Repairing tear or episiotomy

Only do if skilled — but repair should be done as soon as possible to reduce risk of blood loss and infection

Do not

If anal sphincter or rectum torn — do not attempt repair

If you can’t do repair

  • Treat tear/episiotomy as open wound waiting to be sutured AND medical consult
  • It is most important to stop/control bleeding
    • Apply pressure with pad
    • Ask woman to keep legs together to hold pad in place
    • Check blood loss often and reinforce pads as needed

What you need

  • Portable light
  • Protective apron, glasses and face shield
  • Sterile gloves x 2 — double glove
  • Chlorhexidine aqueous solution
  • 10–20mL lidocaine (lignocaine) 1%​
  • Syringe and needles for infiltration
  • Sterile dressing pack
  • Sterile combine (small)
  • Sterile gauze swabs (preferably radiopaque) x 3 packets
  • Sterile suture pack with needle holders, scissors and toothed forceps
  • Sterile artery forceps (fine)
  • 30–40mm half-circle or tapered needle
  • 2.0 or 3.0 absorbable synthetic suture (eg Vicryl, Vicryl Rapide, Dexon)
  • Water-based lubricant for rectal exam
  • Sterile towels/drape
  • Ice pack
  • Combine or pad

What you do

  • Allow woman's support person to be present and explain clearly the importance of assessment and repair
  • Allow for baby to stay with the mum if appropriate
  • Position woman so she is comfortable and you can see tear clearly — good lighting is essential
  • Wash hands and put on sterile gloves — double glove — repairing tear or episiotomy is an aseptic technique
  • Lay out dressing pack and equipment
    • Count gauze squares, packs, needles — record count in file notes
  • Put on apron, glasses and face shield
  • Gently examine vaginal/perineal tear
  • Clean site with chlorhexidine solution
  • Drape site with sterile towels/drape
  • If LA given to do episiotomy — make sure area is still anaesthetised before doing repair
    • Give more if needed — lidocaine (lignocaine) — 10mL usually enough,  but can use up to 3mg/kg up to 200mg (20mL) in total over 1 hour
  • Wait a few minutes THEN check area is anaesthetised properly before beginning repair
  • Check wound again. If tear too big for you to repair — stop now
    • Control bleeding
    • Medical consult to send to hospital — consider indwelling urinary catheter for evacuation
  • May need to put in vaginal pack/combine to enable good visibility while suturing — record in file notes. Do not forget to remove it
  • Start by repairing vagina first — find apex of tear and put first suture 3-5mm behind it — Figure 3.25
  • Do not pull stitches too tight as area can swell and cause a lot of pain
    • In vagina — use continuous non-locking stitch — Figure 3.26
    • In muscle layer — use interrupted or continuous non-locking stitch — Figure 3.27
    • In skin of perineum — use continuous subcuticular stitch — Figure 3.28

Figure 3.25   

Figure 3.26   

Figure 3.27     

Figure 3.28     
  • If vaginal pack/combine used while suturing — take out
  • Inspect repaired vagina to make sure bleeding has stopped
  • Remove top pair of gloves THEN apply water-based lubricant
  • Do digital rectal exam to check
    • Sutures haven’t gone through rectal mucosa. If they have — take down and remove the stitch
    • No openings between vagina and rectum
    • Sphincter feels intact
  • Count gauze squares, packs and needles again — make sure count is correct and record number in file notes
  • Use ice pack, inside pad, to help decrease pain ​and swelling
  • Give pain relief, if needed

Follow-up

  • Talk with woman about
    • Personal hygiene
    • Resumption of sexual intercourse
    • Diet and fluids
  • Provide coloxyl to stop straining when using bowels