Hesperian Health Guides

Hesperian Health Guides

Sewing a tear or an episiotomy

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HealthWiki > A Book for Midwives > Chapter 19: Advanced skills for pregnancy and birth > Sewing a tear or an episiotomy


Most tears can be prevented if the mother is in good general health. During pregnancy she should eat well, get plenty of rest, and do squeezing exercises regularly. It may also help to slow the birth of the baby's head during labor. But sometimes tears do happen.

Small tears will usually heal on their own. Ask the woman to rest for a couple of weeks after the birth. She should keep her legs together as much as possible, although she should move them regularly. Others should do her household work for her and help her with the new baby.

Other tears and cuts heal better if they are sewn together. It is not hard to sew them, but it is important to learn how from a skilled teacher.

Contents

How to judge if a tear needs to be stitched

Tears are hard to see clearly. A woman's vagina is usually swollen after the birth, and blood clots can get in the way. Sometimes there is more than one tear. Take your time, and use a strong light. Someone may have to hold a flashlight for you.

    illustration of the below: a vaginal tear.
    1st degree tear
    This tear is only in the vagina.
    vaginal
    opening
    length
    of tear
    anus
    1st degree tears do not need to be sewn.
  1. Wash your hands well and then put on sterile gloves.
  2. Judge how long the tear is and how much of the tissue is torn. Look at the tear from the outside. Gently put 1 or 2 fingers into the tear to feel how deep it is. Carefully stretch the vagina to see how long the tear is.
  3. Decide with the mother if you need to sew the tear or not. Small tears that stop bleeding quickly do not need to be sewn. Deeper tears, or tears that will not stop bleeding, do.


2nd degree tear
3rd degree tear
This tear goes into the vagina, in the perineum (the outside skin between the vagina and the anus), and in the muscle under the skin.
This tear goes into the vagina, the perineum, the muscle, and the rectal sphincter (the muscle around the anus).
2nd degree tears will heal better
and are less likely to become
infected if they are sewn, but
they can heal on their own.
3rd and 4th degree tears
must be sewn. If possible,
they should be sewn by
someone very experienced.


To test if the muscle
around the anus is torn


Lightly brush the anus with a gloved finger.

If the anus tightens, the muscle is probably OK. If the anus does not tighten, the muscle may be torn.
After you do this test, throw your glove away or sterilize it, and wash your hands well.
4th degree tear
This tear goes into the vagina, the perineum, the muscle, the rectal sphincter, and into the rectum.
4th degree tears are very difficult to repair. If a mother has a 4th degree tear through her rectum, get medical help right away.


Sew tears as soon as you can after the birth so they will heal well. It is best for a tear to be sewn within 12 hours.

If you cannot sew within 12 hours, and the woman has a 1st or 2nd degree tear, do not sew it. Clean the cut well and tell the woman to rest as much as she can for 2 weeks. If she has a 3rd or 4th degree tear, it must be sewn or she can have permanent damage to her body. She may not be able to control her need to pass stool. If possible, take the mother to a medical center.

WARNING!   You may not have the skills to sew every tear yourself. If a tear seems very complicated or deep, if you do not have sterile tools to sew with, or if you do not have experience with this kind of tear, get medical help.


Tools for sewing tears

To safely sew a tear, you must have:
sterile gloves
sterile scissors
chromic gut or absorbable synthetic suture (likeVicryl)
a strong light
boiled water and disinfectant or soap
sterile cloth for putting under the mother while you sew
sterile gauze for cleaning the tear while you work


Chromic gut or Vicryl sutures are best because they dissolve and do not have to be removed. You must use this kind of suture for stitches under the skin.

If there is no chromic gut or Vicryl suture available, you can use plain cotton thread that has been boiled. But since you will need to take the stitches out later, make only 1 layer of stitches on the skin.

Use size 000 sutures for inside the vagina, and size 00 for sewing muscle. If you have only 1 of these sizes, you can use it for all the sutures.

It is easiest to sew with a curved needle. Some sutures come with the needle already attached.


If possible, you should also have:
needle holder to grip the needle
forceps or toothed tweezers to hold muscle while you sew
sterile needle and syringe for giving anesthetic
local anesthetic (medicine to make the area around the tear numb)


Note: See how to sterilize your tools.


Getting ready to sew a tear
Ask the mother to lie on
her back with her legs
bent and open.
Wash your hands.
Put on sterile gloves.
Set your sterile tools
on a sterile cloth.
Put a sterile cloth under
the mother’s bottom.
Gently wash the tear with
warm boiled water and
disinfectant or mild soap.
Ask a helper to shine
a light on the tear.

Numb the torn area

If you sew a tear immediately after birth, the woman’s genitals may still be numb, and you may not have to use an anesthetic. But if possible, you should numb the cut before you sew it.

Before you give the anesthetic, ask the mother if she has ever had this medicine. Do not give the medicine if she has ever had any reaction to an anesthetic (like itching, rashes, or trouble breathing).

To numb the genitals before sewing
  • inject up to 10 ml of 1% lidocaine without epinephrine in the torn tissue
or
  • inject up to 20 ml of 0.5% lidocaine without epinephrine in the torn tissue
or
  • spray topical lidocaine onto the skin and into the torn tissue
Lidocaine is a common local anesthetic. It is sometimes called lignocain. There may be other local anesthetics in your area. Be sure these do not contain epinephrine.


Before you inject an anesthetic, look carefully at the shape of the tear. Think about what pieces of tissue must be sewn together. This is important because the tear will swell and change shape after you inject the medicine.

  1. Slide the needle under the skin, just inside one side of the tear.
  2. Pull the plunger back just a little. If any blood comes into the syringe, pull it out and try inserting it again.
  3. Slowly inject medicine and at the same time, slowly pull the needle out.

    This will inject a line of medicine under the skin instead of injecting it all in one place. The tissue will swell a little. Inject medicine on the other side in the same way.

    Inject about 4 ml into each side of the tear. Do not inject more than 10 ml all together.


Another way to inject the medicine is
to put several small doses along the
sides of the tear. Inject a dose just
under the skin at each x spot.
If the tear is in the lips of the
genitals, you can inject little doses
of medicine around it.

If there is still some medicine left in the syringe, set it down on your sterile cloth. You may need to use a little more medicine later.

General rules for sewing tears
  • Do not sew until after the placenta has come out, and you are sure the mother and baby are healthy.
  • Wear gloves and use sterile tools.
  • Sew tears inside the vagina before tears of the skin.
  • Think about what parts should be sewn to each other, and where to put each stitch, before you put the stitch in.
  • Use as few stitches as you can — just enough to hold the tear together.
  • Do not sew blood clots or hairs into the tear. This can cause infection.
  • To be sure the womb is small and hard, have a helper check it from time to time as you sew. Do not forget to watch the mother’s overall health.
  • Know your limits. If a tear looks too deep or complicated, get medical help.


Sewing well takes practice. To learn how, try tearing a piece of meat and sewing it closed.


How to sew tears

Use a curved needle this way: If possible, use a needle holder.
using a curved needle.
If you want the point to come out in this direction,
you have to put the needle in pointing down.
Grasp the needle in the middle, but a little closer to the base than the point. Do not grasp the suture in the needle holder — it may break.

There are a few different types of stitches you can use. Do the stitch you are trained to do and feel the most comfortable using. A simple and strong stitch is called the interrupted stitch. An interrupted stitch is simply a single stitch that is knotted with a 4-layer knot, then both sides of the suture are cut.

illustration of the below: an interrupted stitch.
Put the needle in one
side of the cut or tear,
about ½ centimeter
from the edge of
the tear.
Bring the needle up on
the other side of the
tear, ½ centimeter
from the edge
.
Make a
4-layer knot
.


Match the sides of the tear carefully. Try to put the skin back where it was before the birth. This can be difficult with a complicated tear and swollen tissue.

The torn edges of the tear
should line up closely.
torn edges that are carefully matched.
like this
torn edges that do not line up well.
not like this


The suture should come through just above the bottom of the tear. If the stitch is too shallow, the space under the stitch can fill with blood or pus and get infected. If the stitch is too deep, it can pierce the rectum. This can cause serious infection.


a stitch that is just above the bottom of the tear.
a stitch that does not go deep enough.
a stitch that goes too deep.
This stitch is done right. This stitch is
too shallow.
Blood and pus
will collect here.
This stitch is too deep.
It goes into the rectum
where the stool is.


stitches that are just tight enough.
stitches that are too tight.
The edges should
line up closely.
They should not
bunch the skin.

Make each stitch tight enough to bring the sides of the tear together snugly. Do not make them too tight — that can cause pain or infection.


A step-by-step way to sew a tear or episiotomy

  1. If you have it, put sterile gauze in the vagina above the tear. It helps to stop blood from leaking and getting in your way. Remove the gauze when you are finished sewing.

  2. The inside of the vagina is made of a kind of tissue called vaginal mucosa.Under the mucosa is muscle which is more red and tough. It is important to sew mucosa to mucosa, and muscle to muscle.

  3. Using chromic gut or Vicryl suture, put the first stitch above the inside tip of the tear in the vagina and tie a 4-layer square knot. Clip the stitch with sterile scissors.

  4. Continue to make interrupted stitches as shown, through the length of the vagina.

    From time to time, push all the pieces of the tear together to make sure things are going together nicely.

  5. If the tear goes into the muscle, use interrupted stitches to sew the inner muscle layer together.

    Use as few stitches as possible, just enough to hold it together. Usually 2 or 3 will do. With each interrupted stitch, tie a 4-layer knot and clip the ends with sterile scissors.

  6. Now close the skin of the perineum over the muscle, using the same type of interrupted stitches and 4-layer knots.

    Clip the ends with sterile scissors. Be sure the stitches that close the muscle are covered by the skin.

  7. Before you finish, gently put a finger into the mother’s rectum to be sure that no stitches went all the way through. If you feel a stitch in the rectum, you must take her stitches out and do them over again! Be careful not to get any stool on her wound.

  8. Throw away (or sterilize) your gloves and wash your hands well.


Sewing the rectal sphincter

a tear in a woman's vagina and rectum.
tear goes into the rectum

If a woman’s rectal sphincter tears, she is at risk of never being able to hold her stool in again. This is a very serious problem, and it is very important that her sphincter is sewn well. If possible, take the woman to a medical center or have someone very experienced sew this kind of tear.

WARNING!   Before you sew a torn rectal sphincter, check to see if the wall of the rectum itself has torn. Do not try to repair the wall of the rectum yourself. Get medical help right away.

  1. The sphincter muscle is inside a thin casing of tissue called fascia. The muscle and fascia may withdraw a little into the woman’s body.

    Using a sterile forceps, clamp, or tweezers, pull one end of the muscle and fascia a little so you can see them. Use a second pair of forceps to pull the other end of the muscle so it sticks out a little too.

  2. Use size 00 chromic gut or Vicryl suture for sewing the sphincter muscle. Pull the 2 sides of the sphincter close together. Insert the needle through the fascia and muscle on one side and pull it out through the other side.

  3. Use 3 or 4 interrupted stitches to hold the muscle and fascia together.

  4. After the muscle is together, sew the rest of the tear.


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