct use of instruments, guarding the needle and knot tied correctly.
Illustrations by Ben Hassler
Step 1 – suturing the vaginal wall
► Identify the apex of the vaginal trauma
► Insert the first stitch 5mm to 10mm above the apex to secure any bleeding points that may not be visible
► Using a surgeon’s square knot, secure the first stitch (cut off the short end of the suture material, leaving about 1cm to 2cm)
► Sutures should be placed approximately 5mm to 10mm from wound edges
► Each stitch should reach the trough of the wound to close any dead space
► Match each stitch on either side of the wound for depth as well as width
► Suture the posterior vaginal trauma using
a loose continuous non-locking stitch (usually about three to four stitches)
until hymenal remnants are reached
► Insert one more suture to close the hymenal ring.
Step 2 – suturing the perineal muscle layer
► Insert the needle at the level of the fourchette (near to the hymenal ring) to emerge deep in the centre of the muscle layer
► Check the depth of the trauma
► Using a continuous non-locking suture, place each stitch 5mm to 10mm below the wound skin edges and match each stitch for depth and as well as width
► Close the perineal muscles in one layer, or if the trauma is very deep use two layers, ending with the needle at the inferior aspect of the trauma.
Step 3 – suturing the skin layer
► Reverse the stitching direction at the inferior aspect of the trauma
► Close the perineal skin by inserting fairly deep sutures in the subcutaneous layer
► Each stitch should be placed opposite each other, not pulled too tight and approximately 5mm to 10mm apart
► Complete the repair to the hymenal ring, swing the needle under the tissue into the vagina behind the hymenal remnants
► Complete the repair by using a loop or an Aberdeen knot.
Once suturing is complete, the midwife should inspect the repaired perineal trauma to ensure it has been anatomically aligned correctly and that haemostasis has been achieved. A vaginal examination should be performed ensuring that two fingers can easily be inserted into the vagina. Next, a rectal examination should be carried out (with consent) to confirm that no sutures have penetrated the rectal mucosa. A detailed account of the assessment and repair should be documented so that it meets the NMC’s Record keeping: guidance for nurses and midwives (2010) and maternity units’ local requirements.
Finally, the woman should be given advice to promote self-management of her perineal trauma and general health and wellbeing. She should also be given information about when and who to contact if there are any short- or long-term postnatal health problems (Bick et al, 2010).
*Identification of anal sphincter injury
► Look for absence of ‘puckering’ around the anterior section of the anus (between 9 and 3 o'clock)
► Observe if trauma extends down to the anal margin
► Insert your index finger into the woman’s anus (with consent) and ask her to ‘squeeze’.
► If the external anal sphincter is damaged the separated ends can be observed retracting backwards towards the ischiorectal fossa
► If there is damage to the internal anal sphincter this is more difficult to detect as this is a less well defined paler muscle
► Feel the muscle bulk of the sphincter by palpating between finger and thumb.
Senior research midwife, University Hospitals Coventry and Warwickshire NHS Trust
Professor in women’s health, Staffordshire University
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