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Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA
A Holiday Treat from gentlebirth.org
Sing Along with the Nutcracker Suite - Yes, there are lyrics!
Perineal Repair After Childbirth from the NHS of Scotland
At the end of this article, there is an excellent "Perineal trauma and repair literature search":
NICE - Intrapartum care: care of healthy women and their babies during childbirth mentions perineal tearing/trauma throughout, but see sections 8.5 and 10.4 in particular.
NHS QIS - Sharing good practice in Scotland’s maternity services: Forth valley (page 7)
NHS Forth Valley
1. Before developing a best practice recommendation on the management of perineal repairs, NHS Forth Valley undertook a
training needs analysis of midwives’ skills in relation to this aspect of maternity care. The audit included: information on the
labour experience of the individual midwife; their decision for suturing, including skills and technique used; circumstances/
reasons why an individual would not suture a perineal tear; and suggestions and ideas of what training/advice would be helpful
to improve an individual’s competence and knowledge in this area.
Gillian Morton, General Manager, Women and Children
Tel: 01324 624000 x 5004, Email:firstname.lastname@example.org
From the WHO:
Episiotomy for vaginal birth
Repair of vaginal and perineal tears
From the Royal College
PEARLS: Perineal Assessment and Repair Longitudinal Study
Evidence-based guidelines for midwifery-led care in labour
see page 71, care of the perineum practice points
see page 81, suturing the perineum
[I found something similar as Practice Guidelines - Suturing the Perineum.]
Linda Arnold teaches a GREAT continuing education class about Suturing in a Real Midwifery Practice! She is assisted by her daughter, Alyson Kuntz-Butler CPM, LM, who is an excellent midwife and teacher as well.
Skills has great video clips of Knot
Tying and good information about Instrument
Handling and general Suture
In her thought-provoking piece, 4 Questions You MUST Ask Before Hiring Your Midwife, Jill McDanal writes, "And about suturing. Is it a true benefit to hire a midwife that can sew up a tear? I offer that it is NOT. Unless she has been a surgeon in another life, most midwives don’t suture tears nearly enough to be quick, accurate and proficient. And, if she IS that quick, accurate and proficient, you should really find out why. I have known at least a few midwives to suture for fun/practice. Tearing to a degree that requires sutures is a pretty serious thing and a situation, again, not usually encountered when birth is allowed to proceed physiologically. My feeling is that serious tears need to be sewn by a surgeon. Any minor tears probably should be left alone for natural healing. End of story."
On the one hand, I agree about the problem of HOW a midwife
becomes proficient. Either she's suturing tears that don't
really need it, or she's not doing a very good job of preventing
tears. I have often wished that homebirth midwives could
shadow a hospital-based practitioner with a high tear rate and
learn to suture under their tutelage. However, I also agree
with this response to the above piece:
" I did suture when needed and very well, too. Perhaps not
as quickly as a doc, but I was not about to transport a
mother after a beautiful home birth if there was a tear that
required a few stitches. This was not often, but it did happen.
Yes, we practiced on beef hearts to know what kind of stitches
would be best in varying situations."
Ideally, homebirth midwives would have suturing backup who could come to the home to suture more complicated tears so the mother doesn't have to make the difficult choice of going to the hospital or having a midwife perform a repair beyond her comfort zone.
Do any of you just not suture at all - ever? When selecting a midwife (DEM) I found 2 I liked and the one I liked the best did not do suturing (although she knew how). This made me somewhat nervous but I liked everything else about her and her approach to birth so I selected her. She really had some incredible stories of women with bad tears who healed on their own with sitz baths and herbs. I think she used to say "If you put 2 pieces of perineum in a room they'll grow back together!" Of course a lot of her moms did not tear. I always feel kind of bad for the moms I assist who give birth naturally and have their baby and then it's time for the stitches which is painful (The shots to numb her bottom that is).
Was my midwife unusual or are there others who practice this way.
BTW I had a large labial split that healed on it's own but I've
been told that even drs. rarely suture labial splits (true???)
I have found that you don't have to do as much suturing if the
woman is willing to use herbal sitz baths and Castor oil packs on
her yoni. This causes the tissues to heal faster if there is a bit
more tearing, and if the mom is cooperative you may not feel the
need to suture as much. I like to talk about all this ahead of
time to get an idea of what she wants to happen. Also, supplements
such as vit. C, E, A, and St. John's Wort tincture help promote
healing of these delicate tissues.
A torn perineum can heal on its own. Usually. Not always. I have
done births for clients whose first midwife did not suture, or who
did not "believe" in suturing. I have also seen suturing jobs that
just broke down, for whatever reason. In both cases the woman is
left with a big gaping hole, that can only be fixed with
reconstructive surgery. In my opinion, tears happen, sometimes, no
matter what we do. If those tears are very extensive, they need to
be repaired. if the midwife can't do it, the mom needs to be
referred to someone who can fix it, immediately. In my practice,
we regard suturing as a part of our duty to our clients. Who wants
to have a wonderful homebirth, and then be drug into an ER to be
sutured? Even more of a disservice is tell the woman that she'll
heal, and then have her left with an irreparably damaged vagina.
I don't suture or feel suturing is necessary unless the
laceration exceeds a 2nd degree or is a messy 2nd degree. Personal
opinion: our great-grandmothers weren't sewn and would have
probably had a fit if anyone had suggested it.
I also have seen women with unhealed peri tears with wrinkled creased skin that never approximated. And (the worst IMHO) with unhealed vaginal tears, with just skin for perineums, not an underlying muscle layer because previous tears were not stitched on the advice (or neglect) of other midwives. I have to think most women would not choose to leave large gaping tears unsutured.
I covered for another midwife once who had 2 births happening at once. Drove 120 miles, got there just as mom was feeling pushy. Quickly set up, put a compress on her peri and noticed her anus was off to the side. I just thought "variation" till she said she'd had an unrepaired tear (unattended hb w/ first baby), fistula and reconstructive surgery. Yikes! She gave birth sidelying, slowly, about 20 minutes after I arrived, no tears, but I certainly would have taken her in for stitches if she had, and she certainly would have insisted on it.
I think 2nd degree tears should be stitched, or 1st degree tears
that don't lay closed or have too busy moms attached to them.
Tract Trauma and Related Pain Following Spontaneous Vaginal
Leah L. Albers, CNM, DrPH, and Noelle Borders, CNM, MSN
J Midwifery Womens Health 2007;52:246–253
"Also, allowing the perineal skin to remain unsutured, as long as
it is not gaping, is associated with less perineal pain."
suturing make a difference? The SUNS trial.
Fleming VE, Hagen S, Niven C.
BJOG. 2003 Jul; 110(7): 684-9.
"CONCLUSIONS: While acknowledging the small sample size, the
results are nonetheless important, showing persistent evidence of
poorer wound approximation in those women who had not been
sutured. Practitioners need to review the present practices
of not suturing perineal lacerations until research
examining the longer term implications is undertaken."
Calvert S, Hagen S. Trial of non-suturing underway.(letter)
The Practising Midwife 1999;2(7):15
Susan Calvert, Research midwife and Suzanne Hagen, statistician.
SUNS-study ( Sutured Versus Unsutured), which is a large randomized controlled study including 300 women. The study is/was funded by the Chief Scientist Office of the Scottish Office.
The only information I have about this study is from this page.
If you have better information about this study, please e-mail me
about it. Thanks.
Is It Necessary to Suture All Lacerations After a Vaginal
is free.] [Full
article in sample
by Martina Lundquist, RNM, Ann Olsson, RNM, Eva Nissen, RNMTD, PhD, and Margareta Norman, MD, PhD
Birth 27 (2), 79-85
Conclusions: Minor perineal lacerations can be left to heal spontaneously. The benefits for the woman include the possibility of having a choice, avoiding the discomfort of anesthesia and suturing, providing positive effects on breastfeeding.
How often do any of you decide not to suture a laceration that could be sutured?
I sometimes work with another midwife who rarely sutures anything, and advises women to keep their legs together for a few days. I think that this advice is unrealistic. But on the other hand, I haven't heard complaints from these ladies, although they rarely heal together.
I once had two sisters as clients who seemed to have very anteriorly placed vaginas. Have any of you seen that? During delivery, they crowned forever -- and in both cases it looked as though the baby was trying to come directly out of the anus. ( Or is that anuses, or ani?) They both eventually got episiotomies and refused repair. And were very happy with what seemed to me to be the gaping results.
Anyway , I 'm interested in knowing what goes into your decisions re: when to repair and when not to. For me the availability of postpartum help for the mom, and the mom's wishes factor very heavily.
As the owner of a vagina, I feel I would want a repair, but I
realize that there are many women who wouldn't always agree. What
do you think?
I repair all second degree lacerations unless the mom refuses, (and I try to persuade her to have the repair). The possible exception might be (and I haven't had this happen yet) where the tear falls together naturally and doesn't bleed a lot. First degrees I look at where they are, how much they bleed, and talk to the mom. Often I will use topical anesthesia and just put in one or two stitches to support the tear while the body heals itself.
I think that suturing is very important when there is extensive bleeding from any tear, probably because as a student I had a mom who lost 500 cc from an anterior vaginal wall tear before we could get it stitched enough to achieve hemostasis.
My question for the list: Have any of you encountered horizontal
labial tears? How did you suture them? I had one, and I kind of
muddled through the repair basing it on what seemed to work. It
healed perfectly, and the mom had no complaints at her 6 week
checkup (you couldn't even see the line of the tear). I hope never
to see one again, but I would be curious to know what approach
others took. I used 4-0 chromic on an SH (itty-bitty) needle and
topical lidocaine at the insertion point before each stitch. I
think it took 4 stitches to approximate the edges.
As a general rule: I don't repair 1st degree lacerations unless they are bleeding. Then, only with one stitch to stop the bleeding. I use 4-0. Since I work in a hospital, I don't always get to choose if I want vicryl or chromic. It's what the hospital purchases. And I don't have much input - yet. (First CNM in this area with priv. Need to tread with discretion. Choose my battles wisely.) BTW, when I was in school we were using only chromic. Took me a long time to get use to the feeling of Vicryl. Didn't like the way the thread would "drag." I think it had to do with something regarding an old dog and new tricks.
If it's a long 1st degree, (along the periurethral or labial area) I may use 1 or 2 stitches to bring the edges together. Make sure that side A lines up well with side B.
I once worked in a hospital where one of the physicians never sutured 1st or 2nd degree lacerations. He used Allis clamps. Placed them on the skin area for approx 20 min. Then removed them. That was it. Said that the vagina would heal all by itself. Didn't need suture. (Did the same of the skin layer of C/S) I have to say that I never got to see these women again, so I don't know how it turned out. Anyone else know of someone using Allis clamps?
I believe 2nd degree lacerations need repair. I don't use a lot of stitches, but I do repair the lac.
In my hospital protocols, 3rds and 4ths must be repaired by MD.
I think it is very important for all midwives to know how to
suture correctly for when the need arises. But it is equally
important that women be given the choice when suturing might be an
option. Some women really feel strongly about not having any
stitches...they can have personal opinions on this issue that need
to be respected as it is their body and they should have full
control over it. As with so many issues in women's healthcare, a
midwife should be able to thoroughly inform a client as to her
choices and then be ready to act on behalf of the best interests
and wishes of that client.
I had my fourth baby at home and it was my first home birth. We
did it alone and I went into the Dr 3 hours later. He checked and
said I only had a very small tear almost a skid mark. Later 2
births later, I was told by a midwife friend that I had torn
before at a birth and never been repaired. She said it was a
pretty substantial tear. It hadn't made much difference in
activity or anything that I noticed except I did notice a bigger
opening. Now 20 years later I wish I had been repaired but it
hasn't made to much difference except psychologically. The Dr I
think, knew that I had torn more but wanted to "teach" me a lesson
some kind of dark joke. That is another story about when I was 6
weeks before having my baby I told him that I was going to have it
at home. We were in the military and he was NOT amused.
Regarding the study on non repair of 2nd degree lacerations, I'm
wondering why anyone would want to leave such a wound open.
If it occurred anywhere else on one's body such as the arm or
mouth, I don't think the person would find non repair a desirable
option. Why then would they treat the perineum with less
respect? I had a laceration after the birth of my
first child (don't know what degree, that was a while ago).
The repair was fairly unpleasant, but once it was done, it was
done. I felt no further discomfort from it. My friend
had a very sloppy repair of her 2nd degree laceration and
her bottom was sore for a month. Someone posted
about packing the mom with herbs and having her keep her legs
together for some time. It's good to know such treatment
would be successful in an emergency, but I'd hate to think of
putting a woman through such discomfort unnecessarily.
I have found honey to work great on tears. I have had some
ladies who refuse stitches when I would recommend maybe at least
3-4 stitches (I stitch conservatively). They use the honey
and have healed up wonderfully! A note of interest though is
that they find it soothing until the wound has knit real well and
then find it to be irritating. Has anyone else experienced
On the family docs delivering list (famdel) we've been talking
about not repairing second degree tears, and how few studies have
been done. We frequently get hassles from other doctors, wanting
proof that leaving tears unrepaired is safe. Personally, I think
they should be providing proof that epis and suturing are safe.
But that's beside the point. Someone mentioned that they had heard
in 1996 at the Birth conference that there was an ongoing British
study on non-repair of 2nd degree tears. no one has seen any
references to this since. Do any of our British members have any
more info on this? I'm considering doing such a study here, but
only if it's really needed and not ongoing elsewhere.
Safe and optimal physiologic/anatomic results are something else.
Anecdotally, I have seen many women who have had previous births *without any tears* (per their report). Generally they come to the office w/ complaints of decreased sexual satisfaction, urinary stress incontinence, sometimes fecal incontinence. Their vaginas are totally wide open. It is evident that they have had unrepaired second degree tears (or worse). The hymen is totally unapproximated.
I would think that most folk who are familiar with the literature would agree that there is no evidence supporting routine epis. However, I am not aware of any literature which addresses leaving second degree (or greater) lacs unrepaired.
This should probably be *safe*, but in my experience, it has not
resulted in satisfactory anatomic/physiologic results. Non-repair
of mucosal tears (first degree) should be OK, but, IMO, muscle
disruption should be repaired.
If it were *my* bottom, I'd rather be stitched, but I am
interested to learn how suturing affects healing. The more
info I have, the more informed my clients can be. Some
clients really don't want to be sutured. As midwives, we
have a tremendous influence on our clients and can often persuade
them to follow our counsel. In an effort to be a midwife of
integrity, I want to be able to give them the best, most accurate
info possible. If it really *is* dangerous to leave a 2nd
degree wound unsutured, then I would more strongly suggest
sutures, even to one who really didn't want them.
I, too am very leery about leaving a large laceration to heal on
its own. I am the one that said something about the 14 year
old that had the baby at home, but had a tear that I intended to
suture. However, she became HYSTERICAL when I mentioned this
repair, and was willing to do anything to keep from having it
done. She took responsibility of caring for this tear, and
basically refused any repair. It amazed me to see how well
she healed, and how little trouble she actually had from it.
She has had a very happy marriage, and babies since then. I
don't believe this is the answer for everyone, but it is nice to
remember, occasionally, that our bodies are wonderfully made, with
tremendous healing capacities.
I agree. There is currently lots of discussion up here
about whether or not to suture. I feel that a well-sutured
tear offers little discomfort to the mother, and she may be less
likely to end up with nasty skin tags and so on from less than
satisfactory results. Furthermore, a busy mom with other
kids is not about to be able to sit with her legs together for an
indefinite period of time waiting for the process to be
complete. Have seen them forget and then tear open an
unsutured tear by squatting down to do something for one of the
I'm replying to several people, so not including their messages.
I'm used to being one of the "doctor types" on the list, and
usually more prone to use procedures than many of you. So I'm
surprised to find several people are all more likely to want to
suture. I wonder if we are really talking about the same thing.
Big second degree tears that don't spontaneously approximate and
stop bleeding I would never consider leaving unrepaired. Likewise
a tear big enough to be opened by mom squatting a few days later
should be sewn, I think. But I have many tears which are in low
stress locations which heal just fine without stitches. We know
that any foreign body, including suture material, creates an
inflammatory response. I strongly suspect that women have more
pain from a sutured tear than an unsutured one. And there is no
difference in healing time - sutures don't speed healing, just
provide approximation and stop bleeding. In fact, by cutting off
part of the blood supply, they may slow healing. If a tear is
truly well approximated it should heal just as fast without
sutures, avoiding the discomfort of placing the sutures and of the
inflammation from the sutures. healing time for the perineum is
really very fast - under a week. We've all seen bad outcomes after
previous babies, but remember we never really know those stories.
I've seen some pretty bad outcomes from previous suturing too.
That's why I'm looking for studies. Until then, I don't think
anyone should change what they are doing. There are no studies
showing that suturing is better, either.
All of my following comments are purely anecdotal....one, there *are* no studies looking at this issue, and two, I've never left a second degree tear unrepaired. I'll be right up front....my bias is clearly to repair all but minor first degree lacs.
My concerns come from "natural history" type observations of women who have had unrepaired second degree lacerations, and also of women who have had allergic reactions to suture material, have had a breakdown of the repair, and have had to heal by secondary intent. I think we would probably all agree that *if the edges of the wound are not approximated*, healing will be delayed, and will occur by secondary intent, rather than a primary closure. The torn muscles contract, and I don't see how they will automatically approximate.
If women could stay in bed with their legs tightly shut for 7-10 days, there might not be any differences....but that is not the reality of the situation. Walking, sitting on the toilet, sitting on a chair, getting in and out of the car, doing stairs....all will cause lack of approximation of the wound edges. Women who have a breakdown of the repair come in with gaping, open bottoms....the edges of the laceration or epis do not come anywhere near each other, and they take *weeks* to heal.
I've had probably 5 or 6 women come complaining of inability to enjoy intercourse because "I'm too stretched out since I had my baby. My husband says he can't feel anything, and I can't feel anything either." As part of my history I ask about their previous births, any epis or lacerations, any stitches. "Oh no", they all have said. "I didn't have any tears". They, when you look at their bottom, the hymenal ring is separated by about 2 inches, and there is no tone. And I know perfectly well that they had an unrepaired second degree tear. I have not heard this complaint from anyone who was sutured.
I never used to repair periurethral splits unless they were bleeding...and I got *lots* of complaints about pain with urination (for many days). Now I put in one or two stitches w/ 3-0 or 4-0 chromic on a tiny needle, no anesthesia, and no one ever complains about pain with urination.
Are there problems with suturing? Yes, of course! It can be done carelessly, too tightly, or with lack of understanding of the anatomic tissue planes. Women can have allergic reaction to the suture. But I can't imagine not suturing. Yes, it will eventually heal regardless of whether it is sutured or not. But my personal opinion is that anatomically one gets better results w/ suturing.
Is there really a study which is looking at this issue? I'd
sure love to see their results.
I agree. I saw a few second-degree tears left unsutured
when I was still apprenticing years ago. They healed with
the use of comfrey compresses and bedrest with legs together but
the integrity of the pelvic floor was compromised and the ladies
were left with relatively poor perineal tone, in my
estimation. I suture second degree tears (haven't had
any for years though, thank goodness!). I suture first
degree tears that don't lay together well and I've now used super
glue on two minor 1st degrees with excellent results.
I was curious too so I've had a hunt right through all my copies
of MIDIRS back to 1992. Why do I keep on finding things that
I've think I've never read before whenever I do that? I keep
getting side-tracked by interesting
articles!!! There seem to have been very few
studies done about perineal tears anyway, but aside from
that I could only find three about non-suturing and am not
even sure how much use they are in answering your
question. However....... Head M. (1993)
Dropping stitches. Nursing Times, vol. 89, no 33, pp64-65
This small study was done in a small unit in Somerset (UK) where
they hadn't stitched any first or second degree tears for
the previous 15 years. So they did a retrospective study and
sent questionnaires out to 75 multips who had been sutured
for at least one birth; they were asked to compare the pain
from the sutured perineum with that of an unsutured perineum
(either with a tear or intact) which they experienced with
their births in the unit. 62/75 replied; 7 were excluded
because they hadn't had any suturing leaving 55 in
total. 92% hadn't had any infection. There didn't appear to
be any impediment in healing when not sutured and none of
the women appeared to have experienced any complications
from not having been sutured. Pain levels were lower and
comfort levels appeared to be more satisfactory with intercourse
resumed earlier. Long term effects of not suturing weren't
known. The other two I found were reports about
an audit system called "Are you sitting comfortably?" that
was used by midwives from the Whittington Hospital NHS Trust
in London following the publication of the Changing
Childbirth government report about maternity care in the
UK. Lewis L (1994) Tea time. Using herbs to help
treat the unsutured perineum. MIDIRS, vol. 4, no.4,
pp455-456 and Lewis L, Rounce C. (1996) Extending the
midwives' role in perineal management. Nursing Times, vol
92, no 11, pp39 - 41 They used semi-structured
diaries that: a) the midwives (91 of them) filled in a "What
did I do and why"-type questionnaire concerning their
perineal management at the time of delivery of each woman
and b) their clients filled in at 10 days, 6 weeks, 8 months
and 13 months post-natally. For a three-month period all
women attending their 34-week check at the clinic were
offered the opportunity to take part in the study..... in
the end 89 sent back completed diaries. These
reports are kinda complicated to explain and to summarize, because
they used an action research design. From the
diaries it appeared that there were differences in practice
and outcomes depending on how/where the midwives worked.
Unsutured second degree tears cared for by the independent
midwives (who also used a variety of herbs) healed at about
3-4 weeks postnatally; unsutured second-degree tears
that were managed by hospital/community midwives took 6-8
weeks to heal. When the audit began, midwives
started to practice non-suturing. At the start of the study,
80% of first-degree tears were sutured while 20% were
unsutured; by the end of the study 80% were unsutured and
20% were sutured. However, they didn't state if there were
any changes to the midwives' practice with second degree
tears. The episiotomy rate also fell from 17.5% for the three
months prior to the study to 11% for the duration of the
study. Then it fell further to 6.6% for the last month of
the study and to a low of 3.3% after the initial findings
had been presented to the staff in the obstetric
unit. Mostly this was because the clients and
the midwives themselves began to question the value of
suturing; but they concluded that there was a need to
investigate: a) the practice of non-suturing especially for
second-degree tears b) the ways midwives were being educated
about repairing the perineum and c) the possibility of using
herbs more widely because women who'd received that kind of
care appeared to be really positive about the
outcomes. If you want, I could post you copies
of the studies snail mail - easier than trying to explain
them!!!. I also had a look in ECPC but couldn't
find anything at all about non-suturing second degree
tears. Any help?
I have a home birth practice and can suture, but almost never do. My experience has been that if the tear (1st or 2nd degree) approximates with the mother's knees together, she probably does not need stitches. If there is gaping with the knees together, it is up to her whether she wants them or not. Most of the women I deal with choose to let their bodies heal naturally. They are also reminded to keep their knees together for a few days. This does not mean in bed, only that they are consciously trying NOT to sit wide-legged. I have had a few moms who I thought would have benefited by a stitch or two who refused. Their bottoms healed beautifully. These tears are not bleeding, of course, or else that would need to be taken into consideration.
None of these women have come back complaining of feeling stretched out, etc. All are encouraged to continue doing kegels in many positions. Although a number of women who had previous hospital births with stitches for tears/episiotomies have complained about many lingering problems/pains from those repairs. When they later compare a non-repair for a tear, they claim it was nothing in comparison and their bottoms feel improved.
I'm not sure if these studies are quite what you are looking for,
but I believe a few years ago, Nancy Fleming, CNM, had a
research article in the Journal of Nurse-Midwifery on
episiotomy/tears and the integrity of the women's vagina's
postpartum. She used a special vaginal probe to
measure vaginal muscle strength. A book, Episiotomy
and the second stage of Labor also has some studies that are
loosely related to repairs of tears or non-repair of tears
and healing and women's perception of how well they healed.
I must add something about periurethral tears. True, suturing
them does prevent the intense stinging with urination, but so does
spraying the area with lukewarm water (via peribottle) while
urinating. You have to do this each time you urinate, but it's
only a few days and well worth the trouble, IMO. As one who has
had periurethral splits both repaired and unrepaired, I'll have to
vote for not repairing. The repair hurts more than the pain with
urination (I don't care HOW small the needle is).
Anything that bleeds, I suture. If the edges won't approximate, I feel they need a bit of help. If a tear is deep, I might place a deep suture to prevent a pocket. Otherwise, I feel it can usually heal on it's own. I have heard lots more women complain of past suture jobs than of non-repair.
I would love the experience of observing different suturing techniques of various experienced practitioners. Being in a small practice, I don't get enough practice to be as proficient as I would like with suturing. Perineums *are* forgiving, but I would hate to ever make someone worse off than they would have been without stitches!
I was called in to another midwife's birth to suture one day last month and I couldn't believe the lack of integrity of her tissue. Any needle stick caused more bleeding and the sutures wanted to pull right through the tissue. It would have been better off without sutures except that the edges would *not* meet. I have never understood how one could tear such that the edges didn't want to meet again!
My midwife taught me that one should use the minimum number of
stitches that gets the job done.
Here are the available options for my clients:
1. Leave the tear alone.
2. Regularly apply peri powder or peri paste (better known as People Paste, from the book 10 Essential Herbs). I include comfrey in the recipe however.
3. Peri powder/ paste and/or daily herbal baths until healing is well established.
4. "Suture" glue - basting stitches are made across the tear while the edges are being held together. The ability to adhere properly is dependent on a dry surface. We usually have an extra person fanning the perineum after mom has been cleaned up and while we are applying glue.
5. Suture the tear.
All the above, with the exception of #5, require mom to keep
knees together. The choice in tear repair depends a lot on
the mother's lifestyle, how many small children, nutritional
status and her commitment level.
I suture all second degree tears, however I had a certain client
who decided to ride to the local 7-11 on her four wheeler 24 hrs
PP. She tore [or popped is more accurate] her
stitches. After much talking and counseling she agreed to
stay put. She healed nicely except for a small tag on the
We have a suturing philosophy, protocol and skill acquisition program at our hospital. under the protocol any tear must be checked with a suturing teacher (i.e. me or the boss) before the decision can be made not to suture. we rarely suture 1st degree tears at the fourchette - we will suture 2nd degree tears that are bleeding or apositional or if the client requests suturing. For suturing material we use Dexon 2-O - it is difficult to get the hang of as it is slippery but is kinder on the tissue than catgut. On labials I advocate the use of vicryl 4-O as it is a very fine material. When repairing tears we teach the simplest method so that everyone is suturing the same way. I encourage people to get a feel for the tissue and once they are confident with the routine of suturing they can then get fancy if they wish. I personally use Flemings method as I like the results and it uses minimum material. I have noticed that the repairs that break down tend to be the O&G's as they use a lot of material and for some reason seem to feel it has to be locked tight. I always tell colleagues that Midwives are 'cobblers' - aim for haemostasis and wound approximation using big chunky stitches we seem to get the better results. Kate - I haven’t forgotten that info but I am on days off right now! so I don’t aim to go near the place.
I have to agree, also there is a historical precedent. In the
earliest days of the Cesarean Section operation, there were
surgeons who did not suture the uterus, reasoning that the edges
would grow back together naturally and/or that the uterine
contractions would force the edges of the uterus together so that
they would heal. The concern was to avoid placing a foreign object
(suture) into the abdominal cavity where it could be a focus of
irritation and infection. Tragically, many women did not survive
this type of procedure, and for sometime after this the operation
of choice for the truly necessary Cesarean was the cesarean
hysterectomy. Part of why I study the history of midwifery,
medicine, and surgery, is to try to avoid making the same mistakes
over and over again simply because one generation has forgotten
the lessons painfully learned by the past generations.
This is another reason to treat BV during pregnancy.
Those "hamburger" perineums that won't hold stitches and won't
hold together without them are the ones I believe heal wide
open. And you must take into account the nutritional status
and sex practices of women you encounter. Our homebirth
ladies often have a much better knowledge and practice of
nutrition than most health care providers, are meticulous about
cleanliness and do not begin to have intercourse until they are
completely healed. There is a portion of our hospital
practice however, who don't have such good habits. Many of my
clients have returned to coitus, like it or not, long before their
6 week visit. I see a lot of BV and HPV, both of which
retard the healing process as well as (unfortunately) being more
likely to shred during the birth. You cannot compare the
perineal integrity of apples and oranges. Just pray for an intact
With Rapidly Absorbed Material Best for Perineal Repair -
Lancet 2002;359:2217-2223. [Medscape registration is free]
To apprentices I say this: Don't let tears wig you. If you can sew the seam in a mans' pair of pants, you can suture a perineum. Take your time. Look at the tear with a GOOD light (by the way, I just saw a thingy advertised in a construction mans catalog that holds the small flashlights. I am definitely going to get one!). Try to reconstruct where everything goes. Once you have determined where everything goes, begin to plan out what needs to be sutured first so that you may build the perineum back up. Feel free to numb the area before you try to reconstruct. That will allow you to look at things without hurting the woman. If the woman is flinching or making uncomfortable noises you will feel like you need to hurry. Numb her. Let her tend to baby.
Also, I find an old large, thick book and wrap it in an underpad
and place it under moms hips to elevate for easier access &
visibility to area. I also take a 4x4 gauze sponge and
insert it into the vaginal area. If you must place it high
in the vaginal area, have a string tied to it so you can remove it
easily. You should make up a few of these. You want to
keep the area as free of flowing fluid as possible so that you can
visualize what you need to suture and what you are suturing.
Reevaluate after every stitch. You have hours to do this so
take your time. Stretch if your back hurts. If a tear
is extensive it can easily take 20 minutes to suture.
I learned a suturing technique from a fellow midwife years ago
that I call the zipper. It is continuous and done sub-cutaneous
beginning deep and progressively getting shallower. There are no
stitches left on the outside to cause irritation and it leaves a
very nice look. It is also very quick once you get the hang of it.
I use it only for those posterior labial tears, using interrupted
for labial splits.
not so much one layer as few knots. 'an alternative, scientific
method of suturing' presented at ICM Oslo congress 1996 'can the
suturing method make a difference in postpartum perineal pain'
journal of nurse midwifery vol. 35 jan/feb 1990 essentially knot
at apex, come down the vagina in loose running stitch to just
behind the fourchette (probably two - three turns at best). knot
at the fourchette but do not cut and leave one end for finishing
knot loop under the fourchette and do the perineal muscle layer in
loose non locked stitches (as vagina) turn at anal end and
come up towards the fourchette knot with the sutures made below
the subcutaneous layer i.e. away from the nerve endings. dip back
under at the fourchette and knot. the fourchette should not have
any sutures in it as this leads to lumpy scaring. the skin layer
will look like an open cut but of course as soon as the client
shut her legs it is together. fleming found that the women had
much more comfortable perineums and very fine scars. get the
journal piece as it has pictures and I have not explained it
brilliantly. (suture queen off!!)
Spray-on lidocaine has alcohol in it and it does sting. But if
you fan it, it is more tolerable than the injections. I get it
I'm no expert, but I hate injecting lots of Lidocaine into
someone to suture. It seems like more trauma and swelling.
Sometimes I do, but I always start with Cetacaine gel or Xylocaine
spray if I'm out of gel. That gives me about 50% numbness, which
is usually sufficient for a normal 1st to small 2nd degree tear at
a normal birth. People seem to experience the pain of suturing
VERY differently, so I figure it's best to start with as little as
possible, and move up as needed. Also, some people (like me,
actually) have unpleasant (and rarely dangerous) reactions to
Lidocaine or Epinephrine, so why use it on everyone if it's only
needed some of the time?
I know a renowned midwife who sutures without local all the
time. She usually does just one or two stitches, and since
local would require injection with hollow bore needles, there is
less pain and less trauma without the needle. Quicker
I made a discovery several years ago that works very well prior to suturing. What I was doing was pouring tea tree oil on the wound before suturing to aid healing. What I discovered was happening was that when I went to inject lidocaine the ladies perineums were already numbed! Much to my surprise! Now it's the only thing I use for just one or two stitches, and always prior to injecting lidocaine
Verbal anesthesia helps (talk confidently, distract her, be quick
and sure), and we often resort to singing anesthesia too. This is
most effective when loud songs reminiscent of childhood can be
sung in 3-part harmony with everyone in the room belting it out.
Favorites? "Leaving on a Jet Plane", "Hundred Bottles of Beer on
the Wall", "Glory, glory, Hallelujah" - you get the idea. I guess
it's obvious I practice at home, eh? Also, I love to sing.
I'm always concerned about further tissue trauma inflicted by unnecessary suturing. Are most midwives injecting lidocaine prior to stitching?
Also, I've noted that most women I talk to, when given a choice,
would rather not have scissors (epi) or needles near their
Are most midwives injecting lidocaine prior to stitching?
I believe in drug-free childbirth, but stitches are another matter! If anyone sews MY bottom, it better be numb!
I do use lidocaine, though I have heard of suturing without
it. I make as few sticks as possible, injecting more
lidocaine as I withdraw the needle, instead of making multiple
I do, if there is more than one stitch. Except some
labials, when I'm just going through skin to approximate
edges. Then I use viscous lidocaine (or Hurricane would
probably be more effective here) because I am just suturing such a
thin layer. I don't think injected lidocaine has much
of an effect on skin or superficial mucosa. (I don't
routinely suture little tears but sometimes a labial lac would
leave a ragged edge if left unsutured).
Before I use lidocaine, I use Cetacaine topical gel to numb the
area before an injection. Works great!
I've used the gel for years. Just dab it on the area to be
injected with lidocaine, wait about 3-4 minutes then you can give
the injection and the woman experiences less discomfort if any.
We drip a bit of lidocaine from the syringe on the spot we're going to inject, then wait a few minutes before giving the shot.
I like to use Cetacaine on hemorrhoids if they are painful during
I made a discovery several years ago that works very well prior
to suturing. What I was doing was pouring tea tree oil on
the wound before suturing to aid healing. What I discovered
was happening was that when I went to inject lidocaine the ladies
perineums were already numbed! Much to my surprise!
Now it's the only thing I use for just one or two stitches, and
always prior to injecting lidocaine. Ladies have also
reported that it feels great on hemorrhoids.
we use the same sort of method for anaesthetising the area but I have seen docs make multiple injection sites - ouch cant wait for their prostates to play up.
We have seen tears heal beautifully without any suturing. The tissues, if they "hang together" immediately after the birth, will heal together.
The main thing is that the mom has to make sure she does not sit
crossed-leg, or squat or do anything else, (like pulling it apart
to see if its healing!) to disrupt the healing process. It
really does work. We do not suture much at all.
Something that works as well, if not better for numbing is
Hurricane. It comes in several forms, and does s great job of
numbing things. Its available over the counter, though the
pharmacy had to order it for me. Comes in a gel and spray form. I
too like to use such things for the birth, as I think it allows
for better control.
“...personally, no, but then perineal massage and the use of oils at birth in general is not a 'big' thing here in the UK...”
Well, I am convinced that much of birth is mental and emotional, so I tell my ladies, esp the primips, that when it's time for the crowning, if they feel the burning it's *good* news, because it means that they haven't torn (otherwise, if they had torn, they wouldn't have as much resistance to cause the burning feeling--and I illustrate the burning by stretching out my mouth with 2 fingers).
BUT, I say, in addition to their bodies' natural anesthetic that the burning causes the brain to send to the perineum when the baby crowns, I will put on a bit of topical numbing medicine (viscous lidocaine) to take the pain away and which has the additional advantage of being slippery to help the baby slide out easily.
I don't know how much I believe any of this, but when I apply the
lidocaine, the ladies believe me, and it seems to help them
control the delivery so that I get about 80% of them out
intact. And many moms set themselves up for a
stitch-less delivery by reminding me in early labor that I'm
supposed to put that numbing medicine on when the baby comes out,
right? And I remind them that they can help by giving gentle
pushes then so I have time to do it, right? So I guess I
don't care if it's "really" true that the lido helps; the story is
a good one that seems to work even if it's total fiction!
One of the reasons that I prefer castor oil or olive oil is that
they are somewhat organic and have no chemical taste or smell to
be the first external sensory perception for the baby. I
wonder if Hurricane and Viscous Lidocaine (which I sometimes use
BTW, but I wonder anyway) have any effect on gag reflex or vision
(i.e. pupil dilation, like ocular anesthetics) etc? Does
anyone have any opinions? One local hospital doesn't allow
use of topical anesthetics by the CNM for this reason (or maybe
just for harassment?). I personally have never seen any
symptoms in the newborn that I thought was actually related to any
of this, but it is an interesting concept.
Well, this would be doubtful to me, but I couldn't prove it
either way. I don't use much and the baby I doubt ingests
much. Its not like I am rubbing it on the baby's face or in its
eyes. Just a small amount around the perineum. It makes for
great numbing following the birth, for the stitches.
With Rapidly Absorbed Material Best for Perineal Repair -
Lancet 2002;359:2217-2223. [Medscape registration is free]
Two-Stage Perineal Repair Has Advantages Over Three-Stage Repair [Medscape registration is free]
"The benefits of [polyglactin 910], confirmed and strengthened by this follow-up, reinforce our view that polyglactin acid-based materials should replace chromic catgut in the repair of perineal trauma," the researchers add.
I've used chromic for repairs since 1978, tried vicryl a few
years back under the influence of a doc who thought it was great.
( Yes, it makes lovely knots.) But then I noted I was picking a
lot of undissolved purple suture out of perineums...my own repairs
as well as others. In addition, I've begun first assisting on gyn
surgeries as well as C/Ss, and note the left over purple stuff in
a variety of tissues (recommended sites or not) from surgeries
years before. So, I'm back to chromic and would suggest it over
vicryl, but am open to suggestions and/or comments.
I use chromic for the exact same reason - it is out of the tissue
much sooner, and most of the lacerations I repair aren't extensive
enough to need suture hanging around for nearly as long as vicryl
does. I know chromic is supposed to be more irritating to the
tissue, but I haven't seen that as a problem with my clients.
Have to say that I'm a chromic fan myself. I find that it slides
nicely through tissue, and I don't have a problem with tying knots
with it. The OBgyn list just had a huge discussion on this,
wherein vicryl was compared to a "wire saw"...I tend to agree.
I've also seen vicryl not resorbing properly, and despite the
"evidence", I don't see that women heal with less pain with it.
One of my midwife teachers also feels that you get more of those
epithelial vaginal wall cysts with vicryl.
I prefer chromic for ease of suturing. Interestingly, the
Cochrane Database suggests only vicryl for repair.
My belief is that Vicryl is less inflammatory to the mom's tissues (hence less painful) but it does take forever to dissolve. I too have sometimes had to pluck out a few scraps at the 6 week visit, but I balance that against the comfort factor in the immediate postpartum period. Vicryl is a little harder to tie knots in, though! I have heard that there is a new form of Vicryl or Dexon that is more rapidly dissolving. Has anyone tried it?
I am also very fond of the suturing technique espoused by Nancy
Fleming CNM (see Journal of Nurse-Midwifery, 1/1990) which is a
single suture, continuous technique. I would love to hear form
some others out in the field if 1)you have tried this, and 2) what
do you think?
I am glad to hear that others prefer chromic to vicryl. I thought
I was just identified with something I had used for years and kept
trying to get used to the "new" stuff...I always reach for the
chromic and the vicryl gets deeper in the pockets of the birth
bag:-) I too have found it does not absorb as well as chromic and
is so sticky.
I am interested in your comments on Vicryl. I had heard that it
could take several weeks to break down but doesn't cause the
inflammation reaction that chromic does. The midwife I worked with
when I was in CNEP always used vicryl (I believe it is because she
is a vegetarian and uses no animal products) for the last 14 years
and never has noted any problems other than pieces of it coming
out sometimes weeks after birth. Because of working with her, I
learned to use vicryl, and liked the feel of it better than
chromic (reminds me more of quilting thread, I guess).
I have used nothing but vicryl for the last 15 years, (I was
taught to) but I have never seen any problem with it. I must say I
like it, it feels very nicely and it heals nicely too.
I have heard that there is a new form of vicryl or dexon that is
more rapidly dissolving. Has anyone tried it?) What do you think?
Yes, that is vicryl rapide. We use it for small tears. It
dissolves really quickly. But for an episiotomy I wouldn't
I've tried the new vicryl rapide also, didn't like the feel and
tried using 3-0 for an epis and the stuff kept breaking when I
tried to tie it. I agree with what everyone else has said about
vicryl, I use it for repair of anything more than 1st degree, tell
people to expect it to still be there in six weeks but have found
not nearly the tissue reaction that chromic causes. I heard a neat
story about why it's purple, seems that the original polyglycolic
acid that it was made from was made from grape husks, therefore
had a purple color, don't know if it was just salesman BS or not!
Well, I'm not an expert, but I would say it is salesman BS as you
can get the vicryl dyed or undyed. The reasoning here was so that
you can see your suture as you go.
Yeah, the only thing I like about vicryl is that it's so easy to
distinguish from pubic hair when your light source is a flash
From Skinstitch to GluSeal® - they have a nice tutorial.
Or maybe they changed the name back? The following was from
SS-2ml Skin Stitch Adhesive Dermabond equivalent [2ml (10 per box), 5ml (10 per box), $179.84] - SkinStitch® is the world's finest liquid bandage. Its primary use is to cover small cuts, scrapes, burns, and minor irritations of the skin and help protect them from infection
comparing enbucrilate tissue adhesive with conventional sutures.
Bowen ML, Selinger M.
Int J Gynaecol Obstet. 2002 Sep;78(3):201-5.
"Results: Patients treated with enbucrilate were found to have
significantly less postnatal pain while walking, became pain free
in a shorter period (mean=25 days vs. 18 days; P<0.01) and were
able to resume pain-free intercourse sooner (mean=34 days vs. 52
days; P<0.001). Conclusions: Tissue adhesives incorporate the
qualities of an ideal skin-closure material. The results
demonstrate their advantage over the current standard suture-based
methods of repair in the perineum. The use of adhesives merits
A good discussion of
Tissue Adhesives for Laceration Repair During Sporting Events
Quinn J and Kissick J
Clinical Journal of Sport Medicine (1994) 4:245-248
Physicians covering sporting events are often required to repair
lacerations. Traditionally these lacerations have been sutured.
Some of these lacerations may be closed with a tissue adhesive.
Tissue adhesives have been available for many years. The benefits
and potential problems of these substances are discussed as well
as proper wound selection and application.
TIP - When using SuperGlue on the outside, it makes sense to have
the mom hold her legs TOGETHER, so the tissue approximates
naturally. Then you don't need to hold the tissues together
or try to bridge the gap. Depending on the mom's physique
and flexibility, she may be able to have her feet apart with her
knees together and bent, so you can see the perineum with the legs
Fabulous collection of information on Suturing
& Knot Tying from Moondragon
The new SuperGlue approved for human use is Dermabond:
1-877-DERMABOND. Ethicon's site includes their Wound
Manual and Knot
Super Glue for Repairing Tears
First do a thorough exam to determine the extent of the tear.
Then we are off to informed consent. The decision about who, what,
when, where, why and how the tear will be repaired Must be
meticulous. Then, clean the wound, dry the tissues after placing a
piece of gauze into the vagina just deep enough to absorb the
lochial flow and keep the perineal area dry. Air drying is ok but
a hair dryer is great. Approximate the edges of the tear and apply
the glue to either side of the tear and then after pulling the
sides together, put on one or two more strips to meld it all
together. The strips are thin, not globby! The perineum should be
monitored very closely, glue reapplied if there is separation. The
glue falls off as a plaque some days later,. It is even more
important for the mom to be clean, off her feet, no stairs or car
rides, and no tailor sitting. The edges of the tear will not heal
properly if the edges are pulled apart. The best healing takes
place with any alternative, with mom in bed cuddling and nursing
that new baby!
Just ran across a synopsis of an article from Pediatrics
1996:98:12-14. Some peds emergency depts did a study comparing
suturing to Histoacryl Blue (a type of superglue) in repairing
pediatric lacerations. There were 30 kids in each group. Time
involved in repair was 7 minutes with superglue as opposed to 17
minutes for suturing. Pain during repair was significantly less
with superglue and the parents were quite impressed! And, photos
the the wounds before and after closure (at 1 wk and 2 months
follow-up visits) were assessed by 2 plastic surgeons who were
blinded to method of repair. They declared similar or better
healing outcomes with superglue. Additionally, because superglue
peels off spontaneously in 5-8 days, there is no need for suture
First of all, the tear needs to be fresh, clean, and fairly
shallow with straight edges that lie together on their own. The
glue is applied to bridge over the closed edges, not inside on raw
surfaces. (Covering the raw surfaces with SuperGlue could actually
PREVENT the surfaces from knitting together!) Insert a
tampon first and insert your finger between the edges and pull it
out to bring the edges forward slightly. This ensures that edges
won't roll inward toward each other, but meet perfectly. You could
also use a tissue forceps for this. Hold gauze below apex to catch
any drips and apply tiny dots of glue sparingly where the edges
meet. You can also apply a bead of tiny droplets to bridge the
edges. Use a hair dryer or fan to dry, which takes about 30
seconds. The adhesive stiffens as it dries and prolonged soaking
isn't too good for it. It will flake off by itself in usually less
than a week. Some rare allergic reactions are inflammation and
swelling. I learned everything I know about this from one of my
favorite teachers, Anne Frye.
I've just seen the 10 day pp results of my first attempt with supergluing a laceration. She did not want sutures, but wanted to do something about it, so the husband went out and got some OTC superglue. Worked great. Too great. Superglued my glove to her pubic hair, then a gauze pad to her thigh. It does dry as immediately as it does when using it for other things. I was amazed at how it held in spite of the "wetness of the area." The "crusty" of the glued area fell off spontaneously at four days. It looks the same as if it had been sutured, except I do think it healed much faster. The mom is THRILLED, but she talks to a couple of other women who I assisted, one got sutured, one didn't and wishes she had....they want to know why I didn't superglue them!! ;)
I'm sold on the idea enough to try it again when it seems
appropriate. My current definition of appropriate is when I look
at the laceration and say, "Ooooh, if I only had some tape that
What is your reasoning for using the tissue paper? Is this so you
can't overdrip on the tissues?
Yes, it's all a control issue. I like to hold tissue edges
together in a nice apposition and I had too much trouble with
gluing my gloves to the repair. Then the repairs would pull apart
as I struggled to get free. When I soak a tissue, though, and then
glue my glove to the tissue instead, I can pull my glove away, the
tissue tears, and I'm free without disturbing the repair.
Would it work to superglue the perineum after suturing the
vaginal vault?? I ask this because it seems less painful.
Considering the vault has no nerve endings, I would assume that
you could repair without anesthetic or undue pain for the client.
Possible or not ???
I've never used super glue. Do you think that a first degree would heal just as well without it? I'm afraid that I might make the situation worse if I got glue in a place that kept the would edges from healing together. Could you elaborate?
I do use super glue for 1st degree tears, the gaping kind you
look at and say, "Geez, if I could only tape it together for a
week." It works wonderfully!!!! I have been
considering making it part of the birth supplies list that parents
have to acquire...it won't go to waste. They can always use
it around the house, and it only costs $2. I do carry the
medical super glue, but it is significantly more expensive, and
there are times when I run out, and I like to know it's on hand
with the parents.
I get medical super glue from a vet supply house (Jeffers). I think I remember that it has somewhat of a different chem composition...I can't remember exactly what it is, but it's documented somewhere. Honestly, I'm questioning if it's as effective, but generally, it's ok, and I strive to use it more frequently. It is tinted light purple which makes it easier to visualize. It comes with tiny pipettes, so that you can use the same bottle for multiple people. I have no problem, however, with using OTC super glue. There was an article written somewhere QUESTIONING (not proving) if super glue would burn tissues. That has not been my experience. The women do not feel it at all.
As I said, I use super glue for the types of tears which are 1st degree and gaping...the kind that obviously will probably not heal well on their own because the edges are too far apart...the kind you look at and know that if the outside would just sit together, she might heal fine with nothing. The glue does just that...holds the outside together so the insides can heal (tears heal from the inside out).
The idea is not to put the glue into the raw part of the tear. The idea is to create a BRIDGE of glue across the outside surface of the skin (think "taping it together"). I have spilled glue onto the raw parts of the skin, and we have had no detrimental effects, but I can imagine that it would deter healing if those surfaces are coated. I place a fairly think bond, so that she can feel it (but not so thick that it easily peels off). That is part of the healing process for me...if she can feel it tugging when she assumes certain positions, it reminds her to be cautious. For most women, it falls off about day 5-8, just enough time to do its job (if necessary, we redo it). The first few times I used it, the women soaked daily, and the bond stayed intact. Then I started having a few come off (I went and redid it). They all approximated well in the end except one, but it was a hassle to have to go back and redo it. Now, I am experimenting with having women shower only, no soaks, and I have had NONE of the glue come off (but the glue didn't come off in the first few I did who DID soak, so that doesn't say anything). I just tell them it may decrease the likelihood that it will come off, and since these are women who are motivated to heal without large intervention, they agree it's worth it.
As far as holding it in place, I don't really. The super glue works on bottoms as it does on anything else...FAST. I have glued gloves to pubic hair, and I have had a few anuses that got glued shut when the glue dripped down...no big deal...we just clean it off and laugh about it. The glue's a little tough to work with at first, until you understand how it drips. I once found a newer type, a GEL super glue, and I loved it, but I haven't been able to find it lately. It was thicker, so it didn't run off as quickly. You learn to like certain brands with certain applicator tips.
I've had one client on whom it just did not hold...she was Japanese, though I can't imagine that has anything to do with it. I was amazed as I'd already used it several times with great success with other women, and it just would not adhere to her skin. She adamantly refused suturing completely. She did not heal well.
As far as ethics...well, primarily, my ethics start with me and the families I serve. When someone is refusing suturing but is amenable to super glue, it's more ethical to use it than not suture for a tear that needs approximation. I don't see it as a huge risk really. I know there is always the possibility it could become an issue, but as homebirth midwives, we do lots of things that aren't documented in medical literature, and hell, DOCS do lots of things that are not documented in literature (or are clearly documented as poor practice, but they do it anyway). I try to practice carefully, but I don't know of any midwife who does everything by the book...sometimes, the book just ain't written yet and we are ahead of the game! We can't make all our choices based on whether it's been tried and proven, because that is the only way things DO get tried and proven. Anne Frye wrote an article on it a few years back which I am sure one of our more "file-it-away" type midwives here would have.
Some ERs are using it for facial wounds on children, finding less scarring and quicker healing and significantly decreased emotional trauma (at least one study was done). It's a pretty old idea.
Bottom line, the clients LOVE it, and it works. They are so
thrilled with the results, and so am I. My birth asst had a
baby last month, and she opted for super glue. It fell off
at day 2 (she was up way too much), so we re-did it. It
worked great, and she is so excited to have learned first-hand a
midwifery trick that she can carry with her into her own practice
when she becomes a midwife.
I've now used super glue on two minor 1st degrees with excellent
I recently heard one OB say that it cannot be used on mucous
membranes...but au contraire.
I have used Nexaband for two 2 nd degree tears. Had absolutely
wonderful results. Both mothers refused any sutures.
I've used this stuff a few times, and really like it. It's
a snap to use. The way I purchased it, it came from a midwifery
supplier (bought at a MANA conference), with syringes so that you
could use the same bottle several times without contaminating
it. Just fill the syringes with how much you need (a little
goes a long way), then take off the needle (if you want) to squirt
it on the area to be repaired. I only use it for first
degrees (not quite sure I want to rely on it for a muscle repair),
that are a little more than superficial. It has worked quite
well, and the moms are very happy with it, since there are no
stitches or xylocaine involved. The "superglue" eventually
sloughs off once tissue starts healing back on its own.
The company I use the most, Revival, has 3 brands of skin adhesive. Vetbond 3ml #15-251 $12.25, Nexaband liquid 2ml
You can order a catalog. Phone is 800-786-4751 Website is www.revivalanimal.com
Business hours are M-F 7am-8pm CST and Sat 8am-4pm.
Medical superglue is great. The kind that has been approved for humans has a slightly different chemical composition than the veterinary superglue. I avoid the 3M brand (which I think is Vetbond), because it's exactly the same chemical comp as superglue. If I'm gonna just use superglue, then I'm going to pay superglue prices, not the more expensive vet product prices. Nexaband is a different comp except for one of their products which is the same as the Dermabond that is the human equivalent. Medical superglue has been used for years on humans, though I doubt they've ever done trials on perineal use. They're using it more and more on peds.
It is wonderful for first degree tears that need SOMEthing.
I agree that it's not the thing to do for muscle tears, since
those will shrink back and not often just heal without being held
together. The glue is not placed inside the vault; it's used
on the outside only. The ladies on whom I've used it have
been so happy to avoid suturing. The glue sloughs off in
about 6 days or so...they can even bathe with it. A few
times, I've had the glue fall off too soon, so I've just reapplied
it...usually, the women have admitted to picking at it or thinking
it was dried blood and pulled it off accidentally.
I know a midwife who cuts up a strip of gauze and uses medical-grade adhesive to glue it in place over the tear - kind of like an iron-on patch, but without the iron. It allows air and fluid to pass through nicely and stays in place for about four days.
ps --as to the question of WHY someone would glue rather than
suture: some women absolutely refuses stitches, many midwives are
legally prohibited from suturing, glued wounds don't sting as much
a sutured wounds when moms urinate, and surgeons report that glued
wounds heal very nicely and very quickly, probably faster than
But, I'll share a brainstorm I had a while ago.
Suppose we used the suture strips to approximate the tissues, but
secured the ends with super glue?!?
I tried this, and it worked terrifically. In fact, I've
tried it twice . . . the mom who kept her knees together had
beautiful results - the tear was healed perfectly by Day 6 . . .
the mom who was up and about had the strips come off on Day 4 and
had a panic that the tissues then were separated. They
eventually healed just fine, but it took longer as it had to fill
I find that the steri-strips anchored by Super Glue work really,
really well with women who have a lot of hair in the perineal area
. . . you're essentially gluing the steri strips to the hairs,
which holds much better than to the skin!
From Anne Frye's Healing Passage, 5th edition, p. 44.:
Tissue adhesive: In 1959, a variety of cyanoacrylate adhesives were developed, some types of which are now used for wound closure in Canada and Europe. Some midwives have assumed that retail cyanoacrylate adhesives such as Super Glue are identical to medical adhesives. However, retail products contain methyl alcohol because it is much cheaper to produce, and are manufactured to industrial, not medical, standards. Cyanoacrylates cure by a chemical reaction called polymerization, which produces heat. Methyl ester has a pronounced heating action when it contacts tissue and may lead to tissue necrosis during metabolism.
Medical grade products contain either butyl, isobutyl or octyl esters. They are bacteriostatic and painless to apply, produce minimal thermal reaction when applied to dry skin and break down harmlessly in tissue. They are essentially inert once dry and have been shown not to be carcinogenic. Butyl products are rigid when dry, but provide a strong bond. Available octyl products are more flexible when dry, but produce a weaker bond. Ideally the wound to be closed is fresh, clean, fairly shallow, with straight edges that lie together on their own. The glue is applied to bridge over the closed edges; it should not be used within the wound, where it will impair epithelization. The only FDA approved adhesives suitable for use as suture alternatives are veterinary products; n-butyl-cyanoacrylate tissue adhesives Vetbond (3M) and Nexaband liquid and octyl-based Nexaband S/C (intended for topical skin closure when deep sutures have been placed). Histoacryl Blue (butyl based) (Davis & Geck) and Tissu-Glu (isobutyl based) (Medi-West Pharmaceuticals) are sold in Canada for human use. DMSO (dimethyl sulfoxide) or acetone serve as removers. (Helmstetter, 1995; Quinn & Kissick, 1994)
Well, I disagree. Real-life experience (not theory) is that OTC superglue does NOT cause burns or tissue necrosis!! An awful lot of folks have posted here about using OTC superglues-- they haven't posted any experience of burns or necrosis, have they?
Anne's a friend of mine; but even the best of friends can disagree. We've both looked at the same information; we drew different conclusions
Also -- I'm very certain that Anne has never personally used
either surgical adhesive OR superglue. I think this is a simple
instance of over-emphasis on theory....
I disagree about the relative importance of using medical grade surgical glue.
While I agree that medical grade super glue is probably (theoretically) superior to the OTC stuff, I do have to defer to the real-life experience of a LARGE number of non-insured Americans who have been using OTC superglue for many years.
I first heard of it years ago from a woman who described how she treated a boy for shallow buckshot wounds. It didn't matter that the boy was an innocent bystander on a school play-yard - the family had no money to pay an emergency room medical bill. So the wounds were washed out -- EXTREMELY WELL!!!! -- and tacked with superglue. I was impressed with the healing when I saw it after a week or so....
Even the outlaws and other "fringe classes" all know the basics of selfgluing -- they make certain the wound is clean and leave a space open for drainage....
OTC superglue is classic folk medicine!
Used it for the first time at 2 of the most recent births I did.
It is SO fantastic!! I sutured with chromic gut in the interior,
then closed the exterior by dripping it criss-cross fashion over
the exterior. No pain (as outer stitches always hurt/I don't use
lidocaine) and it healed beautifully!! I am sold on it.
Nexaband wound closure "SuperGlue" cyanoacrylate
item #FACU $7.65 for a 2 ml tube w/extender applicators
Livestock/equine shoulder-length OB gloves (for waterbirth)
item #ATG2 $9.90 for a box of 100
There's a $5 service charge for orders under $50. If you order
for a group of midwives, you can order 2 boxes of gloves and 4
tubes of Nexaband for just over $50, to avoid the service charge.
Natural Alternative to Suturing by Denise Gilpin-Blake, LM,
CCE, CLE and Summer Elliot, SM, RN, BSN - from Midwifery Today
I read this article when it was first printed, and I have
reservations about it. Seaweed is known to speed tissue
healing, that I don't dispute. However, I cannot understand
how it is possible to repair second degrees with seaweed and no
suturing. The nature of muscle is to retract when lacerated,
and the severed ends don't reach out to find each other.
Muscle, in any knowledge I have about anatomy & physiology,
does not work that way; there has to be some force on the side
that muscle needs to go, and if there is no longer an attachment,
how can that happen? If anyone out there believes this to be
valid, please explain it. I can understand suturing second
degrees and using seaweed to speed up healing of that, but what
mechanism is at play to draw those two ends of lacerated muscle
together and hold them together if not sutured?
I also have doubts about using seaweed on second degree tears. I can totally understand the physiology of using the seaweed with first degree lacerations, but I have seen the results of far too many second degree tears which were not repaired at all, and even a third degree which left the mother with a huge rectocele. I have also had couple of moms with no remaining perineal body due to no repair of previous second degree lacerations. This is really negligence. Ignoring the severed muscle ends, or underestimating the extent of the laceration, and telling the mom to "keep her legs together" is not appropriate. The tissue will eventually heal, but the muscle integrity will be irreparably harmed. Those midwives who refuse to suture are doing these clients a great injustice if they do not transport for second degree lacerations.
But the seaweed does sound like a great idea for the first
In addition to the idea articulated above about using steri-strips with superglue on the ends to secure them in moist areas, you could also try the new
http: Closure Strips -- Stick With The Best
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