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Vacuum extraction

Analgesia
Cup selection
Cup placement
Safe deliveries cup package
Soft cup
Hard cup
Kiwi cup

Kiwi Forceps

Location of Flexion Point (3 cm in front of posterior fintanelle)


Holding & Inserting the Kiwi Cup
Maneuvering Cup Over Flexion Point
Create Vacuum & Exclude Maternal Tissue
Pulling Along Axis of the Pelvis

Bakri Ballon
This video is a 3-minute video showing step by step instructions for the ebb® Complete
Tamponade System for Treatment of Postpartum Hemorrhage. Postpartum Hemorrhage is
consistently one of the top three causes of maternal mortality and is often the leading cause of
maternal death; even in developed countries. Studies suggest that most bleeding deaths are
preventable. Early and proper intervention is key. A rapid-response system is critical. ebb
provides a complete tamponade solution to the emergency of postpartum hemorrhage.

Episiotomy

Overview
Published November 4th, 2019
In this chapter we will show you how to suture a mediolateral episiotomy.

We will illustrate two types of suture technique.

The consistent, continuous suture technique and a mixed suture technique.

The continuous suture technique is recommended within international guidelines as the


technique in which the least pain is experienced during the healing process.

This technique is described, amongst others, by Christine Kettle from Staffordshire


University in England in the scientific publication Lancet in 2002. It is also described in
international textbooks for midwives.

The inverted knot technique is a technique, which is used in other types of operations where
one needs to gather the tissue without stitching directly through the skin.

This mixed suture technique can for example be used if you prefer to support the anatomical
structures by using interrupted sutures instead of a continuous technique.
First-degree lacerations
Overview
Published October 28th, 2019
The following shows how a 1st degree perineal laceration is diagnosed, anaesthetised and
sutured. The same principals are shown using animations, medical models and real patients.

You can choose how you will view this by clicking on the icons on the top right. You can
find the headings for the different chapters on the right side of the homepage. You can also
click between chapters as needed.

Instruments
Published October 28th, 2019
The sterile preparation of a suturing set should contain: Needle holder. Surgical forceps.
Scissors. Swabs.

Record keeping
Published October 28th, 2019
The extent of the perineal tears must always be described in the patient medical notes. The
suturing and the suture material used must also be described. An example of a memorandum
about the suture of a 1st degree perineal tear can be:

A 1st degree perineal tear is diagnosed after a systematic inspection of the perineum.
Lidocaine gel is used for analgesia. The wound surfaces are assembled using two inverted
stitches. The suture material is Vicryl Rapid 3-0.

Animation
Published October 28th, 2019
In medical terms, the perineal lacerations are divided into degrees from 1-4. A 1st degree
perineal laceration is a superficial laceration on the vaginal mucosa or on the skin of the
perineum.

No muscles are involved in the laceration. If the surfaces of the wound do not fit together
symmetrically or if the wound is bleeding, it may be necessary to suture the tear.
Patient
Published October 28th, 2019
I now palpate the rectum to make sure that it is intact. I ask the patient to tense the pelvic
floor, as though trying to pass some wind. It won´t feel so uncomfortable now, as I carefully
insert my finger. The simplest method to assess if the pelvic floor muscles are intact is to
palpate them from both sides. The sphincter around the rectum appears to be intact, as I can
feel a ring of muscle tissue. 

Ask the patient to squeeze down here. I see that her muscles are functioning perfectly. The
sphincter also contracts fully, as part as a reflex to the touch. The patient has two minor
lacerations of the labia near the urethra as well as a slight laceration to the vagina.

I now select the appropriate anaesthetic before putting in a few stitches. 

Animation
Published October 28th, 2019
Pain relief must always be offered before the suturing commences.
With 1st degree perineal tears it is often sufficient to apply an anaesthetic gel, which is
effective within approx. 5 minutes.

Alternatively, small deposits of local anaesthetic can be applied directly to the wound
surfaces.

The skin is equipped with many nerve endings and is therefore extra sensitive to the touch
and needle sticks..

A local anaesthetic should therefore be applied just beneath the perineal skin by sliding the
needle into the tissue.

The needle is retracted while local anaesthesia is injected slowly into the tissue.

It is sufficient to use a few millilitres of local anaesthetic for a 1st degree perineal tear.

The local anaesthetic takes optimal effect within approx. 5 minutes.

Animation
Published October 28th, 2019
A 1st degree perineal tear is a superficial laceration and is therefore usually sufficient to use a
few stitches to assemble the wound edges.

The wound should be assembled without pricking in the skin, because the skin is very
sensitive.

The stitches can be inverted so that the healing process is not disturbed by the knot and thread
ends in the wound surface.

An inverted stitch begins in the depth of the laceration and the needle is brought out just
beneath the skin. Then the needle and thread are retracted through the tissue until there is
about 10 cm of short thread end in the bottom of the tear.

The opposite wound surface is pierced with a stitch which is equivalent to the first incision in
the opposite side. In this way, the wound surfaces are assembled and the knot is depressed in
the tissue.

The knot is now tied using two square knots. The first loop around the needle holder is a
double loop. The free end of the suture material is now pulled through the loops.

Note that the second loop is made in the opposite direction around the needle holder and the
short end of the suture material is now retracted 180 degrees in the opposite direction.

Now a surgical knot has been made, which is just as durable as a square knot. To ensure that
the knot is stable, one more square knot is made.

This time with two single separate loops around the needle holder. The suture material should
be cut approx. 1 cm from the knot.
An inverted stitch begins in the depth of the laceration and the needle is brought out just
beneath the skin. Then the needle and thread are retracted through the tissue until there is
about 10 cm of short thread end in the bottom of the tear.

The opposite wound surface is pierced with a stitch which is equivalent to the first incision in
the opposite side. In this way, the wound surfaces are assembled and the knot is depressed in
the tissue.

The knot is now tied using two square knots. The first loop around the needle holder is a
double loop. The free end of the suture material is now pulled through the loops.

Note that the second loop is made in the opposite direction around the needle holder and the
short end of the suture material is now retracted 180 degrees in the opposite direction.

Now a surgical knot has been made, which is just as durable as a square knot. To ensure that
the knot is stable, one more square knot is made. This time with two single separate loops
around the needle holder. The suture material should be cut approx. 1 cm from the knot.

It is not necessary to suture the perineal skin as the wound edges will spontaneously heal
symmetrically within a few days. From bottom to up.

Medical model
Published October 28th, 2019
A 1st degree perineal tear is a superficial laceration. It is therefore usually sufficient to use a
few stitches to assemble the wound edges. The wound should be assembled without pricking
in the skin, because the skin is very sensitive.

The stitches can be inverted so that the healing process is not disturbed by the knot and thread
ends in the wound surface.

An inverted stitch begins in the depth of the laceration and the needle is brought out just
beneath the skin.

Then the needle and thread are retracted through the tissue until there is about 10 cm of short
thread end in the bottom of the tear.

The opposite wound surface is pierced with a stitch which is equivalent to the first incision in
the opposite side.

In this way, the wound surfaces are assembled and the knot is depressed in the tissue. The
knot is now tied using two square knots.

The first loop around the needle holder is a double loop. The free end of the suture material is
now pulled through the loops.

Note that the second loop is made in the opposite direction around the needle holder and the
short end of the suture material is now retracted 180 degrees in the opposite direction.
Now a surgical knot has been made, which is just as durable as a square knot. To ensure that
the knot is stable, one more square knot is made. This time with two single separate loops
around the needle holder.

The suture material should be cut approx. 1 cm from the knot.

The knot is now tied using two square knots.

An inverted stitch begins in the depth of the laceration and the needle is brought out just
beneath the skin.

Then the needle and thread are retracted through the tissue until there is about 10 cm of short
thread end in the bottom of the tear.

The opposite wound surface is pierced with a stitch, which is equivalent to the first incision
in the opposite side.

In this way, the wound surfaces are assembled and the knot is depressed in the tissue.

The knot is now tied using two square knots. The first loop around the needle holder is a
double loop.

Note that the second loop is made in the opposite direction around the needle holder and the
short end of the suture material is now retracted 180 degrees in the opposite direction.

To ensure that the knot is stable, one more reef square is made. This time with two single
separate loops around the needle holder.

The suture material should be cut approx. one cm from the knot.

It is not necessary to suture the perineal skin as the wound edges will spontaneously heal
symmetrically within a few days.

Animation
Published October 28th, 2019
Alternatively, an uneven wound surface can be sutured with a continuous suture. Begin with
an inverted knot at the bottom of the laceration near the anus.

Optimally a secure knot is achieved by making two square knots on top of each other. First
make a double loop around the needle holder followed by three separate, single loops.

Note that the short thread end is pulled in the opposite direction for each loop. The suture
material should be cut approx. one cm from the knot.

Continuous stitching is now used to gather the subcutaneous tissue, just beneath the perineal
skin.
Each stitch must have an ample quantity of substance so that the thread does not subsequently
slide out of the tissue.

When the thread is tightened the wound surfaces will be drawn symmetrically towards each
other. The continuous suture can be completed with an Aberdeen knot in the vaginal mucosa.

This knot is made by making a noose with the long thread end. The short thread end is used
to bind three knots on top of each other. This is completed by pulling the short thread end
through the noose to position the knot.

The suture material should be cut approx. 1 cm from the knot.

It is not necessary to suture the perineal skin as the wound edges will spontaneously heal
symmetrically within a few days.

Medical model
Published October 28th, 2019
Alternatively, an uneven wound surface can be sutured with a continuous suture. Begin with
an inverted knot at the bottom of the laceration near the anus.

Optimally a secure knot is achieved by making two square knots on top of each other. First
make a double loop around the needle holder followed by three separate, single loops.

Continuous stitching is now used to gather the subcutaneous tissue just beneath the perineal
skin. Each stitch must have an ample quantity of substance so that the thread does not
subsequently slide out of the tissue.

When the thread is tightened the wound surfaces will be drawn symmetrically to each other.
Continuous stitching is now used to gather the subcutaneous tissue just beneath the perineal
skin. Each stitch must have an ample quantity of substance so that the thread does not
subsequently slide out of the tissue.

When the thread is tightened the wound surfaces will be drawn symmetrically to each other.

The continuous suture can be completed with an Aberdeen knot in the vaginal mucosa. This
knot is made by making a noose with the long thread end. The short thread end is used to
bind three knots on top of each other.

This is completed by pulling the short thread end through the noose to position the knot. The
suture material should be cut approx. one cm from the knot.

It is not necessary to suture the perineal skin as the wound edges are aligned and the wound
will heal spontaneously within days.
Healing
Published October 28th, 2019
The woman should be encouraged to keep the wound area clean by regular rinsing with tepid
water several times a day during the first week postpartum.

A stinging sensation during micturition and perception of some pain from the wound area is
normal during the first weeks after vaginal delivery.

The woman should be informed that the suture material will dissolve in one or two months
and that it is not necessary to remove the thread.

The healing of the wound will be complete after about one week. and sexual activities can
commence when the woman is ready.
About suturing minor perineal tears
Odijk R, Hennipman B, Rousian M,et al. MOVE-trial: Monocryl® vs. Vicryl Rapide™ for
skin repair in mediolateral episiotomies: a randomized controlled trial. Pregnancy Childbirth.
2017 Oct 16;17(1):355.
Seijmonsbergen-Schermers AE, Saloomeh S, Lucas C et al. 
Nonsuturing or Skin Adhesives versus Suturing of the Perineal Skin After Childbirth: A
Systematic Review. April 2015. Birth. DOI: 10.1111/birt.12166

Gordon B, Mackrodt C, Fern E et al. The Ipswich Childbirth Study: 1. A randomised


evaluation of two stage postpartum perineal repair leaving the skin unsutured. Br J Obstet
Gynaecol. 1998; 105(4):435-40.
 
Glue as an alternative to sutures
Feigenberg T, Maor-Sagie E, Zivi E et al. Using adhesive glue to repair first degree perineal
tears: a prospective randomized controlled trial. Biomed Res Int. 2014;2014:526590.
  
Mota R, Costa F, Amaral A et al. Skin adhesive versus subcuticular suture for perineal skin
repair after episiotomy--a randomized controlled trial. Acta Obstet Gynecol Scand.
2009;88(6):660-6.
  
Cochrane review: Repair or leave be
Elharmeel S, Chaudhary Y, Tan S et al. Surgical repair of spontaneous perineal tears that
occur during childbirth versus no intervention. Cochrane Database Syst rev. 2011 Aug 10;(8):
CD008534.
  
Research: Repair or leave be 
Langley V, Thoburn A, Shaw S et al: Second degree tears: to suture or not? A randomized
controlled trial. British Journal of Midwifery, 2006; 14 (9): 550 – 554.

Fleming V, Hagen S, Niven C. Does perineal suturing make a difference? The SUNS trial.
BJOG 2003;110(7):684-9.

Lundquist M, Olsson A, Nissen E et al. Is it necessary to suture all lacerations after a vaginal
delivery? Birth 2000; 27(2):79-85.
Second-degree perineal tears
Welcome
Published September 3rd, 2019
Welcome to the module on second-degree perineal tears.

This section explains how second-degree tears are anesthetized, diagnosed, sutured and
healed.

This section is intended for student midwives and doctors in training, as well as for
experienced clinicians wishing to update their professional knowledge.

This section presents photos and videos that may appear offensive or violent for
nonprofessionals.

It is therefore important that you view this section in discrete surroundings. 

Learning objectives
Published August 21st, 2019
GynZone has three specific learning objectives in this section, focusing on the diagnosis and
treatment of second-degree perineal tears.

Learning objective 1: Diagnosis involves rectal examination. The goal is that you always
perform a rectal examination as part of a systematic inspection for potential genital trauma or
perineal tears. Rectal examination is the only way you can rule out involvement of the
sphincter muscle or that defects have occurred between the rectum and vagina.

Learning objective 2: Using instruments to establish an overview. The goal is that you know
how to use a series of instruments to establish an overview over a perineal tear. This
overview gives you the best conditions for a correct diagnosis and therefore also for ensuring
that the woman receives the right treatment.

Learning objective 3: Suturing must restore the anatomy. There are both theoretical and
practical advantages and disadvantages associated with different suturing techniques. In
practice, the goal is to select the suturing technique based on how you can best reconnect the
tissue, focusing on the superficial muscles in the perineum.

We will therefore show you examples of several different suturing techniques. We hope you
enjoy this learning experience.
References and guidelines
Published August 22nd, 2019
GynZone's e-learning teaches the professional treatment of genital trauma and perineal tears.

Our recommendations are based on existing evidence from clinical research projects.

Where clear evidence is still lacking, we present the experience of specialists based on many
years of clinical practice.

If you are interested and would like to learn more, you can see an overview of recommended
literature in the References section.

The reference section includes references to guidelines from professional organizations,


overview articles from Cochrane and direct references to randomized trials.

In England, the Royal College of Obstetricians and Gynecologists (or RCOG) has specified
the classification of perineal tears in the guideline for handling injuries of the sphincter
muscle.

The English NICE guideline "Intrapartum care for healthy women and babies" includes
national guidelines for diagnosing and treating second-degree perineal tears.

Most hospitals have also established regional and local professional guidelines, and you are
required as an employee or student to follow the local guidelines.

You can find the latest studies in a database such as PubMed. Improved treatment is
continually being researched, also bringing new evidence.

If you wish, you can also follow ongoing research and completed studies at
www.clinicaltrials.gov.

Skill training
Published August 22nd, 2019
Suturing is a clinical skill that you will master through practical training. Workshops are a
good way to train. A more experienced student or a competent colleague can supervise.

You can practice handling the instruments, knotting techniques and different types of sutures.
In Scandinavia, we have had good results in suturing workshops using simple and
inexpensive suture training simulators.

Training on a suture training simulator lets you simulate a given procedure without involving
an actual woman.

Once the student has mastered the technique, for example by suturing a second-degree tear on
a suture training simulator, they can continue on with simulation exercises and use them in a
birth room.

Another student can lie down with the suture training simulator between their legs to play the
role of the woman. This enables the student to learn to suture in a realistic environment in
which they have to prepare the operation, take out materials, interact with the "woman" and
work using sterile methods.

Communication with the woman is also an important learning objective. The person playing
the role of the "woman" can often help with feedback on the experience of "receiving
stitches." The student will then be ready to suture a woman with close supervision by an
experienced clinician. Working with systematic checklists can be a practical tool for
expressing the skills and competencies.

Authors
Published August 22nd, 2019
This material is subject to copyright and is the property of GynZone ApS in Denmark. If you
wish to quote e-learning material in a written presentation, this is done as follows:

Kindberg, Bek, Glavind-Kristensen, Tietgen. Second-degree perineal tears. E-learning from


GynZone and with the URL as shown. The date for searching must also be included, e.g.
2019-03-04. These are the authors of the e-learning section on second-degree perineal tears:

Midwife Sara Kindberg, MHS, PhD. Sara works as a clinical specialist in genital trauma and
perineal tears. She wrote her PhD thesis on suturing of second-degree perineal tears in 2008.

Senior consultant and associate professor, Karl Møller Bek, PhD. Karl works as a
urogynecologist and is an international specialist in the reconstruction of sphincter injuries.
He wrote his PhD thesis on the diagnosis and treatment of third and fourth-degree perineal
tears in 1993.

Senior consultant and associate professor, Marianne Glavind-Kristensen, PhD. Marianne


works as a urogynecologist and is a specialist in the reconstruction of severe perineal tears.
She wrote her PhD thesis at Aarhus University in 2001.

Midwife Julika Tietgen. Julika works as a midwife and specializes in the healing of genital
trauma and perineal tears.

We perform clinical obstetric and gynecological work at Aarhus University Hospital in


Denmark. Our interdisciplinary focus is to optimize the anesthetization, diagnosis and
suturing of genital trauma and perineal tears.

We also perform academic work, guiding students at Aarhus University. We have published a
series of articles in international peer reviewed journals such as the BJOG.

Since 2013 we have also conducted a screening program for all women giving vaginal birth
at Aarhus University Hospital. We check their stitches 2–3 days after birth. If the stitches
have failed, early resuturing is offered.

You can learn more about resuturing in GynZone´s healing and resuturing program.

We contribute to national work with guidelines on the prevention and treatment of genital
trauma and perineal tears such as in the Danish Society of Obstetrics and Gynecology.

Communication
Published August 22nd, 2019
This film shows examples of how the midwife informs the woman about the examination of
tears, and what she finds during the examination.

During this examination, it is always important to gain the woman’s consent for any of the
procedures that you perform during this time.

It is also important to explain the treatment you are recommending for the repair and to gain
consent for this as well.

“Now I will check you to see if there are any tears that have to be stitched. I've given you a
good anesthetic, so it should not hurt but you will still be able to feel my fingers, when I
examine you.... is it OK if I start now?

All right…. First, I'll check the labia… You have two small superficial tears on the inside of
the labia that need stitches so that they will heal quickly. Now I'll also check inside the
vagina….

There is about a 2 cm tear here. There is also about a 3 cm tear in the muscles in the tissue in
between.

My next step is to check your bottom. I always do this after a birth to make sure this part of
your body is fine. This requires me to insert a finger in there. Is it OK for me to do this?

And now try to tighten your muscles around my finger. That's good. None of your rectum or
bottom muscles have been damaged.

So, it's only the superficial muscles around the vagina that have torn. It is quite common for
these muscles to be torn during birth.

We always recommend that these tears be stitched because muscles don't grow back together
by themselves.

The tear will take about 14 days to heal, and most people don’t notice anything from the tear
after it has healed.

If you continue to feel pain or discomfort after this time, I recommend you speak to a health
care professional about it. This could be your family doctor or your midwife”.
Preparation
Published August 22nd, 2019
Before starting to suture, you should consider whether this is the right time to be suturing.
Immediately after birth, you have a unique opportunity to ensure the best conditions for the
first meeting in the new family and for the first breastfeeding.

For many women and their partners, it is not a disturbance if suturing is done as an immediate
extension of birth, as long as the woman is not in pain. However, for some families it may be
appropriate to delay suturing until the first breastfeeding is completed.

This will give the partner or another family member the opportunity to hold the baby if
necessary, during suturing. The woman must be positioned to give you the best possible
working conditions.

This is best ensured by using the lithotomy position. The woman will also find it comfortable
to be able to rest the legs in leg supports.

The area to be sutured must be clean. We recommend that you wash away any bleeding and
any residual feces from the birth with clean water before you place a sterile drape under the
woman. It is not necessary to disinfect the area of the wound.

The actual suturing can often be completed in 20 to 60 minutes.

However, the total treatment time includes anesthetization, onset time, diagnosis and possibly
a second opinion before suturing is started and can therefore quickly add up to 1 to 2 hours.

For both yourself and the woman, it is therefore best to plan your work based on the total
treatment time.

If you are also tired after a long shift, it may be a good idea to postpone suturing long enough
for drink of juice, for example, or to take a few minutes to use the bathroom.

You can even consider whether it would be best for the operation to wait for a rested
colleague to take over suturing. This may be necessary, for example, in the event of complex
obstetric tears.

Studies have shown that suturing can be postponed for 8 - 12 hours with no effect on the final
result. Of course, this assumes that hemostasis has been ensured and that the woman is
willing to postpone the treatment.

Analgesia
Published August 22nd, 2019
The objective of analgesia for the woman should be to ensure that she experiences the least
possible pain in connection with the diagnosis and suturing of a tear.

This is in part under consideration of the woman's experience and her ability to establish
breastfeeding.

But also, because it is easier to identify the muscles and fascia correctly when the woman has
received good pain relief.

Local anesthetic can effectively eliminate the pain of stitches with a needle, but it is not
always possible to eliminate the discomfort of being touched or the feeling when the suture is
drawn through the tissue.

Because pain is subjective, only the woman can evaluate whether she needs additional
anesthetic. A good tip can be to ask the woman about her experience of pain, such as with a
VAS scale.

You have various options for reducing the woman's experience of pain.

The physical closeness of her partner or a family member can help to reduce the experience
of pain. 

Music requested by the woman can have a distracting and calming effect.

You can also choose between different types of anesthetic, depending on what is available in
your labor ward.

The following are the most common forms:

Premedication, such as paracetamol and NSAID administered a half hour before suturing.

Nitrous oxide is an anesthetic the woman can administer herself. This has both a pain
relieving and calming effect.

Local analgesic gel that is spread directly on the wound surfaces. Local analgesic spray that is
applied directly on the wound surfaces.

Local anesthetic. This is also known as infiltration analgesic and is applied directly to the
tissue.

Pudendal block. The transvaginal pudendal block is placed with a tube through the vagina.
The pudendal block can also be applied directly through the skin. This is called a
transcutaneous pudendal block.

If the woman already has an epidural block it can be good to continue with that. A bolus of
extra medicine can also be administered via the epidural catheter.

For suturing a second-degree tear, it can be a good idea to combine several pain-relieving
methods, for example to offer nitrous oxide, Xylocain spray AND a pudendal block.
Be aware that different types of analgesic take different lengths of time to achieve a good
analgesic effect.

In pharmacological terms, analgesics have an onset time and a duration of action.

For example, a local analgesic spray often takes effect after just a few minutes. This is known
as the onset time of the medication.

The duration of action is roughly 20 minutes. After that the patient will experience slight pain
in the area.

If your suturing of a tear takes longer than the duration of action of the analgesic, you can
supplement with additional analgesic during the procedure.

So, you can "boost" an analgesic again with the same type of analgesic during extended
procedures.

If you are unable to achieve a level of pain relief that the woman finds acceptable, you should
call a colleague or consult with an obstetrician or anesthesiologist. You must work together to
find a better solution.

You can find more information in the section on analgesics in GynZone´s online e-learning.

You can also find specific videos there explaining the administration, effects and side effects
of the various types of analgesic.

Instruments
Published August 22nd, 2019
This video shows which instruments you will need as a minimum for suturing a second-
degree tear.

A needle holder. The needle holder has ridged surfaces in the section that secures the needle.
When the needle holder is locked, it is therefore well-suited to holding the needle in the
desired orientation.

Forceps. The forceps can be anatomical forceps. Anatomical forceps have small ridges on the
tips, which make them well-suited to holding the needle.

The forceps can also be surgical forceps. Surgical forceps have pointed teeth near the end and
are therefore especially well-suited to holding tissue.

Scissors. The scissors can have slightly curved blades to enable the thread to be cut without
damaging the tissue. The scissors therefore often also have rounded tips.

You should also have some gauze available. The gauze is used for wiping away blood from
the edges of the wound while you are suturing.
It can also be useful to have some other tools to improve your overview and the precision of
your work.

More information on this is given in Section "Establishing an overview."

Suture materials
Published August 22nd, 2019
In this video, you will learn about

Results and evidence from practice,

The properties of suture materials and

Needles and needle tips

A dissolving suture material can be made in such a way that it is absorbed over a given period
of time.

In technical terms, a suture product can be:

Fast absorbing

Standard absorbing

Or slow absorbing

In most labor wards, a standard absorbing suture product is used for repairing second-degree,
third-degree and fourth-degree postpartum tears and episiotomies.

The tissue involved in these tears will be muscles, fascia and/or vaginal mucosa.

A standard absorbing suture product is recommended because it can be assumed that this type
of tissue will need to be supported by the suture material during healing for at least 3 to 4
weeks.

A fast absorbing suture product is recommended for repairing skin and superficial tissue such
as the labia.

This is because skin and mucosa heal within a maximum of 1 week.

A Cochrane review from 2010 summarizes 18 randomized studies with over 10,000
participating patients.

The focus is the selection of suture material for second-degree tears and episiotomies.
The conclusion is that there is no difference between fast and standard absorbing suture
material for the following parameters:

Sutures pulling through tissue

Pain 3 days after birth

Pain 10 days after birth and

Pain during intercourse 6 and 12 months after birth

More women had to have stitches removed when normal absorbing suture was used.

The suture material can be a multifilament or monofilament thread.

A braided suture material is known as multifilament, because it is braided together from


multiple smaller threads.

In contrast, a monofilament suture consists only of a core.

It is easiest to tie stable knots in a multifilament suture product.

The quality of a suture material is described in terms of tensile strength and absorption.

The term tensile strength is used to describe the ability of the thread to hold the tissue
together over a given period of time.

Absorption describes the time until the suture material has completely dissolved in the body.

A standard absorbing suture material loses 50% of its tensile strength after approx. 21 days. It
can be anticipated that there is no remaining tensile strength after approx. 35 days. The
product will be completely absorbed by the body after approx. two months.

A standard absorbing suture product will often be violet. This is because violet is the easiest
color to see against red tissue such as muscle.

Examples of standard absorbable suture trade names are Vicryl from Ethicon and Novosyn
from B. Braun.

A fast absorbing suture material loses 50% of its tensile strength over approx. 5 to 7 days.
The suture material can be anticipated to have lost all of its tensile strength after 10 to 14
days and it will be dissolved in the body after one month.

A fast absorbing suture product will always be either white or colorless. This is because the
suture should not leave coloring dyes in the skin where it was sitting.

Examples of fast absorbable suture trade names are Vicryl rapid from Ethicon and Novosyn
quick from B. Braun.

The thickness of a suture threat is most often described by the American USP. USP is an
abbreviation for United States Pharmacopeia.

Thread thicknesses of either 2–0 USP or 3–0 USP are especially used for repairing tears.

You can always read more about the properties of the suture product on the package insert.

Needles are produced to be either straight or with different types of curvature. The curvature
describes the bend in the needle.

Semicircular needles are used for suturing tears. Semicircular needles are available in various
sizes.

The sizes are indicated on the suture package. The size of the needle should be such that you
are actually able to penetrate a sufficient depth of tissue with each stitch.

A needle with a length of between 30 and 40 mm is therefore well-suited for the vaginal
mucosa and perineal muscles.

A smaller needle of 20 to 30 mm is better suited for more delicate tissues such as the labia
and skin.

The tip of the needle must be appropriate for the tissue you are suturing.

Taper or taper point needle tips are most widespread for suturing postpartum tears. These are
formed such that they slide through the tissue well without leaving behind large channels.

Always use needle holder and forceps to handle the needle in order to avoid needlestick
injuries.

The needle is formed to be flatter exactly 1/3 of the way along the curvature from the thread
end.

The needle holder therefore grips the needle best at exactly this point. This gives you good
control of the needle during suturing.

Classification
Published August 23rd, 2019
In most of the world, perineal tears are classified in degrees 1, 2, 3 or 4, depending on the
anatomical layers involved in the tear.

This classification system is used by many professional organizations, including the British
professional organization for obstetrics and gynecology.

This system defines a second-degree tear as Injury to the perineum involving the perineal
muscles but not involving the external anal sphincter muscle.
The perineal muscles are the bulbocavernosus muscle and the transverse perineal muscle.

A second-degree tear therefore ranges from a small tear with partial involvement of one of
the superficial perineal muscles to a large tear involving both the superficial muscles and the
rectovaginal fascia.

It has been suggested that second-degree perineal tears be more precisely diagnosed in the
future by specifying the extent in the same way as is currently done for an anal sphincter
rupture. A suggestion for a more specific classification system could be as follows:

A degree 2a perineal tear involves only the bulbocavernosus muscle.

A degree 2b perineal tear also involves the transverse perineal muscle.

And a degree 2c perineal tear also involves the rectovaginal fascia.

Illustrations
Published August 23rd, 2019
This video provides an introduction to the diagnosis of second-degree tears.

A perineal tear is second-degree when the superficial perineal muscles are involved without
any tearing of the external anal sphincter muscle.

The superficial perineal muscles are the bulbocavernosus muscle and the transverse perineal
muscle.

This can be seen in the illustration, where the skin is transparent.

Prerequisite for correct diagnosis is that, as a midwife or obstetrician, you perform a


systematic inspection of the vulva, vagina, perineum, the external anal sphincter muscle and
the anal mucosa.

The perineum is the area extending from the entrance to the vagina down to the anus. The
perineal skin is most often torn in a second-degree tear When the muscle tears, it draws back
into the surrounding tissue. It will therefore appear as though the tear were opening up.

Visually, you will therefore often recognize a second-degree tear by the way it opens in a
heart shape, as the bulbocavernosus muscle draws up along the labia and the transverse
perineal muscle draws out to the side.

If you ask the woman to tighten the muscles of the pelvic floor, you will be able to see a
movement in which the bulbocavernosus muscle draws up along the labia without lifting the
perineum up towards the symphysis.

A vaginal tear will frequently also result in combination with perineal tears. You must always
identify the top point or apex of the vaginal tear.
The hymen forms the transition between the introitus and vagina and will therefore frequently
also be torn.

A systematic inspection also includes a rectal examination. Rectal examination is necessary


in order to determine whether the external anal sphincter muscle or the anal mucosa are
involved in the perineal tear.

Suturing of a second-degree tear must always be offered to the woman. Torn muscles do not
spontaneously grow back together and is therefore necessary to adapt them in order to restore
normal function.

This image shows 6 different second-degree tears. This is shown to illustrate the fact that
diagnosis can be difficult.

In the following section, you will see films showing the systematic inspection of a number of
different that have all been classified as second-degree tears. These illustrate the different
appearances of second-degree tears.

Second-degree tear
Published October 28th, 2019
This case is a regular second-degree tear. The scope of the tear is evaluated in a systematic
inspection.

First the labia are inspected on the outside and inside. There are no tears here.

The key anatomical structures are shown here to provide an overview. Urinary opening.
Right and left labia minora. Vagina. Perineum and anus.

The left hand is used to hold the vagina slightly open so that bleeding can be wiped away
with a piece of gauze in the right hand.

The tear in the vagina extends approx. 3 cm up along the vagina from the hymen and inward.
We use the fingers to identify the top point.

The top point of the tear in the vagina must be located because the suture must start above the
apex.

There is a perineal tear approx. 2 cm long from the vagina and down towards the anus.

There is still a roughly 1 cm section of intact skin over the anus. It is therefore the superficial
muscles, the bulbocavernosus and transverse perineal muscles that are torn.

A rectal examination must be performed to determine whether the anal sphincter muscle or
anorectal mucosa are (is?) involved.
The index finger is inserted in the anus. Use your index finger to carefully press the rectal
mucosa upwards to give you a better overview of the structures in the vagina and perineum.

Here you evaluate if the external anal sphincter muscle is intact by ensuring that there is good
intact muscle tissue from the base of the tear and down to the anus. Then remove your finger
again.

Overall, one can say that this tear has a heart shape. Second-degree tears often have this
appearance.

They form a well-defined "V" shape down towards the anus, and the bulbocavernosus muscle
is drawn back in the tissue up towards the vagina, so that the tear opens up in a "heart" shape
when you examine.

Intact perineal skin


Published August 23rd, 2019
This case is a second-degree tear beneath intact perineal skin. The photo shows the vulva and
perineum immediately following birth.

The perineal skin is intact, and this is therefore a tear that cannot be seen with the unaided
eye but is only evident in a systematic examination.

A transcutaneous pudendal nerve block has been placed in advance to prevent pain during the
inspection.

The vulva is first inspected with a small piece of gauze and with the fingers.

A small superficial tear is seen on the left of the labia minora. There is fresh bleeding from
the tear, and this must therefore be sutured to achieve hemostasis.

A superficial tear is visible on the right labia majora that extends further into the introitus.
The ends of the tear are pressed carefully aside to obtain a better overview of the full extent
and depth of the tear.

The tear in the introitus is lateral from the centerline and is directly behind the perineal skin.
It extends approximately 1.5-2 cm in depth.

This is the area where the bulbocavernosus muscle lies and it is therefore probable that this
muscle is involved.

This can be verified by palpating both sides of the tear where the ends of the muscle can be
felt.

The bulbocavernosus muscle extends around the vagina and tears in this muscle can therefore
also be lateral, as is the case for this tear.
Finally, a rectal examination is performed to ensure that no sutures have been placed through
the rectal mucosa.

The external anal sphincter muscle is palpated over the area from 10 o'clock to 2 o'clock.
There is good substance here and it is assessed that the external anal sphincter muscle is not
involved in this tear.

The full extent of the tear is seen here. This is a second-degree tear, as one of the superficial
perineal muscles, the bulbocavernosus muscle, is involved in the tear.

This is a small second-degree tear, as neither the vagina, the transverse perineal muscle, the
rectovaginal fascia or the skin are involved.

Rectovaginal fascia
Published August 23rd, 2019
This video covers the diagnosis of tears in the rectovaginal fascia. You will see videos and
photos of two different defects.

The rectovaginal fascia is a thin tissue structure lying between the vagina and the rectum. Its
function is to hold the intestine in place. Defects that are not sutured can therefore later
manifest as a rectocele.

The rectovaginal fascia can be recognized as a thin whitish structure. This image shows the
rectovaginal fascia in a tear, where the vaginal mucosa is torn down to the fascia. The fascia
is intact but visible in the image.

This video will now show how a defect in the rectovaginal fascia is diagnosed. The defect is
part of a second-degree tear beneath intact perineal skin. Suturing is performed in the
operating room because the woman was transferred for manual removal of the placenta
following delivery.

The obstetrician performs a rectal examination to assess the extent of the vaginal tear. The
rectal examination is a prerequisite for diagnosing potential defects in the rectovaginal fascia.

During rectal examination, you will notice a reduced resistance corresponding to the defect,
when you carefully lift the posterior wall of the vagina. Note in the video how the
obstetrician lifts the index finger and meets less resistance there.

She also palpates the area from the vaginal sides in the area where she suspects a tear in the
rectovaginal fascia. The tissue will be thinner in the area corresponding to the defect. The tear
in the rectovaginal fascia is marked to give you a better overview of the defect.

You will most often be able to visually recognize tears in the rectovaginal fascia as a
rhomboid form under the vaginal mucosa.
The following photos show another second-degree tear with a defect in the rectovaginal
fascia that has developed in the middle of a vaginal tear.

The edges of the vaginal tear are here. Inside this tear you can recognize a thin structure on
each side where the clinicians index finger is lifting the vaginal wall. These are the wound
edges of the rectovaginal fascia on each side of the defect.

This means that the vaginal tear involves both the vaginal mucosa and the rectovaginal fascia.
In this photo, the clinician has secured one edge of the wound. The wound edges in the tear in
the rectovaginal fascia are again marked to give you a better overview of the tear.

Perimysium
Published August 23rd, 2019
This case is a second-degree tear. This tear also involves a tear in the perimysium around the
external anal sphincter muscle.

By definition, this type of tear is classified as a second-degree tear, i.e. the tear involves the
perineal muscles but NOT the anal sphincter muscle. The photo here shows the tear
immediately following birth.

The area around the introitus and the hymen is clearly damaged.

The perineal skin from the vagina and down to the anus is also damaged.

When a tear has this extent, the bulbocavernosus muscle is involved.

The area further down towards the anus also involves the transverse perineal muscles.

And there is a whitish structure that appears to have been damaged, just above the intact
external anal sphincter muscle.

The actual anus is somewhat opened following a long period of pushing, and hemorrhoids
can also be seen around the anal opening. Now we examine closer by separating the tissue
with the fingers and wipe carefully with a piece of gauze.

In this video you can see that a finger is placed in the anus to press the structures in the tissue
slightly forward. The thick white tissue known as the perimysium is held with anatomical
forceps. The perimysium is also held on the other side with the forceps.

It is held in two places to show the top and bottom areas of the defect, which measures
roughly 2 cm. The finger is now removed from the anus and preparations are made for
suturing. The perimysium is identified and held with forceps on one side and the other.

Suturing is performed with a normal size 3-0 absorbable multifilament suture. The needle is
26 mm, so it is small and easy to handle.
The two sides of the tear are brought together, and the needle is drawn out of the tissue. Here
the suture is placed approximately 3-5 mm from the edge of the tear on each of the two sides
of the damaged perimysium.

When the two edges of the tear are brought together, it can be seen that the tissue is now
adapted well over the external anal sphincter muscle. A stable knot is now tied, and we hold
the suture from the first stitch up over the area so we can see the defect.

The tear in the perimysium has a rhomboid shape. If you find it difficult to see the defect, you
can use the suture from the first stitch to hold the tissue out to different sides. Here the suture
is held directly up, and the tear can be seen more easily.

There is no research to show what suturing technique is best for repairing the perimysium.
Here we choose to make a continuous suture with four stitches, because it goes relatively
quickly and leaves less suture material in the tissue than for individual stitches.

When suturing continuously, you can always use the suture to hold the tissue” up”, while you
are preparing the needle in the needle holder for the next stitch. Once the perimysium has
been evenly joined, the continuous suture is finished off.

Then the vaginal mucosa and the muscles in the second-degree perineal tear are sutured.

Edema
Published August 23rd, 2019
This video shows how diagnosis and suturing can be performed on women with significant
edema in their genital area after birth.

The photo shows a second-degree tear in a woman who has given birth to her second child.
The vulva is swollen here immediately following the birth.

The inspection reveals no tears in the labia minora. The tear extends into the hymen as can be
seen here. The vagina is not involved in the tear. A tear can be seen in the perineum that
extends from the introitus and approximately two cm down.

The tear stops above the anus, which can be seen here with hemorrhoids immediately after
birth and the pushing associated with the second stage of labor. It is assessed that the
bulbocavernosus and transverse perineal muscle are involved in this tear.

The external anal sphincter muscle is assessed to be intact. This is therefore a second-degree
tear. The photo here shows the result after primary suturing.

The tissue is swollen, making it difficult to reliably assess whether the normal structure has
been restored. For example, the hymen is still in the introitus after suturing, presumably
because of the edema.

The woman is then seen on the following day to assess the healing process. The tissue is no
longer edematous, and it is therefore easier to see that the skin has been correctly adapted.
The hymen is no longer in the introitus and good muscle substance is also noted on palpation.

This photo was taken to show that in rare cases, the tissue can be so edematous, that it is
impossible to assess the true extent of the tear.

To begin suturing in such a case would entail a high risk of the tissue not being correctly
adapted. The tissue will also often be difficult to suture. The tissue is often described as being
as soft as butter and the suture thread therefore slices through the tissue.

In these cases, it can therefore be necessary to postpone suturing until the edema has
lessened. Several studies show that suturing can be postponed for 8 - 12 hours with no effect
on the final result. Ice pads and medical treatment with an NSAID will help to reduce the
edema.

Positioning the woman


Published August 27th, 2019
You can improve access to your work area by the way you position the woman.

The image shows a woman in the lithotomy position for suturing. Her legs are in the leg rests
and she is relaxed with a pillow behind her neck.

In this position, the overview of the posterior wall of the vagina and access especially to the
lower area of the perineum is limited.

In this image, the woman is instead inclined with her head low and the legs lifted in what is
known as the Trendelenburg position.

When the woman is positioned in this way, the vulva is tilted at an angle and you have a view
of a larger portion of the posterior wall of the vagina and can also more easily reach the lower
area of the perineum.

Assistance
Published August 27th, 2019
It can be useful during suturing to have the help of an assistant who can hold the labia out to
the side. This gives you a better overview of the vagina and the perineum. This is shown here.

When the assistant holds the labia out to the sides, you a better overview of the vagina and
you also have your fingers free to inspect the extent of the tear.
Another advantage of suturing together with a colleague is, that you can continually evaluate
your stitches.

It is therefore good practice to work in pairs. This should be the case as a minimum if you are
inexperienced or if the tear is complicated.

Suture tampon
Published August 27th, 2019
Slight bleeding from the uterus immediately following delivery is normal. However, it can
impair your overview and can interfere with suturing. It can therefore be helpful to place a
suture tampon in the vagina.

A suture tampon is a larger piece of gauze that absorbs bleeding from the uterus. This
prevents frequent interruptions during suturing to wipe away the bleeding from the uterus.

The video shows how a suture tampon is placed. Note how the midwife applies exploration
gel and shapes the suture tampon. Both of these steps help to reduce discomfort in connection
with placement in the vagina.

A suture tampon can easily be forgotten and retained because it is not visible after placement
in the vagina. It is therefore a good idea to tape the string to the woman's leg as a reminder to
remove it after suturing is complete.

Traction suture
Published August 27th, 2019
Another method for obtaining a better overview during suturing is to place a traction suture.
The purpose of a traction suture is to obtain a better overview of the wound area and is
therefore not necessarily a permanent stitch.

A traction suture is useful for moving tissue to obtain an overview. This image shows a
traction suture placed in the bulbocavernosus muscle.

The thread is secured with a pean or Kelly forceps, and the weight of the pan pulls the stitch
slightly upward. This makes it clearly visible that a stitch also has to be placed below the
holding suture to ensure sufficient strength.

It is also easier to place the stitch when the tissue is lifted up with the traction suture.

This image shows another example of a traction suture used to move the tissue. This is a
second-degree tear behind intact perineal skin, where the person performing the operation has
placed a traction suture in the intact perineal skin.

Slight tension on this yields a significantly better overview of a tear which is otherwise
difficult to access.

A traction suture can also be used as a fixed point for a complicated tear, when it is difficult
to obtain an overview of the anatomical structures and where they need to be joined.

The image shows an example of such perineal trauma. This is an episiotomy involving the
vagina and the superficial perineal muscles, the transverse perineal muscle and the
bulbocavernosus muscle.

The wound area is asymmetrical, and it can be challenging to determine where it is best to
join it.

The same trauma is shown here with a traction suture indicating the point for the stitch to
restore the introitus.

This makes it easier to establish an overview and to plan where the suture should end and
how the wound surfaces have to be joined to restore symmetry in the tissue.

Allis forceps
Published August 27th, 2019
When a second-degree tear is repaired, it is important to join the superficial muscles, the
bulbocavernosus and transverse perineal muscle.

It can be difficult to reliably identify the individual muscles simply by looking, as they rarely
appear as clearly as in illustrations.

It is therefore advantageous to ensure by other means, that you have identified a muscle and
that it is the muscle you want to repair.

An Allis forceps can be useful for this. An Allis forceps has small teeth on the end that make
it possible to grasp the tissue, enabling you to identify and then hold the musculature.

The video shows how one end of the bulbocavernosus muscle is identified using an Allis
forceps.

Pull gently with the Allis forceps. Notice how the tension can be seen all the way around
where the bulbocavernosus muscle is located.

Now the same is done on the other side. And now both sides are pulled.

You can clearly see that the bulbocavernosus muscle has been identified on both sides and
can now be repaired.
Speculum
Published August 27th, 2019
It can be advantageous to use a speculum to obtain a better overview inside the vagina in
connection with diagnosis as well as suturing of complicated tears. A wide variety of specula
are available.

The speculum shown here is commonly used for the diagnosis and suturing of genital trauma.

Notice how the speculum is introduced from the side to reduce discomfort for the woman.

Only when the speculum is inside the vagina is it turned to expand the vaginal opening and,
in this case, to lift the anterior wall of the vagina. This gives you a good overview of the
wound area and the tear can be sutured.

The speculum has the drawback that you are dependent on an assistant who must stand in an
awkward working position to hold the speculum while you are suturing.

Another possibility is a Hegenberger speculum, which is designed for use in especially


complicated tears or for tears with a poor overview, such as in a severely overweight woman.

This speculum has the advantage that it remains in place and therefore does not require an
assistant to stand in an awkward working position to hold the speculum in place during
protracted suturing.

It will generally be more comfortable for the woman with a traction instrument that remains
in place, rather than that you repeatedly have to press the labia aside to reestablish an
overview.

This speculum presses both the anterior and side walls of the vagina aside and is therefore
also very suitable when it is difficult to obtain an overview of the tear.

Here you can see how you have a good overview of the posterior wall of the vagina after
placement of the speculum.

Animation
Published August 27th, 2019
This video shows an animation of how a second-degree tear can be sutured using a mixed
method. This method can be used in cases where, as a midwife or doctor, you assess that the
perineal rupture will be easier to see or will be repaired more anatomically correctly by
working with interrupted sutures.

If the vaginal tear is extremely deep, the rectovaginal fascia may have been torn. The fascia is
the strong whitish connective tissue between the vagina and the rectum. If the rectovaginal
fascia has been torn, it must be aligned with a separate suture before you suture the vaginal
mucosa.

Suturing is started in the vagina. This is because you have the best overview of the vaginal
tear before joining the perineal muscles.

The animation now shows how the tear in the vaginal mucosa is joined with a continuous
suture up to the edge of the hymen. One objective of suturing the vagina is to ensure
hemostasis.

The first stitch is placed in the vagina above the top point of the tear. This provides a good
anchor point for the suture to be placed and, theoretically, you can also prevent bleeding from
any vessel that may have come up in the tissue. The best argument is that the top point is
actually located.

The suture is secured with a stable knot; in this case with a surgeon's knot. You can learn
more about tying knots in GynZone's section on surgical skills. 2-1-1-1

The short end of the thread is cut approximately 1 cm from the knot. The continuous suture in
the vaginal mucosa is started here. Each stitch should include approx. ½ cm of tissue from
each side of the vaginal mucosa.

You should be able to see the needle the whole time you are suturing. By not inserting the
needle below the bottom of the tear, you can avoid inadvertently perforating the rectal
mucosa that is directly below the vagina.

You can place the stitches at intervals of approx. 1 cm. Suturing is continued with running,
continuous stitches up to the hymen.

The continuous suture is finished just before the edge of the hymen with a straight stitch. The
finishing knot shown here is an Aberdeen knot that holds just as well as two square knots tied
above each other.

The vaginal mucosa is now repaired, and now you can localize the superficial muscles in the
perineum.

If you use interrupted sutures to repair the superficial perineal muscles, it is often easiest to
first join the torn ends of the transverse perineal muscles. This is because you have the best
overview of this muscle before repairing the bulbocavernosus muscle.

The transverse perineal muscle is attached to the ischial tuberosity, which is 90 degrees out to
the side. If you pull on the muscle tissue with an Allis forceps, you can therefore see a
movement of the tissue out to the side, if you have correctly identified the muscle.

The animation now shows how the needle is inserted in the muscle end from one side of the
transverse perineal muscle. Then needle is then inserted in the muscle in the opposite face of
the tear.

The edges of the muscle can be joined as anatomically precisely as possible when the stitch is
placed in two steps.
Before tying the knot, you can check if the stitch has actually joined the two muscle ends
symmetrically. Pull the threads tightly together and check if the tissue has been joined
anatomically correctly.

Now two square knots are tied above each other (1-1-1-1). You can use either instrument
knots or handtied knots. This depends on how you can tie best and what you have practiced
during your training. The threads are cut approximately 1 cm from the knot.

It will often be necessary to join the transverse perineal muscle with two stitches. The
animation again shows that the needle is inserted in the two muscle ends separately.

This ensures that you include precisely the same amount of tissue with the needle in each
step.

Then tie two square knots above each other. Note that the square knot is tied by switching the
direction of each turn. When working with multifilament thread, it is recommended to tie two
square knots above each other to ensure a stable knot. The thread ends are cut approximately
1 cm from the knot.

The next step in repairing the perineum is to join the bulbocavernosus muscle.

This is the muscle that surrounds the vaginal opening and ensures symmetry and the
contraction function in the area of the introitus. If torn, the ends of the muscle will be drawn
up into the surrounding tissue.

It is therefore useful to localize the muscle by pulling on the tissue with an Allis forceps.

The animation again shows how the two muscle ends are pierced with the needle in two
separate steps. This ensures that you include precisely the same amount of tissue with the
needle in each step.

When you tighten the thread, you can assess whether the ends of the muscle have been
correctly joined. You can evaluate this by seeing if the introitus has been restored so that the
vaginal opening is joined as it was before delivery.

Then tie two square knots above each other. You can place extra stitches to ensure
anatomically correct joining of the muscles.

It will often be necessary to place two stitches to join the bulbocavernosus muscle.

You can now restore the superficial part of the perineum. The area just below the skin is
called the subcutaneous tissue, and you can align the edges of the tear with either a
continuous or interrupted suture.

Here you can see how the subcutaneous tissue can be joined with a continuous suture.

This shows how the knot is buried in the tissue with an inverted stitch. Cut the short end of
the thread approx. 1 cm from the knot. After making a continuous subcutaneous suture, turn
the needle around in the needle holder.
You can select a suitable small needle and a fast absorbing suture material to repair the
subcutaneous tissue.

When you use a continuous suture in the subcutaneous tissue just below the skin, it is
important that you include sufficient tissue in each individual stitch. Otherwise the thread can
tear through the tissue and the suture can pull out.

This suturing method is continued just under the perineal skin until you reach the area of the
introitus. Here you can complete the suture by drawing the needle from the subcutaneous
tissue up through the vaginal mucosa.

The woman will not experience pain from suturing in the vagina and you can therefore finish
off with a knot either before or just behind the edge of the hymen. The knot shown here is an
Aberdeen knot, which can be used to finish off a continuous suture.

Cut the short end of the thread approx. 1 cm from the knot.

It is acceptable if the wound has a gap of several millimeters in the edge of the skin when the
woman is in the lithotomy position. When the woman places her legs together, the edges of
the tear will be joined, and the wound will heal completely on the surface in a few days.

After suturing, you should palpate the rectum with your index or middle finger to ensure that
you have not inadvertently placed any sutures through the rectum.

If rectal examination shows that you have placed a stitch through the rectum, you must undo
the suture to remove this stitch in the rectum.

Patient
Published August 27th, 2019
This video shows how a second-degree genital tear can be sutured using a mixed method.

The trauma involves the vagina, the rectovaginal fascia, the bulbocavernosus muscle, the
transverse perineal muscle, the subcutaneous tissue and skin.

The selected suturing method is mixed. The vagina, the rectovaginal fascia and the skin are
repaired with a series of continuous sutures, while the perineal muscles and subcutaneous
tissues are repaired with interrupted sutures.

A rectal examination is performed with the non-dominant hand to obtain an overview of the
tear. A tear has formed in the rectovaginal fascia between the hymen and over the external
sphincter muscle.

The wound edges of the rectovaginal fascia are on each side of the tear. The rectovaginal
fascia is also repaired using a normal 2-0 absorbable suture.

The suture is first inserted through one side of the rectovaginal fascia here... followed by the
other side.

Note how the doctor includes approx. 3 to 5 mm of tissue on each side to ensure that the
suture does not subsequently cut and pull out through the tissue. The suture is secured with a
stable knot…. and the short end of the thread is cut.

Suturing is continued. The suture is now placed through the rectovaginal fascia on both sides
of the tear in the same step.

This is possible because the edges of the tear are directly adjacent to each other and because
the tissue is thin.

The fascia has now been repaired and the suture is completed. All suture manufacturers
recommend tying four times to ensure a stable square knot.

Note how the doctor has protected against a needlestick injury by locking the tip of the needle
facing the needle holder.

Suturing is started in the vagina. As the person performing the procedure, it is best that you
achieve a good overview of the vagina before you repair the perineal muscles.

The vagina is sutured with a multifilament 2-0 absorbable suture and a 36 mm semicircular
needle.

The tip of the needle is held with forceps to prevent the risk of a needlestick injury.

The suture is started here with a square knot using the one-hand method.

Your training will often determine whether you tie knots by hand or using instruments. There
is no difference in the final knot.

It can be challenging to suture vaginal tears because of the poor viewing conditions. It can be
helpful to have an assistant to hold the tissue aside. For more serious vaginal tears, it can also
be helpful to use a speculum to hold the area open during the operation.

The second suture is placed approx. 0.5-1 cm. after the first one. The tear in the vagina is
superficial in this location and the doctor therefore chooses to join both sides of the vaginal
mucosa in a single step.

However, it can often be advantageous to place the suture in the vagina in two steps, so that
each side of the vaginal tear is sutured separately.

This ensures that you include the same amount of tissue from each side of the tear and that
each suture is placed as precisely as possible.

Regardless of this, it is important that the needle always be visible in the bottom of the
vaginal tear, to ensure that you are repairing the vaginal mucosa to the bottom of the tear but
NOT below it.

If you go below the tear, you risk placing sutures in the rectum. The vagina is now repaired
up to the edge of the hymen with a series of continuous sutures that have not been tied off.

The suture is completed with a stable knot… and the ends of the thread are cut approx. 0.5
cm from the knot.

Now the vagina and the rectovaginal fascia have been repaired, and the next step is to repair
the perineal muscles.

If the perineal muscles are repaired with interrupted sutures, it can be advantageous to start
by repairing the transverse perineal muscle, as you have the best overview of this muscle
BEFORE repairing the bulbocavernosus muscle.

When the muscle tears, it draws back into the surrounding tissue. It can therefore be helpful
to use an Allis forceps to identify the muscle and draw the tissue out.

The video shows how the doctor first takes the transverse perineal muscle on one side. She
pulls the muscle slightly to verify that she has the transverse perineal muscle. The muscle is
taken in the same way on the other side.

The perineal muscles are sutured with a multifilament 2-0 absorbable suture and a 36 mm
semicircular needle. Note how the suture is placed in the muscle in two steps, first on one
side and then on the other.

This ensures that you have the same good amount of tissue from both sides of the tear. Buried
sutures are placed here.

This means that the first part of the suture starts under the muscle and goes up towards the
subcutaneous layer, while the other part of the suture starts from above and goes down under
the muscle.

When the knot is tied, it will therefore be buried in the tissue. The doctor waits to tie a knot in
this suture and instead cuts the needle from the suture and secures it with a pean. In this way,
she avoids closing up the area before the next suture has also been placed.

This increases the precision of the next suture. The suture is again placed in two separate
steps to gather the muscle ends from each side.

The needle is again inserted from the underside of the muscle and up to the subcutaneous
layer. On the opposite side, the needle is instead inserted from above on the subcutaneous
layer and down under the muscle. This forms a round suture in the shape of an "O," joining
the ends of the muscle together symmetrically.

The transverse perineal muscle has now been repaired and a stable knot is tied in both
sutures.

The bulbocavernosus muscle is now identified and taken on both sides with an Allis forceps.
Once you have the bulbocavernosus muscle, pulling lightly on the Allis forceps will result in
an upward movement corresponding to how the bulbocavernosus muscle goes up along the
labia.
The muscle is again repaired by placing the suture in two separate steps to join the ends. A
stable knot is tied…. and the ends of the thread are cut. The bulbocavernosus muscle has now
been repaired.

However, note that it will often be necessary to place two sutures in both the transverse
perineal muscle and the bulbocavernosus muscle.

The subcutaneous tissue is now sutured with a multifilament 3-0 absorbable suture and a 36
26 mm semicircular needle. This is done here with two subcuticular sutures.

The first part of the suture is placed in one side of the tear by inserting the needle in and back
out through the subcutaneous tissue.

The second part of the suture is placed in the opposite side of the tear. The needle is inserted
on the opposite side such that the suture enters and exits the tissue at the same points on the
two sides.

Then a stable knot is tied. A second subcuticular suture is placed above this suture and is also
completed with a stable knot.

The subcutaneous tissue has now been repaired.

If the remaining gap from the tear is no greater than half a centimeter, the skin can be left
unsutured.

However, in this case the doctor repair to repair the skin with a continuous intracutaneous
suture, as she assesses that the tear is still fairly wide. The skin heals quickly and can
therefore be repaired with a multifilament 3-0 fast absorbing thread.

Here the doctor secures the continuous suture with a subcuticular suture. The short thread is
cut, and the suture is continued above the first suture.

The needle is then turned, and the skin is repaired by placing sutures above each other a few
millimeters below the surface.

It is also important for this suture that you include a good amount of tissue in each stitch, as
there is otherwise a risk of the thread pulling out through the tissue.

In this method, the skin is closed from below and up towards the introitus without placing a
suture through the skin.

The muscle layer and the subcutaneous tissue are joined evenly and well, so the thread in this
tissue only has to hold against an even and superficial pull.

The suture is continued up to the introitus, where the needle is brought up from the
subcutaneous tissue through the vaginal mucosa.

The suture is completed with a knot above the mucosa. Placing the knot above the mucosa
and not between the edges of the tear prevents the suture from interfering with the healing
process. The tear has now been repaired and the skin exhibits a minimal gap.
Finally, a rectal examination is performed to ensure that no sutures have been placed through
the intestinal rectal mucosa.

Animation
Published August 27th, 2019
This video shows a demonstration of how a second-degree perineal tear can be sutured by the
continuous method.

Investigations comparing the continuous and interrupted methods shows that the continuous
method takes less time and uses less suture material. The disadvantage with the continuous
method is, that you cannot secure each individual stitch during suturing.

If you have to undo a stitch along the way, this requires that you open the entire suture. A
continuous method is therefore primarily suitable for a completely normal second-degree tear
or if you are highly experienced.

Start the suture with a knot above the top point of the tear in the vagina. Leave a thread end
of approx. 10 cm in the vagina so that you have something to tie the first knot with.

Making two turns around the needle holder for the first part of the knot makes a strong so-
called surgeon's knot, which also ensures that the knot lies flat against the tissue. You can
learn more about tying knots in GynZone's section on surgical skills.

Note that the first stitch is placed above the top point of the vaginal tear. This ensures a good
anchoring point for the suture to be placed. Theoretically, this can also prevent bleeding from
a vessel that may have been drawn up into the tissue.

The best argument is that you have ensured that you have actually found the top point. The
short end of the thread is cut approx. 1 cm from the knot.

The continuous suture in the vaginal mucosa is started here. Each stitch should include
approx. ½ cm of tissue from each side of the vaginal mucosa. You should be able to see the
needle the whole time while you are suturing.

You can place the stitches at intervals of approx. 1 cm. Suturing is continued with running
continuous stitches up to the hymen.

Place the last stitch in the vagina on the back side of the edge of the hymen, so that you
complete the suture without pulling obliquely on the edges of the tear.

It can be advantageous to secure the suture in the vaginal mucosa with a knot before
proceeding with the continuous suture. In this way it is not necessary to reopen the entire
suture, if you later elect to redo a single stitch.

The vaginal mucosa has now been joined, and the edge of the hymen is restored with the
stitch on the back side.

Now place a stitch from the inside of the edge of the hymen down towards the depth of the
tear and the muscular layer of the tear. It can be helpful to place one or two continuous
stitches in the tissue under the edge of the hymen in this area to restore substance in the
perineum.

You can also place the stitches as precisely as possible here by inserting the needle in one
side of the tear at a time. This makes it possible to better match each insertion of the needle
with the depth and position of the stitch.

Now it is time to focus on joining the muscles in the perineum.

A second-degree tear in the perineum involves the bulbocavernosus and transverse perineal
muscle. The bulbocavernosus muscle surrounds the vaginal opening and ensures symmetry
and the tightening function in the area of the introitus.

You can best ensure anatomically correct restoration of a torn muscle by identifying the two
ends of the muscle independently from each other and inserting the needle in two separate
steps. It is helpful to use an Allis forceps to identify the bulbocavernosus muscle on each side
of the tear.

When the bulbocavernosus muscle is joined, it is important to insert the needle deep into the
tissue to ensure good substance in the stitch and that the entire muscle is drawn out from the
underlying tissue.

You can place multiple continuous stitches in this area to ensure a strong connection and
anatomically correct restoration of the musculature.

If necessary, you can change the angle at which you insert the needle so that the direction
goes through a different part of the muscle fibers. When you tighten the thread, you can see
that the stitch in the bulbocavernosus muscle has joined the tear edges around the introitus.

The next step in repairing the perineum is to identify and join the transverse perineal muscle.

The transverse perineal muscle is a lateral muscle line between the bulbocavernosus and
sphincter muscles. You can locate the ends of the transverse perineal muscle a few mm below
the perineal skin in the area between the introitus and the anus.

We again recommend that you insert the needle in one side at a time so that each stitch is
placed as precisely as possible in both depth and placement.

The needle is first inserted on one side of the transverse perineal muscle. The opposite side of
the tear is also joined, and the needle is now close to the lowest part of the tear surface near
the anus.

The perineal muscles have now been joined. It can be useful to secure the suture in the
perineal muscles with a knot before continuing.

Finally, the superficial part of the tear is repaired. The first stitch must include approx. half a
centimeter of tissue in both depth and length of the needle insertion. Each stitch must include
a good amount of subcutaneous tissue to prevent them from pulling out.

Join the tear edges by a subcutaneous suturing method a few millimeters below the perineal
skin so that the highly sensitive layer of skin is not irritated by pulling suture material during
the healing process.

Continue continuous subcutaneous suturing under the skin from the tip of the tear up to the
introitus. The continuous suture in the subcutaneous tissue is now complete.

To ensure a good cosmetic result, continue the suture all the way to the top of the tear at the
transition between the perineum and the vagina. From the subcutaneous tissue, insert the
needle up through the vaginal mucosa to the outside of the edge of the hymen.

After this, a complete stitch is placed between the two sides of the vaginal mucosa. The
purpose of this stitch is to join any loose tear edges around the edge of the hymen.

When using a continuous suture, you can finish off with an Aberdeen knot. You can also
make two normal square knots. Cut the thread approx. 1 cm from the finishing knot.

A maximum gap of 5 mm between the tear edges is acceptable. When the woman places her
legs together, the edges of the tear will be joined, and the wound will heal in a few days.

After suturing, you should palpate the rectum with your index or middle finger to ensure that
you have not inadvertently placed any sutures through the rectum.

Continuous suturing
Published January 29th, 2020
This video shows how a tear in the rectovaginal fascia is repaired by continuous suturing.

The tear in the rectovaginal fascia is part of a high lateral vaginal tear approx. 10 cm in
length.

The tear includes the right minor labium, which is torn across. The challenge with high
vaginal tears is establishing an overview and room for suturing. To obtain an overview, the
doctor places a speculum to press the posterior wall of the vagina away from the tear.

He also uses two Duval forceps to secure the edges of the vaginal tear. Duval forceps are
well-suited to securing and moving tissue during suturing.

This image shows how the defect in the rectovaginal fascia is exposed when the assistant
draws the wound edges of the vaginal tear aside. The edges of the tear in the vaginal mucosa
can be seen here. Tears in the rectovaginal fascia are under the vaginal mucosa.

The tear edges of the rectovaginal fascia can be seen here. The yellow fat tissue behind the
rectovaginal fascia can be seen in the defect.
When yellow fat tissue is visible, it is certain that the rectovaginal fascia is torn.

Forceps is used to show how the rectovaginal fascia should be joined over the projecting
yellow fat tissue.

The rectovaginal fascia is sutured with a normal absorbable multifilament thread as


recommended in the guidelines.

There is no research yet regarding continuous or interrupted suturing in the rectovaginal


fascia. You can therefore join the fascia using the method you prefer and which you consider
to be well-suited to the tear you are repairing.

For larger defects in the rectovaginal fascia, many clinicians prefer the continuous method,
because it is relatively fast and because fewer knots have to be tied in the vagina.

The suture is started here. The doctor joins both sides of the rectovaginal fascia when starting
the first stitch.

This can be done because the defect is narrow and the tissue in the rectovaginal fascia is thin.

The thread is pulled through and is tied in a double square knot using the two-hand method.

This tear is so high up, the doctor starts the suture near the introitus. Instead of cutting the
short end of the thread, it is used to pull the suture down so that the uppermost part of the
defect can be seen. The next stitch is shown here, roughly 0.5 cm above the starting knot.

The stitch is divided up into two steps here to ensure correct alignment.

The bleeding can be wiped away with a piece of gauze and suturing continued.

Note how the fat tissue becomes less visible as the defect is closed.

After four stitches, the suture is finished with a double square knot using the two-hand
method. The ends of the thread are cut approximately 0.5 cm from the knot. The vaginal
mucosa and the torn labia were subsequently repaired.

Interrupted suturing
Published August 27th, 2019
This video shows how a minor defect in the rectovaginal fascia is repaired with two
individual sutures.

This is a case of a second-degree trauma behind intact perineal skin, involving the
bulbocavernosus muscle and the vagina. In addition to the vaginal tear, a small defect in the
rectovaginal fascia was also identified.

The woman is sutured in an operating room with epidural anesthesia, and a Foley catheter is
therefore placed.

The doctor has also placed a suture tampon in the vagina to minimize bleeding from the
uterus in the area being sutured.

There is no current research yet indicating whether interrupted or continuous suturing should
be preferred for the rectovaginal fascia.

As a clinician, you can therefore select the suturing method you are most comfortable with
and which you consider best for the tear to be sutured.

The available guidelines regarding suturing of the rectovaginal fascia recommend that they be
repaired with a standard absorbable multifilament thread.

The video shows the clinician performing a rectal examination in order to lift the vaginal tear
up in the work area.

A rectal examination provides optimal conditions to evaluate the scope of the vaginal tear and
to identify possible tears in the rectovaginal fascia. 

The rectal examination is performed using the clinician's non-dominant hand to leave the
dominant hand free for suturing.

The finger is lifted up towards the vagina, providing a much clearer overview of the vaginal
tear.

Defects in the rectovaginal fascia can be felt as a reduced resistance in the tissue between the
rectum and vagina, allowing the finger to slide up more easily.

The defect is pressed up in the suturing area. The suture is first inserted through one side of
the rectovaginal fascia and then the other side.

The defect in the rectovaginal fascia is marked to show it more clearly. Tears in the
rectovaginal fascia often form under the vaginal mucosa in the area between the vagina and
the rectum. The clinician now uses the first suture as a traction suture.

Instead of tying a knot to secure the suture, the thread is cut long, and the clinician's assistant
lifts it up as a traction suture.

The traction suture helps to give you an overview of the edges of the tear, therefore also
increasing precision for the next suture.

A stable knot is now tied in both sutures. Notice how the assistant pulls the intact perineal
skin down to give the doctor better access to the suturing area.

It can be helpful to have an assistant when suturing tears that are difficult to access. This
increases the precision of your work.

The tear in the rectovaginal fascia has now been repaired. The vaginal mucosa and the
bulbocavernosus muscle are then repaired.
Documentation
Published August 27th, 2019
When you are treating trauma, you must exactly document all information on the extent of
the tear, the selected suturing method and which suture material you used to repair the tissue.

You must also document that you have performed a rectal examination to assess for trauma to
the anal sphincter and to verify that there are no stitches through the rectal mucosa.

An example of a record for suturing of second-degree trauma could be as follows:

Inspection of the perineum revealed a second-degree perineal tear.

The anal sphincter muscle was palpated and assessed to be intact.

The rectovaginal fascia is also intact.

100 mg Xylocain spray was applied for surface analgesia. 100 mg lidocaine was then
administered as a depot in a pudendal block.

The vaginal mucosa was repaired with a continuous suture.

The perineal muscles were repaired with two individual sutures in the bulbocavernosus
muscle and the transverse perineal muscle.

The subcutaneous tissue was repaired with a continuous suture. The perineal skin was left
unsutured, as the faces of the tear are aligned and are symmetrical and adjacent to each other.

Suture materials used: Vicryl 2-0 for vagina and muscle tissue. Vicryl Rapid 3-0 for
subcutaneous tissue.

No sutures were placed in the rectum and good restoration of the perineum was verified by
postoperative palpation.

Good advice
Published August 27th, 2019
Before the woman returns home, you should ensure that she has understood the nature of the
tear. You should also ensure that she understands how the tear should be treated during
healing.

Women’s' understanding of the perineal anatomy varies widely, and it is therefore useful to
support your information about the womans's tear and your treatment with an illustration of
the vulva.
During the first week after delivery, the woman should rinse the tear with warm water several
times per day. This can be done in connection with urination, for example.

Burning pain during urination is normal the first few days. Slight pain from the tear area is
also normal during the first week after delivery. The woman can use an ice tampon to reduce
swelling and pain in the area of the tear.

If she requires pain medication, she can take 1 gram of paracetamol up to four times per day
over a shorter period and can supplement with an NSAID if necessary.

Explain to the woman that the suture material will have dissolved by itself over a period of
one to two months. If she notices irritation caused by individual stitches after 14 days, she
can have the thread removed by her own doctor.

Tears in the perineum normally heal quickly and most tears will have healed over the course
of two weeks. If the perineal skin has been joined by an intracutaneous or subcutaneous
method, the edges of the tear will take several days to close completely.

Second-degree perineal trauma will be completely healed after approx. two weeks. Over
these two weeks, the woman should rest several times per day and avoid bicycling, horseback
riding or other activities that stress the area of the trauma with direct pressure.

Healing
Published August 27th, 2019
Most genital trauma heals without complications over the course of approx. 14 days.

The healing of regular second-degree trauma is shown in the following images.

The images show the same woman on days 3, 7 and 14 following birth. Healing proceeded
with no complications.

This image was taken three days after birth. The skin has not yet healed, and the tear edges
are therefore visible with a gap of a few millimeters.

The edges of the tear extend from the area directly above the anus and up to the introitus. The
skin was repaired with a continuous suture in the subcutaneous tissue. This is why the ends of
the thread are only visible in the introitus where the suture was finished off.

This image was taken seven days after birth. The skin has now healed and only a tiny amount
of scar tissue that is still reddened is visible. The ends of the thread from the suture with a
fast-absorbing thread are still visible in the edges of the tear.

The last image was taken 14 days after delivery. It can be seen here that the scar tissue has
become whiter and is therefore hardly visible. The thread has now been absorbed and is
therefore no longer visible.
The muscle ends were repaired with a standard absorbable thread that will not disappear until
after 2-3 months. This thread is not visible since it is below the skin, but the woman can
experience the sutures "pulling" at the tear, when she moves.

In rare cases, problems can arise with the healing of second-degree trauma. This can be
caused by a suture pulling out, a hematoma or an infection in the tear.

GynZone has developed a specific e-learning module about complicated healing and the
opportunity to offer early secondary repair.

Rehabilitation
Published August 27th, 2019
The perineal muscles can be rehabilitated immediately after delivery, even during healing of
any tears. Trauma is therefore not a hindrance to starting pelvic floor exercises.

On the other hand, it does not hurt to wait a few weeks until the woman has the energy for
this. A good pelvic floor contraction involves the entire levator ani muscles and the
superficial perineal muscles.

The animation shows how these muscles combine to cause an upward movement from the
anus and toward the symphysis. A good pelvic floor contraction can be seen as a contraction
of the muscles around the vaginal opening and around the anus.

Contraction of the muscles is shown here for a woman seven days after birth. Note the
upward movement from the anus and up toward the symphysis.

This ability to contract the muscles will be weak for most women immediately following
birth. It will become stronger as the muscles and nerves heal.

The same woman is shown contracting the pelvic floor muscles after 14 days. The function of
the pelvic floor is activated more quickly and is also stronger. Individual instruction with a
midwife or a physiotherapist can help to ensure that the woman has correctly identified the
muscles and is training effectively.

GynZone has developed a pelvic floor exercise program for women who have given birth
within the past year. The program can be downloaded as an app.

Authors of this course

Midwife, MHS, PhD Sara Kindberg. Clinical specialist in tears. Sara works as a clinical
specialist in genital trauma and perineal tears. She wrote her PhD thesis on suturing of
second-degree perineal tears in 2008.

Senior Consultant, Associate Professor, PhD Karl Møller Bek. Specialist in reconstruction of
sphincter injuries.
Karl Møller Bek works as a urogynecologist and is an international specialist in the
reconstruction of sphincter injuries. He wrote his PhD thesis on the diagnosis and treatment
of third and fourth-degree perineal tears in 1993.

Senior Consultant, Associate Professor, PhD Marianne Glavind-Kristensen. Specialist in


reconstruction of perineal injury.
Marianne Glavind-Kristensen works as a urogynecologist and is a specialist in the
reconstruction of severe perineal tears. She wrote her PhD thesis at Aarhus University in
2001.

Midwife Julika Tietgen. Specialist in healing of perineal injury.


Julika Tietgen works as a midwife and specializes in the healing of genital trauma and
perineal tears.

We perform clinical obstetric and gynecological work at Aarhus University Hospital in


Denmark. Our interdisciplinary focus is to optimize the anesthetization, diagnosis and
suturing of genital trauma and perineal tears.

We also perform academic work, guiding students at Aarhus University. We have published a
series of articles in international peer reviewed journals such as the BJOG.

Since 2013 we have also conducted a screening program for all women giving vaginal birth
at Aarhus University Hospital. We check their stitches 2–3 days after birth. If the stitches
have failed, early resuturing is offered.
 
We contribute to national work with guidelines on the prevention and treatment of genital
trauma and perineal tears such as in the Danish Society of Obstetrics and Gynecology.

Reviews about suture technique and suture material

The Royal College of Midwives. Evidence Based Guidelines for Midwifery-Led Care in
Labour. Suturing the Perineum. London 2012.

Kettle C, Dowswell T, Ismail KMK. Continuous and interrupted suturing techniques for
repair of episiotomy or second degree tears. Cochrane Database of Systematic Reviews 2012,
Issue 11. Art.No.:CD000947.

Dansk Selskab for Gynækologi og Obstetrik. Sphincterruptur ved vaginal fødsel: behandling
og opfølgning. Sandbjerg Guideline 2011.

Kettle C, Dowswell T, Ismail K. Absorbable suture materials for primary repair of


episiotomy and second degree tears. Cochrane Database of Systematic Reviews 2010, Issue
6. Art. No.: CD000006.

National Institute for Health and Clinical Excellence (NICE). Intrapartum care - management
and delivery of care to women in labour. NICE clinical guideline 55, 2007.
 
 
Randomised studies on suturing techniques in repair of 2nd degree tears or episiotomies
Martínez-Galiano, J.M., Arredondo-López, B., Molina-Garcia, L. et al. Continuous versus
discontinuous suture in perineal injuries produced during delivery in primiparous women: a
randomized controlled trial. BMC Pregnancy Childbirth 19, 499 (2019)

Swenson CW, Low LK, Kowalk KM, Fenner DE. Randomized Trial of 3 Techniques of
Perineal Skin Closure During Second-Degree Perineal Laceration Repair. J Midwifery
Womens Health. 2019 Aug 21

Kokanali D, Ugur M, Kuntay Kokanali et al. Continuous versus interrupted episiotomy repair
with monofilament or multifilament absorbed suture materials: a randomised controlled trial.
Arch Gynecol Obstet. 2011 Aug;284(2):275-80. Epub 2010 Aug 1.

Valenzuela P, Saiz Puente M, Valero JL et al. Continuous versus interrupted sutures for
repair of episiotomy or second-degree perineal tears: a randomised controlled trial. BJOG;
2009; 116(3):436-4.

Kindberg S, Stehouwer M, Hvidman L, Henriksen T. Postpartum perineal repair performed


by midwives: a randomised trial comparing two suture techniques leaving the skin unsutured.
BJOG. 2008; 115(4):472-9.

Morano S, Mistrangelo E, Pastorino D et al. A randomized comparison of suturing techniques


for episiotomy and laceration repair after spontaneous vaginal birth. J Minim Invasive
Gynecol. 2006; 13(5):457-62.

Oboro V, Tabowei T, Loto O, Bosah J. A multicenter evaluation of the two-layered repair of


postpartum perineal trauma. J Obstet Gynaecol. 2003; 23(1):5-8

Kettle C, Hills R, Jones P et al. Continuous versus interrupted perineal repair with standard or
rapidly absorbed sutures after spontaneous vaginal birth: a randomised controlled trial.
Lancet. 2002; 359(9325):2217-23.

Grant A, Gordon B, Mackrodat C et al. The Ipswich childbirth study: one year follow up of
alternative methods used in perineal repair. BJOG. 2001; 108(1):34-40.

Gordon B, Mackrodt C, Fern E et al. The Ipswich Childbirth Study: 1. A randomised


evaluation of two stage postpartum perineal repair leaving the skin unsutured. Br J Obstet
Gynaecol. 1998; 105(4):435-40.
 
 
Randomised studies on suture material

Kokanali D, Ugur M, Kuntay M et al. Continuous versus interrupted episiotomy repair with
monofilament or multifilament absorbed suture materials: a randomised controlled trial. Arch
Gynecol Obstet. 2010 Aug.

Mota R, Costa F, Amaral A, Oliveira F et al. Skin adhesive versus subcuticular suture for
perineal skin repair after episiotomy - a randomized controlled trial. Acta Obstet Gynecol
Scand. 2009; 88(6):660-6.

Dencker A, Lundgren I, Sporrong T. Suturing after childbirth - a randomised controlled study


testing a new monofilament material. BJOG. 2006; 113(1):114-6.

Kettle C, Hills R, Jones P et al. Continuous versus interrupted perineal repair with standard or
rapidly absorbed sutures after spontaneous vaginal birth: a randomised controlled trial.
Lancet. 2002; 359(9325):2217-23.

Leroux N, Bujold E. Impact of chromic catgut versus polyglactin 910 versus fast-absorbing
polyglactin 910 sutures for perineal repair: a randomized, controlled trial. Am J Obstet
Gynecol. 2006; 194(6):1585-90; discussion 1590.

Greenberg J, Lieberman E, Cohen A et al. Randomized comparison of chromic versus fast-


absorbing polyglactin 910 for postpartum perineal repair. Obstet Gynecol. 2004;
103(6):1308-13.

Upton A, Roberts CL, Ryan M et al. A randomised trial, conducted by midwives, of perineal
repairs comparing a polyglycolic suture material and chromic catgut.Midwifery. 2002;
18(3):223-9.

McElhinney B, Glenn D, Dornan G et al. Episiotomy repair: vicryl versus vicryl rapide. The
Ulster Medical Journal 2000, 69(1):27-29.

Mackrodt C, Gordon B, Fern E et al. The Ipswich Childbirth Study: 2. A randomised


comparison of polyglactin 910 with chromic catgut for postpartum perineal repair. Br J
Obstet Gynaecol. 1998; 105(4):441-5.
 
 
Articles on suturing in the OB/Gyn field
Sanson C, Papin S, Pierre F, Gachon B. Perineal suture practices. Are they up to date with the
evidence based medicine data: A local experience into a university maternity?. J Gynecol
Obstet Hum Reprod. 2020;49(5):101634. 
https://www.sciencedirect.com/science/article/abs/pii/S2468784719302296?via%3Dihub

Meltem Aydin, Rathfish G.  2019. The effect of suture techniques used in repair of
episiotomy and perineal tear on perineal pain and dyspareunia. Health care for women.
published online 11. September 2019

Greenberg J, Clark R. Advances in suture material for obstetric and gynecologic surgery. Rev
Obstet Gynecol. 2009; 2(3):146-58.   

Kalis V, Stepan J, Novotny Z, Chaloupka P et al. Material and type of suturing of perineal
muscles used in episiotomy repair in Europe. Pelviperineology 2008; 27: 17-20.

Kindberg S, Stehouwer M. Syning af perineale bristninger og episiotomi. Tidsskrift for


Jordemødre 2008.

Third-degree perineal lacerations


Overview
Published November 18th, 2019
Welcome to the chapter on the suturing of 3rd degree perineal lacerations.

Preparation
Published November 18th, 2019
You should consider these different aspects before you start suturing.

Anaesthetics
Published November 18th, 2019
You should always offer effective pain relief to the woman before starting the repair.

Instruments
Published November 18th, 2019
In this video we will show you what instruments you need when suturing a third-degree tear.

Suture material
Published November 18th, 2019
In this video you will learn about different suture materials.

Anal rectal mucosa: absorbable synthetic product

Needle with blunt pojnt to repair Analrectal mucosa, any torn fascia, perineal muscles
Suture close to the skin tapped needle point

Multifilament material
3-0 – internal anal sphincter
2-0 - external anal sphincter
0-0 –

Antibiotics
Published November 18th, 2019
Medical opinions on the use of antibiotics vary between hospitals internationally.

3rd and 4rth degree OCOG – IV and orally for first 5 days (single dose of Broad spectrum
Cephalosporin showed benefits on a study i.i 1500 mg Cefuroxime IV at time of suturing)

Record keeping
Published November 18th, 2019
As a health professional, it is your duty to describe the extent of lacerations as well as
registering the treatment in the medical records.

Animation
Published November 18th, 2019
A third-degree perineal laceration involves the anal sphincter around the rectum. In this video
we go over how to diagnose a third-degree tear.

Medical model: sphincter


Published November 18th, 2019
This is a medical model showing a cross-sectional view of the female abdomen.

Inspection: perineum
Published November 18th, 2019
In this video we cover the examination of the perineum.

Wall measures 1 cm between vaginal and rectal mucosa


2 and 10 o’Clock

Patient: third-degree a perineal tear


Published November 18th, 2019
This video shows a clinical assessment of a third-degree perineal laceration type 3a.

Rectovaginal fascia, perimysium and external sphincter


Patient: third-degree b perineal tear
Published November 18th, 2019
This video shows a clinical assessment of a third-degree perineal laceration type 3b.

Internal anal sphincter white shinny appearance

Missed third-degree tear


Published November 18th, 2019
You can see an example here of how the woman squeezes when a third-degree tear has been
incorrectly sutured after delivery.

Animation
Anal repair – 3 stitches
Published November 18th, 2019
This video shows an animation of an end-to-end suture of the external anal sphincter muscle.

External sphincter circular striate muscle located beneath the skin around anal opening near
outer most few cm of the anal rectal mucosa

Covered by fibrous muscle membrane called perimysium

3 End to end technique- U suture – 0.5 cm within muscle tissue muscle fibers and
perimysium separated stitches (secure the loose thread ends using secure and stable knots – 2
reef knots on top of one another it’s the best knot for multifilamentar threads. 0,5-1.0 cm
from the knot

Medical model
Published November 18th, 2019
Here you can see how it is possible to gather the external sphincter using the end-to-end
technique, shown on a medical model.

Vertical Mattress suture longe longe perto perto


Patient
Published November 18th, 2019
This patient video shows how it is possible to repair the external anal sphincter with the end-
to-end technique.

Animation
Published November 18th, 2019
This animation shows how the external sphincter can be repaired using the overlap technique.
Secondary repair and primary suturing

Overlap suture:
- Entra em cima de um lado e sai embaixo deste lado
- Entra em cima do outro lado e sai embaixo do outro lado
- Entra em baixo do mesmo lado 2-3 mm do lado e sai em cima deste lado
- Entra embaixo do outro lado na frente e sai em cima do outro lado onde as pontas
vai ter o no

Medical model
Published November 18th, 2019
This video demonstrates how the external anal sphincter can be sutured using an overlap
technique. The demonstration is performed on a medical model.

Animation
Published November 18th, 2019
In this animation you can see that the three U-sutures close the edges of the internal anal
sphincter.

Internal anal sphincter is a thickening of the bowel’s lamina muscularis few mm thick and
approx. 2-3 cm long wide wrapped up around anal rectal mucosa internal.

Simple U suture

Medical model
Published November 18th, 2019
The video shows how the internal sphincter is gathered using 3 U-sutures on the medical
model.

Patient
Published November 18th, 2019
Here you can see a video demonstration of how the internal and external anal sphincter are
sutured on a patient.

Normal healing
Published November 18th, 2019
In this video we give you advice that can beneficial for the patient to know.

Recovery
Published November 18th, 2019
Postpartum pelvic floor muscle training can be commenced as soon as the woman feels fit for
it.

Complications
Published November 18th, 2019
In this video we look at some of the complications that may occur after suturing.

Secondary repair 2-3 weeks post partum

Subsequent birth
Published November 18th, 2019
The woman should receive specialist obstetrical care when planning a subsequent delivery.

5 fold increase from 1 to 5% on second birth if on first she had injury 95% of not
experiencing extensive tear
Reviews on OASIS repair
Harvey MA, Pierce M, Sultan A et al. Obstetrical Anal Sphincter Injuries (OASIS):
Prevention, Recognition, and Repair. J Obstet Gynaecol Can. 2015 Dec;37(12):1131-48.

Royal College of Obstetricians and Gynaecologists. The Management of Third- and Fourth-
Degree Perineal Tears. Date published: Juni 2015.

Friedman A, Ananth CV, Prendergast E et al. Evaluation of Third-Degree and Fourth-Degree


Laceration Rates as Quality Indicators. Obstetrics & Gynecology. 2015; 125(4): 927-937

Fernando R, Sultan A, Kettle C et al. Methods of repair for obstetric anal sphincter injury.
Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD002866.

Dansk Selskab for Gynækologi og Obstetrik. Sphincterruptur ved vaginal fødsel: behandling
og opfølgning. Sandbjerg Guideline 2011.

Dudding T, Vaizey C, Kamm M. Obstetrical anal sphincter injury: incidence, risk factors and
management. Ann Surg. 2008; 247(2):224-37.

 
Review on antibiotics
Buppasiri P, Lumbiganon P, Thinkhamrop J et al. Antibiotic prophylaxis for third- and
fourth-degree perineal tear during vaginal birth. Cochrane Database of Systematic Reviews
2010, Issue 11. Art. No.: CD005125.

Randomised studies on techniques for OASIS repair


Farrell SA, Flowerdew G, Gilmour D, Turnbull GK, Schmidt MH, Baskett TF, Fanning CA.
Overlapping Compared With End-to-End Repair of Complete Third-Degree or Fourth-
Degree Obstetric Tears: Three-Year Follow-up of a Randomized Controlled Trial. Obstet
Gynecol. 2012; vol 120(4).

Rygh A, Körner H. The overlap technique versus end-to-end approximation technique for
primary repair of obstetric anal sphincter rupture: a randomized controlled study. Acta Obstet
Gynecol Scan. 2010; 89(10):1256-62.

Nordenstam J, Mellgren A, Altman D et al. Immediate or delayed repair of obstetric anal


sphincter tears-a randomised controlled trial. BJOG. 2008; 115(7):857-65.

Fernando R, Sultan A, Kettle C et al. Repair techniques for obstetric anal sphincter injuries: a
randomized controlled trial. Obstet Gynecol. 2006; 107(6):1261-8.

Williams A, Adams E, Tincello D et al. How to repair an anal sphincter injury after vaginal
delivery: results of a randomisesd controlled trial. BJOG. 2006; 113(2): 201-7.

Filzpatrick M, Behan M, O´Connell R et al. A randomized clinical trial comparing primary


overlap with approximation repair of third-degree obstetric tears. Am J Obstet Gynecol.
2000; 183(5):1220-4. 
 
Suture techiques: internal and external anal sphincter
Wong KW, Thakar R, Sultan A, Andrews V.  Is there a role for transperineal ultrasound
imaging of the anal sphincter immediately after primary repair of third degree tears? BJOG
Abstract nr. 2129, 126 (S2) Special Issue:Top Scoring Abstracts of the RCOG World
Congress 2019, 17–19 June 2019, London, UK

Norderval S, Røssaak K, Markskog A,


 Vonen B. Incontinence after primary repair of obstetric anal sphincter tears is related to
relative length of reconstructed external sphincter: a case-control study. Ultrasound Obstet
Gynecol. 2012 Aug;40(2):207-14

Lindqvist P, Jernetz M. A modified surgical approach to women with obstetric anal sphincter
tears by separate suturing of external and internal anal sphincter. A modified approach to
obstetric anal sphincter injury. BMC Pregnancy Childbirth. 2010 Sep 9;10:51.
 
 
Incontinence and long-term implications after anal sphincter rupture
Evans E, Falivene C, Briffa K et al. What is the total impact of an obstetric anal sphincter
injury? An Australian retrospective study. Int Urogynecol J. 2019 Sep 16

Halle TK, Salvesen KÅ, Volløyhaug I. 


Obstetric anal sphincter injury and incontinence 15–23 years after vaginal delivery. AOGS
2016. 95(7): 941-947

Svare JA, Hansen BB, Lose G. Prevalence of anal incontinence during pregnancy and 1 year
after delivery in a cohort of primiparous women and a control group of nulliparous women.
AOGS 2016. 95(3): 920-925

Hehir M, Fitzpatrick M, O'Herlihy C. Morbidity and quality of life following rectal injury at
the time of vaginal delivery. AJOG. 2015; 212 (1): 257

Reid AJ, Beggs AD, Sultan AH et al. Outcome of repair of obstetric anal sphincter injuries
after three years. International Journal of Gynecology & Obstetrics. 2014. 127(1): 47-50

Oude Lohuis EJ, Everhardt E. Outcome of obstetric anal sphincter injuries in terms of
persisting endoanal ultrasonographic defects and defecatory symptoms. International Journal
of Gynecology & Obstetrics. 2014; 126(1): 70–73 

Lamblin G, Bouvier P, Damon H et al. Long-term outcome after overlapping anterior anal
sphincter repair for fecal incontinence. Int J Colorectal Dis. 2014 Sep 4.

Visscher AP, Lam TJ, Hart N, Felt-Bersma RJ. Fecal incontinence, sexual complaints, and
anorectal function after third-degree obstetric anal sphincter injury (OASI): 5-year follow-up.
International Urogynecology Journal. 2014; 25(5), 607-613

Shek KL, Guzman-Rojas R, Dietz HP. Significant defects of the external anal sphincter: an
observational study using transperineal ultrasound at a perineal clinic. Ultrasound Obstet
Gynecol. 2014 Mar 20

Dickinson KJ, Pickersgill P, Anwar S. Functional and physiological outcomes following


repair of obstetrics anal sphincter injury. A caseInternational Journal of Surgery 2013 11(10):
1137–1140   

Huebner M, Gramlich NK, Rothmund R et al. Fecal incontinence after obstetric anal
sphincter injuries. International Journal of Gynecology & Obstetrics 2013, 121(1), 74-77

Priddis H, Dahlen HG, Schmied V et al. Risk of recurrence, subsequent mode of birth and
morbidity for women who experienced severe perineal trauma in a first birth in New South
Wales between 2000 --2008: a population based data linkage study. BMC Pregnancy
Childbirth. 2013; 13(1):89

Evers EC, Blomquist JL, McDermott KC et al. Obstetrical anal sphincter laceration and anal
incontinence 5-10 years after childbirth. Am J Obstet Gynecol 2012, (207)425:1-6 
 
 
After OASIS - Planning subsequent births
Edwards M, Kobernik EK et al.Do women with prior obstetrical anal sphincter injury regret
having a subsequent vaginal delivery? BMC Pregnancy Childbirth. 2019 4; 19(1):225.

Cole J, Bulchandani S. Predicting patient preference for mode of delivery following obstetric
anal sphincter injury. BJOG Abstract nr. 1320, 126 (S2)
Special Issue:Top Scoring Abstracts of the RCOG World Congress 2019, 17–19 June 2019,
London, UK
Boggs EW. Berger H, Urquia, M et al. 
Recurrence of Obstetric Third-Degree and Fourth-Degree Anal Sphincter Injuries. Obstetrics
& Gynecology. 2014; 124(6): 1128-1134

 
Studies on artificial tissue
Raya-Rivera AM, Esquiliano D, Fierro-Pastrana R et al. Tissue-engineered autologous
vaginal organs in patients: a pilot cohort study. The Lancet, Early Online Publication, 11
April 2014

Raghavan S, Gilmont R, Miyasaka E et al. Successful implantation of bioengineered,


intrinsically innervated, human internal anal sphincter. Gastroenterology. 2011 Jul;
141(1):310-9.

Aktuel forskning 2011: Human cells to engineer functional anal sphincters in lab.

Birth professionals and their experiences


Miller ES, Barber EL, McDonald, K et al. Association Between Obstetrician Forceps Volume
and Maternal and Neonatal Outcomes. Obstetrics & Gynecology. 2014 123(2). 248-254

Lindberg I, Mella E, Johansson, J. Midwives´experineces of sphincter tears. British Journal


of Midwifery 2013;21(1) p. 7-14.

Räisänen S. Obstetric Anal Sphincter Ruptures -Risk Factors, Trends and Differences
Between Hospitals. Publications of the University of Eastern Finland. 2011
Forth-degree perineal lacerations
Overview
Published November 18th, 2019
Welcome to the chapter on suturing fourth-degree perineal lacerations.

Preparing for suturing


Published November 18th, 2019
Before you start suturing you should consider the following aspects.

Can be delayed 12-24 hours after the delivery

Anaesthetics
Published November 18th, 2019
You should always offer effective pain relief to the woman before starting the repair.

Spinal lasts 2 hrs

Instruments
Published November 18th, 2019
This video shows you what instruments you will need for the procedure.

Scissors, Allis forceps, needle holder, tampon, forceps, swabs, sterile clot
Lone star retractor

Suture material
Published November 18th, 2019
What kind of suture material should you use?

Needle blunt point to suture rectal anal mucosa, perineal muscles and any torn fascia to avoid
damage tissues
Absorbable synthetic product multifilamentar Vicryl
3-0 suture material internal anal sphincter 2-0 for external

Tapped needle point for near skin tissues for precision

1/3 along needle grip with needle driver

Antibiotics
Published November 18th, 2019
Medical opinions on the use of antibiotics vary between hospitals internationally.

Record keeping
Published November 18th, 2019
As a health professional, it is your duty to describe the extent of the laceration as well as to
register the treatment in the medical record.

approximated

Vicryl 3-0 continuous – rectal mucosa


Vicryl 3-0 end to end – internal sphincter end to end U stitches interrupted
Vicryl 2-0 end to end– external. sphincter
Vicryl 2-0 continuous – Bulbocavernosus and transversus perineal muscles
Vicryl Rapide 3-0 continuous subcuticular stitches – skin

Rectal examination / palpation performed at the end of procedure: anal rectal mucosa
repaired sufficiently
Adequate tissue substance is achieved in the angle sphincter and perineal muscles

Animation
Published November 18th, 2019
This animation shows how to diagnose the fourth-degree tear.
Patient: fourth-degree tear
Published November 18th, 2019
This video shows footage of an diagnosis and suturing af a fourth-degree tear.

Missed fourth-degree tear


Published November 18th, 2019
This video shows missed a forth-degree tear.

Animation
Published November 18th, 2019
The animation now shows how the anorectal mucosa can be repaired using a continuous
technique. Anal rectal mucosa and internal sphincter

Cut threat 1 cm above the knot

Aberdeen 3 knots

1 surgical knot and 1 reef knot 2-1-1-1 needle driver, 1 or 2 hand technique

Second layer on top

Few mm above suture line

03:59

Medical model
Published November 18th, 2019
In this video you can see the suturing of the anal mucosa using a medical model.

0,5 cm from wound edge from down up enter on anal mucosa

Normal healing
Published November 18th, 2019
This video gives good advice on normal healing.
Healing 3 weeks

Recovery
Published November 18th, 2019
Postpartum pelvic floor muscle training can be commenced as soon as the woman feels fit for
it.

Complications
Published November 18th, 2019
This video is about possible complications after suturing.

Rectovaginal fistula

Us to detect and Repair defect if anal incontinency

Subsequent birth
Published November 18th, 2019
The woman should receive specialist obstetrical advice when planning a subsequent delivery.

1 % recurrence increase 5 fold increase for a tear or laceration

Elective CS if 3rd 4th degree tears

Reviews on OASIS repair


Harvey MA, Pierce M, Sultan A et al. Obstetrical Anal Sphincter Injuries (OASIS):
Prevention, Recognition, and Repair. J Obstet Gynaecol Can. 2015 Dec;37(12):1131-48.

Royal College of Obstetricians and Gynaecologists. The Management of Third- and Fourth-
Degree Perineal Tears. Date published: Juni 2015.

Friedman A, Ananth CV, Prendergast E et al. Evaluation of Third-Degree and Fourth-Degree


Laceration Rates as Quality Indicators. Obstetrics & Gynecology. 2015; 125(4): 927-937

Fernando R, Sultan A, Kettle C et al. Methods of repair for obstetric anal sphincter injury.
Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD002866.

Dansk Selskab for Gynækologi og Obstetrik. Sphincterruptur ved vaginal fødsel: behandling
og opfølgning. Sandbjerg Guideline 2011.

Dudding T, Vaizey C, Kamm M. Obstetrical anal sphincter injury: incidence, risk factors and
management. Ann Surg. 2008; 247(2):224-37.

 
Review on antibiotics
Buppasiri P, Lumbiganon P, Thinkhamrop J et al. Antibiotic prophylaxis for third- and
fourth-degree perineal tear during vaginal birth.Cochrane Database of Systematic Reviews
2010, Issue 11. Art. No.: CD005125.

Randomised studies on techniques for OASIS repair


Farrell SA, Flowerdew G, Gilmour D, Turnbull GK, Schmidt MH, Baskett TF, Fanning CA.
Overlapping Compared With End-to-End Repair of Complete Third-Degree or Fourth-
Degree Obstetric Tears: Three-Year Follow-up of a Randomized Controlled Trial. Obstet
Gynecol. 2012; vol 120(4).

Rygh A, Körner H. The overlap technique versus end-to-end approximation technique for
primary repair of obstetric anal sphincter rupture: a randomized controlled study. Acta Obstet
Gynecol Scan. 2010; 89(10):1256-62.

Nordenstam J, Mellgren A, Altman D et al. Immediate or delayed repair of obstetric anal


sphincter tears-a randomised controlled trial. BJOG. 2008; 115(7):857-65.

Fernando R, Sultan A, Kettle C et al. Repair techniques for obstetric anal sphincter injuries: a
randomized controlled trial. Obstet Gynecol. 2006; 107(6):1261-8.

Williams A, Adams E, Tincello D et al. How to repair an anal sphincter injury after vaginal
delivery: results of a randomisesd controlled trial. BJOG. 2006; 113(2): 201-7.

Filzpatrick M, Behan M, O´Connell R et al. A randomized clinical trial comparing primary


overlap with approximation repair of third-degree obstetric tears. Am J Obstet Gynecol.
2000; 183(5):1220-4. 
 

Suture techiques: internal and external anal sphincter


Wong KW, Thakar R, Sultan A, Andrews V.  Is there a role for transperineal ultrasound
imaging of the anal sphincter immediately after primary repair of third degree tears? BJOG
Abstract nr. 2129, 126 (S2) Special Issue:Top Scoring Abstracts of the RCOG World
Congress 2019, 17–19 June 2019, London, UK

Norderval S, Røssaak K, Markskog A,


 Vonen B. Incontinence after primary repair of obstetric anal sphincter tears is related to
relative length of reconstructed external sphincter: a case-control study. Ultrasound Obstet
Gynecol. 2012 Aug;40(2):207-14

Lindqvist P, Jernetz M. A modified surgical approach to women with obstetric anal sphincter
tears by separate suturing of external and internal anal sphincter. A modified approach to
obstetric anal sphincter injury. BMC Pregnancy Childbirth. 2010 Sep 9;10:51.
 
 
Incontinence after anal sphincter rupture
Evans E, Falivene C, Briffa K et al. What is the total impact of an obstetric anal sphincter
injury? An Australian retrospective study. Int Urogynecol J. 2019 Sep 16

Halle TK, Salvesen KÅ, Volløyhaug I. 


Obstetric anal sphincter injury and incontinence 15–23 years after vaginal delivery. AOGS
2016. 95(7): 941-947

Svare JA, Hansen BB, Lose G. Prevalence of anal incontinence during pregnancy and 1 year
after delivery in a cohort of primiparous women and a control group of nulliparous women.
AOGS 2016. 95(3): 920-925

Hehir M, Fitzpatrick M, O'Herlihy C. Morbidity and quality of life following rectal injury at
the time of vaginal delivery. AJOG. 2015; 212 (1): 257

Reid AJ, Beggs AD, Sultan AH et al. Outcome of repair of obstetric anal sphincter injuries
after three years. International Journal of Gynecology & Obstetrics. 2014. 127(1): 47-50

Oude Lohuis EJ, Everhardt E. Outcome of obstetric anal sphincter injuries in terms of
persisting endoanal ultrasonographic defects and defecatory symptoms. International Journal
of Gynecology & Obstetrics. 2014; 126(1): 70–73 

Lamblin G, Bouvier P, Damon H et al. Long-term outcome after overlapping anterior anal
sphincter repair for fecal incontinence. Int J Colorectal Dis. 2014 Sep 4.

Visscher AP, Lam TJ, Hart N, Felt-Bersma RJ. Fecal incontinence, sexual complaints, and
anorectal function after third-degree obstetric anal sphincter injury (OASI): 5-year follow-up.
International Urogynecology Journal. 2014; 25(5), 607-613

Shek KL, Guzman-Rojas R, Dietz HP. Significant defects of the external anal sphincter: an
observational study using transperineal ultrasound at a perineal clinic. Ultrasound Obstet
Gynecol. 2014 Mar 20

Dickinson KJ, Pickersgill P, Anwar S. Functional and physiological outcomes following


repair of obstetrics anal sphincter injury. A caseInternational Journal of Surgery 2013 11(10):
1137–1140   

Huebner M, Gramlich NK, Rothmund R et al. Fecal incontinence after obstetric anal
sphincter injuries. International Journal of Gynecology & Obstetrics 2013, 121(1), 74-77

Priddis H, Dahlen HG, Schmied V et al. Risk of recurrence, subsequent mode of birth and
morbidity for women who experienced severe perineal trauma in a first birth in New South
Wales between 2000 --2008: a population based data linkage study. BMC Pregnancy
Childbirth. 2013; 13(1):89

Evers EC, Blomquist JL, McDermott KC et al. Obstetrical anal sphincter laceration and anal
incontinence 5-10 years after childbirth.Am J Obstet Gynecol 2012, (207)425:1-6 
 
 
After OASIS - Planning subsequent births
Taithongchai A, Thakar R, Sultan AH. Management of subsequent pregnancies following
fourth-degree obstetric anal sphincter injuries (OASIS).EJOG. 2020. 250(7): 80-85 
https://www.ejog.org/article/S0301-2115(20)30249-9/fulltext

Edwards M, Kobernik EK et al. Do women with prior obstetrical anal sphincter injury regret
having a subsequent vaginal delivery? BMC Pregnancy Childbirth. 2019 4; 19(1):225.

Cole J, Bulchandani S. Predicting patient preference for mode of delivery following obstetric
anal sphincter injury. BJOG Abstract nr. 1320, 126 (S2)
Special Issue:Top Scoring Abstracts of the RCOG World Congress 2019, 17–19 June 2019,
London, UK
Boggs EW. Berger H, Urquia, M et al. 
Recurrence of Obstetric Third-Degree and Fourth-Degree Anal Sphincter Injuries. Obstetrics
& Gynecology. 2014; 124(6): 1128-1134

 
Studies on artificial tissue
Raya-Rivera AM, Esquiliano D, Fierro-Pastrana R et al. Tissue-engineered autologous
vaginal organs in patients: a pilot cohort study.The Lancet, Early Online Publication, 11 April
2014

Raghavan S, Gilmont R, Miyasaka E et al. Successful implantation of bioengineered,


intrinsically innervated, human internal anal sphincter. Gastroenterology. 2011 Jul;
141(1):310-9.

Aktuel forskning 2011: Human cells to engineer functional anal sphincters in lab.

Birth professionals and their experiences


Miller ES, Barber EL, McDonald, K et al. Association Between Obstetrician Forceps Volume
and Maternal and Neonatal Outcomes.Obstetrics & Gynecology. 2014 123(2). 248-254

Lindberg I, Mella E, Johansson, J. Midwives´experineces of sphincter tears. British Journal


of Midwifery 2013;21(1) p. 7-14.

Räisänen S. Obstetric Anal Sphincter Ruptures -Risk Factors, Trends and Differences
Between Hospitals. Publications of the University of Eastern Finland. 2011

Welcome
Published June 18th, 2020

Introduction Introduction to Hegenberger Speculum


The story of Hegenberger
Published May 15th, 2020

Hegenberger about Hegenberger


Published May 15th, 2020

Learn more about Hegenberger Speculum on the official website


Hegenberger Speculum Homepage

Read more about Hegenberger Speculum on social media


Facebook: Hegenberger Speculum
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Sweden: Wing Plast
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