# Perineal Repair

## Overview

This module describes how to repair an episiotomy or a first or second degree perineal tear postpartum. Third and fourth degree repairs are often repaired in theatre.

## Indications

1. Episiotomies or first or second degree perineal tears

## Contraindications

1. First degree tears where the tissue is well-apposed and not bleeding

2. For third and fourth degree tears, call a senior to assist with anal sphincter repair

## Patient information and consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“You have a cut or tear in your vagina after you gave birth. I need to put a few stitches in so that it will heal well.”

### What can my patient expect?

“I am going to give you an injection that will prevent you from feeling pain, but it will sting a little. Then I will put in the stitches. The stitches will dissolve by themselves while the wound is healing, so you don’t have to have them taken out.”

### What is my patient’s role?

“Let me know if you have any allergies. Let me know if anything is painful, and let me know if you feel faint while I put in the stitches. When you go home, keep your stitches clean and dry. You can sit in a bath of cool water for up to 20 minutes at a time to help ease the pain. Wait for 6 weeks before resuming sexual intercourse. If the wound becomes more painful, appears to be gaping open, or has a discharge, go for a wound check. Do not pull at the stitches.”

## Preparation

Prepare a trolley with equipment. Ensure a female chaperone is present. Ensure you have adequate lighting—general ward lighting is not enough.

### Documentation

1. Patient notes

### Equipment

1. Non-sterile and sterile gloves

2. Alcohol-based hand rub

3. Sharps container
   Sharps container

   If a sharps container is not within arm's length, use a kidney dish or other hard container to temporarily hold used sharps and to carry them to the sharps container for disposal.

4. Skin disinfectant
   Skin disinfectant

   10% povidone iodine is commonly used.

5. A suture pack

   1. Needle holder
   2. Artery forceps
   3. Thumb forceps
   4. Dental syringe
   5. Scissors
   6. Bowl for cleaning solution
   7. Drapes
   8. Sterile gauze

6. Sutures of the appropriate

   size and material
   size and material

   Use 3-0 to 0 absorbable sutures like Vicryl or Chromic.

   (you may need two packets)

7. Lignocaine cartridges for dental syringe

8. Dental needle

9. Irrigation supplies

   1. Bottle of normal saline
   2. Large-bore IV cannula
   3. 20 ml syringe

## Site & Positioning

Position the patient in lithotomy.

## Procedure

Follow medical asepsis with sterile gloves; however, due to the nature of vaginal tears, complete sterility may not always be achievable.

1. Perform hand hygiene.

2. Don non-sterile gloves and

   examine
   examine

   Wipe away clotted blood and inspect the tear. Perform a rectovaginal exam to feel for an intact anal sphincter and to exclude a fourth-degree tear into the rectum.

   the tear to determine the grade. Doff gloves.

3. Open the suture pack and create a sterile field. Pour skin cleaning solution into the bowl. Open syringe, IV cannula, sutures, and

   dental needle
   dental needle

   Not all dental needles come in sterile packaging. See Troubleshooting for how to deal with this.

   onto the field. Drop non-sterile lignocaine cartridges into the iodine solution. Open a bottle of normal saline and place it beside the field.

4. Don sterile gloves.

5. Load the dental syringe and anaesthetise the wound edges. Wait 5-10 minutes.

6. Use gauze and iodine solution to clean the skin around the wound, but not inside the wound.

   Irrigate
   Irrigate

   Use the 20 ml syringe and cannula with the stylet removed to gently irrigate the area.

   the wound with saline if contaminated. Drape the area.

7. Start by making a knot 5 mm above the apex of the wound in the vagina.

8. Approximate the edges of the vaginal wound up to the edge of the posterior fourchette using a

   loose, continuous
   loose, continuous

   Ensure the sutures are loose as the vaginal tissues are expected to swell significantly.

   Although a locking suture technique was traditionally used, research suggests that a loose, continuous suture technique used to close all layers results in less pain, less use of suture materials, and less need for suture removal.

   suture.

9. At the edge of the fourchette, insert the needle back into the skin, to exit at the deepest point of the perineal muscle tear.

10. Approximate the muscles using a continuous suture, working from the vagina

    towards
    towards

    the anal end.

11. Working from posterior (interior) to anterior, close the skin using continuous

    subcuticular sutures
    subcuticular sutures

    In this suture technique, the needle enters and exits just under the skin surface in hidden horizontal stitches.

    up to the posterior fourchette.

12. At the posterior fourchette, tie an

    Aberdeen knot
    Aberdeen knot

    Retain the last loop of your subcuticular suture by putting the fingers and thumb of your non-dominant hand through the loop. Grasp the working end of the suture near the patient's body and pull it through the loop, allowing the loop to slide off your fingers and pulling tight to create a new loop. Repeat this for 4 throws. Finally, pass the entire working end through the loop and pull tight to lock it.

    .

13. Bury the knot by placing a stitch through the wound, into the adjacent skin, and then cutting the suture material flush with the skin.

14. Perform a rectal exam to confirm that no sutures have penetrated the rectum.

15. Cover the wound with a sanitary pad.

16. Dispose of medical waste safely.

17. Record the completion of the procedure in patient notes, and prescribe analgesia.

## Troubleshooting

My needle is bending and losing its curve as I suture through the tough perineal skin.

Make sure you are using a thick enough needle and that you are using a wrist motion that follows the curve of the needle. Good lighting helps with your technique. Losing the curve of your needle makes it harder to put in the next stitch and could result in the tip breaking off. If this happens, contact a senior for help.

## Risks

1. Chronic pain & dyspareunia

2. Uneven approximation with poor cosmetic result

3. Penetration of the rectum/missed 4th degree tear with rectovaginal fistula

4. Missed third degree tear with fecal incontinence

5. Sharps injury to healthcare personnel

## References

1. Kettle C, Dowswell T, Ismail KM. Continuous and interrupted suturing techniques for repair of episiotomy or second-degree tears. Cochrane Database Syst Rev. 2012;11(11):CD000947. doi:10.1002/14651858.CD000947.pub3

2. Marty N, Verspyck E. Déchirures périnéales obstétricales et épisiotomie : aspects techniques. RPC prévention et protection périnéale en obstétrique CNGOF [Perineal tears and episiotomy: Surgical procedure - CNGOF perineal prevention and protection in obstetrics guidelines]. Gynecol Obstet Fertil Senol. 2018;46(12):948-967. doi:10.1016/j.gofs.2018.10.024.