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

• 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