ļ»æEpisode 127 - Do I need stitches if I tear at birth?
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host Dr Melanie Jackson. I'm a clinical and research midwife with my PhD and each episode I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth and postpartum journey.
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[1:20] The big question for today's episode is about perineal tears. So when you have a baby, there's an area of your body that can tear as your baby emerges. And traditionally, in a medical setting, most of these tears will be stitched together. So the question I'm going to talk about today is, do all tears need stitching? And if they don't, what's the alternative?
[1:42] But today we're talking about suturing versus not suturing perineal tears. So if we start by talking about perineal tears, what are they? So basically, as your baby is emerging, there's a body of tissue between your vaginal opening and there's the space in between your anus and your vaginal opening is considered your perineal area, your perineal space. And actually, if you look at this space structurally, the skin and the tissues are quite different to the rest of your body. They seem quite spongy, very well perfused with blood, and there's a lot of immune and lymphatic activity around that area. It's almost as if that area of our body is designed to tear and repair, which makes a whole lot of sense because historically we didn't have the tools or knowledge or capacity to be suturing perineums. So the suturing of perineal tears is only a very new historical process with the invention of needles and sutures and medical management of childbirth.
[2:51] And so, of course, historically, there would have also been a number of women who healed poorly and who had long-term issues from poor perineal healing after childbirth. However, have we gone too far the other way with suturing absolutely every single
[3:06] tear that should occur during childbirth? There will be a separate episode on preventing perineal tears, but that's going to be a hell of a lot longer because that's going to be full of a lot more information. And so if you're a woman listening to this, you...
[3:19] May or may not be aware that if you arrive in hospital, have your baby there and you have anything greater than a first degree tear, you will most likely be recommended to have that repaired with stitches. So I'll start by going through the grades of perineal trauma or tears after childbirth. So first degree involves skin, second degree slightly larger involves skin and some of the muscle layer. Third degree tear starts to encroach upon the anal sphincter and anal muscles and structure and fourth degree tear completely interrupts the anal sphincter.
[3:52] That's a very basic rundown of perineal trauma. I'm probably going to get emails from people going, what about 3A? What about 3B? What about all the subclassifications? For the purpose of this, you need to know that first and second degree tears are usually the realm of midwifery. Third and fourth degree tears need a greater level of assessment and repair
[4:13] that is out of the scope of midwives and that's often referred to obstetricians to repair. And if you're on the mailing list, all of the research papers I'm going to be speaking about today are going to be in the big master folders where all of the evidence papers that from previous episodes have been stored. So anyone on the mailing list gets access to all the research I'm going to be talking about today. So let's start with first degree tears. In hospital or if you've given birth at home, there's a general consensus and understanding that first-degree tears don't need to be repaired. And so if you have a look at the research on that, they have basically found.
[4:50] That to be true is that if we don't repair a first degree tear then recovery will occur in most situations and so there's not many practitioners will routinely recommend stitching first degree tears. There's also not many practitioners that you'll find including myself that will recommend not stitching third and fourth degree tears. First degree tears usually don't need stitching. Third and fourth degree tears, I would always recommend expert repair. Where the contention is, is in second degree tears.
[5:23] In hospital, if they see that you have a second degree tear, they'll almost always recommend that that needs suturing. I don't believe that to be the case and actually the research on it seems to be pretty conclusive also. So I'll run you through what I do. At home as a home birth midwife, what happens if after examining the woman's vagina, perineum and vulva after childbirth if we've identified a second-degree tear. Once you have your baby and your placenta's been born, that you'll be helped into a comfortable position so that your clinician or your care provider can inspect your vulva, your labia, clitoris, your vaginal wall, so the inside of your vagina, your perineum and the anal structures. And this assessment takes a minute or two. However, women do find it to be a disruptive part of their bonding journey with their baby. So this doesn't necessarily need to be hurried. However, the sooner you do the repair, it can be better. So some clinicians...
[6:25] Like to make sure that the repair that's done is done quickly and so this process can often be hurried once your placenta's out your clinician may want to do it sooner but if you feel like you need some time that's okay too again as we spoke about in the vaginal examination episode it's important that women are made comfortable because they're going to be opening their legs and you're going to be touching and inspecting their vulva and vagina where
[6:52] they just pushed a baby out. So very sensitive situation. So the words, I'm just going to see if you've had a tear are not sufficient to describe what will happen when the midwife is inspecting your bum. So here's how I explain it to women. It's that sometimes after having a baby, you can have tears or grazes or some damage from that baby coming through. So we're going to get into a comfortable position to check that. Midwives will use sterile gloves and a little pad, gauze pad. Sometimes they'll moisten it, but not always. And then the process of checking for perineal trauma is that you would start at the top around the clitoris and then part the labia, check for internal grazes on both sides of your labia, and then gradually move down.
[7:42] Moving side to side to check for any grazes, labial tears or any swelling or bruising. It's important to explain to women what you're going to do, how long it's going to take and where you're going to start. If there's any point at which you feel this is too uncomfortable, let me know and I'll take my hands off. And that's the important part is even if you've been given consent to check someone's vulva post-birth, it's important that the woman always feels like they can stop that procedure at any time. So I always remind women, if this feels too much, you let me know and I'll take my hands off. I would absolutely not ever continue, even if I had three seconds of the inspection left, never continue to check someone's perineum if they've told you it's time to take your hands off.
[8:28] And if we identify a second degree tear, this is the time for me at home for women, I talk to them about how now we need to make a decision about what they would like to do. Would they like stitches or not? And so I have a little criteria by which you can assess if a woman needs to have perineal stitches or if that line could be left to heal on its own. So let's talk about firstly, that's the tears that the second degree tears that I would consider suitable to be left to heal on their own without stitches. So firstly, if a woman's lying down, she's prepared to have her perineum checked, her vulva checked after birth. So she's opened her legs and I immediately looked without touching to see what I can see. Is there swelling? Is there bruising? Is there bleeding?
[9:18] Is anything gaping? Is there any obvious damage that's visible from the outside without first putting my hands on? So that tells me a lot about what this woman's options might be for repair. So then if I go ahead and do check and I find a second degree tear but then when my fingers and my hands come away, the woman's vulva moves back into a position that's symmetrical and that the tear is closed even when her legs are open and there's no gaping wounds or active bleeding from that wound that would be considered to me a tear that could repair on its own because after all the only reason we put stitches in a perineum post-birth is so that the edges of the woman's vulva or vaginal space or perineum actually oppose each other they're right next to each other and lying flat against each other so the body knows.
[10:14] Where to heal? What am I putting back together? And it can find the other side of the woman's anatomy. If that's already occurred, my question is why would we then put stitches in a wound that already sits together that isn't bleeding even when the woman's legs are wide open? So my argument would be that sutures are unnecessary in that circumstance. Not to mention you need to inject local anesthetic into that space could be two or four needles into the woman's vulva and perineal space in the golden hour in the time after giving birth when really she should be concentrating on her baby and initiating first feeds and allowing those bonding hormones to take over if you listen to our episode with dr sarah buckley on the labor hormones it would be almost It's scandalous to encroach on that space with a procedure such as suturing a woman's perineum if she doesn't absolutely need it.
[11:13] And so I do consider suturing to be intrusive on that really important space. And so the assessment of whether or not women actually need sutures, I think, has long-term reach for the woman and baby's bonding journey. So in the interest of protecting the woman's postpartum period and not extending unnecessary pain or discomfort, consider whether or not that perineum truly does need to be sutured. Part of the idea of suturing is that you're bringing the two sides together so your body knows what to put back together when it's healing and so if they're not well opposed and there's gaping or asymmetry in when you observe it from the outside the initial period or the initial process of checking someone's vulva and perineum would be to actually just visually see what's going on from the outside is there swelling is there any of the wound gaping open and in which case that could, because really the idea of suturing is that you bring all the structures together as well. So because that's with a second degree tear, there's trauma to the muscle, the perineal muscles. So we want to bring those back together so there's good function at the end.
[12:24] When we're doing or considering how to repair or if to repair someone's perineum, as midwives, we're usually always thinking about how can we make it so that after the birth, this area is going to function as it usually did, rather than how can we make sure that this woman's vulva looks as it used to. Because our vulvas, after we have babies, will always be postpartum vulvas. They will always be postpartum vaginas. So I guess there's an extra element of how do we feel about changes to our vulva as a result of perineal damage versus how we feel about how well our body's going to function after. Is, you know, people like, yeah, put it back together because I want it to look as it was.
[13:09] Midwives and doctors aren't plastic surgeons. So when we're putting it together, we're not really thinking about how can I make this look like it used to or how can I make it look better than it used to. We're not really focused on the detail. We're focused on the macro level of let's make sure this goes back together so it works like it used to. If you're hoping for some kind of finesse or adjustment to what you used to have, it's not going to occur during a perineal repair with a midwife or doctor necessarily. So if you think it's going to look the same even after repair, just be prepared that it may absolutely not. It may. Your vagina and vulva may look exactly as it looked. So I looked at the research on first degree tears. So the research on that is pretty conclusive, is that for women who've had suturing for first degree tears, they experienced high levels of discomfort postnatally.
[14:06] And that actually, regardless of whether you stitch or not, the healing and outcomes are the same. There was also some pretty good research on the use of blues for repair of first-degree tears, which was also pretty promising. But basically, the evidence was suggesting that suturing for first-degree tears wasn't necessary, necessarily necessary from a medical perspective. But obviously, women would have preferences. And I'm not going to go through all the research on that, but those papers will be in the folders if you're on the mailing list. There's a few of those. And then the research on second-degree tears was pretty good also. Essentially, the long-term outcomes were identical.
[14:51] So in terms of function and healing, rates of infection, and whether you suture a second-degree tear or not, your body will heal the same and feel the same in the long term. Obviously, going by that criteria though. So if you've got a second-degree tear that's obviously gaping or has a lot of space in it or isn't opposed to the other side or there's a lot of bleeding, that could be a good medical reason to suture that tear. However, I do believe that one would also heal because if you think about perineal
[15:26] tear and I'm doing hand actions here.
[15:29] The palms of my heels are together. If you imagine this as an open wound, my palms of my head, the bottom of the kind of the wrist, my wrists are together. And if you imagine the perineum like a zipper, so it zips shut from the bottom. So when you are healing, the healing is going to happen from the bottom and go up all the way to the top and in a way kind of zip itself shut most of the time, provided, and I'll talk about adequate healing environments for women who haven't been sutured but I have seen open gaping type wounds heal beautifully as well so what we found in the research and again the papers will be up there is that in the short term women who have their perineum sutured for second degree tears report faster healing but higher levels of pain in the early period and so although the suturing produces faster healing in the early stages.
[16:27] In the long term, the two approaches are considered equivalent and we have to consider whether or not the initial faster healing should be balanced against the need for women to have higher levels of pain relief and higher levels of discomfort in the early part when they have stitches. So when they follow up women at six weeks, there's no difference in unhealed perineums, infection rates, urinary incontinence, discomfort.
[16:53] So whether you choose to have a second degree tear stitched or not, the benefit is that they say women report that a stitched second degree tear healed faster, but they needed more pain relief. And women who didn't have their tear sutured were more comfortable in the early period, but felt that their tear took a little bit longer to heal. If a woman has her perineum sutured or episiotomy sutured and for some reason the wound breaks down or the stitches come away and that wound is left unstitched after the woman intended for it to be stitched.
[17:32] The usual management is actually to leave those. We can't restitch them and we let them heal on their own. So, you know, midwives are like, well, why is it okay to leave a wound that has come apart to heal by itself, but then we can't initially let it heal by itself, right? I mean, it's a very fair thing to be thinking. So, what the research says is actually it's completely reasonable to allow a second-degree tear to heal on its own. And in terms of outcomes, they're very, very similar to if the woman had stitches or not. And we've got to think about episiotomies are not physiological damage. Like I would consider that the perineal space has the capacity to tear and repair. And that's why it's structured in such a way as it is in terms of its vascularity and the lymphatic system and the amount of, you know, when you look at the tissues of the perineum, they're very different to other parts of our body. It looks like it's made for something special and I would suggest it's for tearing
[18:34] and repairing and or moving out of the way when the baby's head's coming through. And a tear will go through the path of least resistance.
[18:41] Usually, your body won't tear at the strongest part of your muscle or through a major blood vessel or anything like that. It'll tear through the weakest points and so episiotomy is indiscriminate and I think, yes, I do think episiotomy should be repaired because that's an imposed injury rather than a physiological one. It also doesn't really fit the bill of sitting together and not bleeding. Like episiotomy wounds usually bleed and you can usually see that they don't sit together. So like you know we consider too whether or not it even fits the criteria for
[19:14] a wound that would not favour.
[19:17] Been repaired whether or not you've decided to have suturing or not a really big part of healing your perineum and your vulva postnatally is lying down you know not sitting up and feeding your baby sitting up on couches walking around lie down allow everything to settle in to heal back together you know when women have had their first babies it's a lot easier to just lie around in bed all day. If women are having second and subsequent babies, I often ask them about what's your postpartum support like, because that's going to change potentially my recommendations for whether or not they should have suturing or not. And also their advice on how to care for their perineum. And so if they say, look, no, I won't be or can't be lying around in bed for at least a week, That would be minimum, I think, in terms of adequate perineal healing, at least a week. If you think that you're going to be up and down, out of the bed, chasing after other children, serving the rest of the household.
[20:18] Then consider that your perineal repair is going to be slower. And so what I always tell women is that your body needs a definite amount of time to heal. And if you give it that time over six weeks, it'll take six weeks to heal. If you give it that time all in one big chunk, it'll take all the healing time and do it all in one big chunk. Whereas if you space it out by interrupting your healing time by not resting.
[20:45] Then your body's just going to take longer and longer to heal. And when something takes longer and longer to heal, you open up the more chance of it not healing well or opening yourself up to the possibility of infection. And so my suggestion with healing is that you can't change how fast or how slow in terms of how much time your body needs to repair. It needs time. A time and if you don't give it to it, it will take it sometime later. So if you decide not to rest, you may come down with an infection or poor healing
[21:17] later on because your body's telling you to stop, sit down so we can heal. So take home message here is that despite the usual practice of every second degree tear being sutured, the research supports suturing versus not suturing, which is an evidence-based way of approaching perineal repair is that if a woman doesn't want to be sutured midwives don't stress about it because actually there's really good evidence that even if you don't suture a second degree tear it will heal as well functionally as if you stitched it and in fact less painfully so women experience more comfort having not been sutured than those who have been and we get to avoid that entire interruption of suturing someone's vulva immediately after they've had a baby.
[22:10] I mean imagine if we could just skip that part. I think any woman has said yeah it was really enjoyable to have my perineum repaired immediately after giving birth.
[22:18] So I think whether or not you've been sutured all of this would apply anyway. So at least a week lying down in bed very little sitting up on your sitting bones or on your vulva don't be sitting cross-legged in bed and nothing like that really getting horizontal and letting your body heal and you know legs together as much as you can to facilitate those the edges of that wound to heal then also I really love the perineal bottles that you can get so when you go to the toilet when as you wee you can squirt your vulva as you wee which partially helps if you've got grazes and things up near your urethra or around your clitoris they can be a bit stingy when you wee postpartum and it can make weeing postpartum really upsetting and so having a peri bottle to spray the area some women add things like pink salt and herbs and things all to that bottle I would just not get fancy with it personally unless if the wound is showing signs of infection yeah I think it's time to add some therapy like pink salt or calendula tinctures or tea tree or lavender or whatever it is women want to add to that wash but don't complicate it just fill it with water go and wee and pour all over yourself if you haven't got a peri bottle a glass of water works just as well or one of those pump bottles with the lid.
[23:45] Yeah, so part of it is comfort, but the other part is keeping that area clean so there's no buildup of goop or anything, postpartum goop. So that will help with hygiene. Changing your pads every three to four hours, even if there's not too much blood on there. You don't want to collect...
[24:02] Moisture and things like that. And actually sitting on a towel instead of being in undies all day. So just like avoiding things that would might irritate the wound and rub against it. So you want to be taking away that moisture from your body. So hygiene, keeping blood away as much as possible from your body. Also, if there's any inflammation of the vulva, bringing down the inflammation as fast as possible will increase the healing, the speed of healing. So for women who've got a swollen vulva, here's my top tip, and I don't think I'm the only one, but packet of condoms in the antenatal period, fill them half up with water, lie them flat, tie them off and freeze them flat. So they become kind of one or two centimeters high and freeze them as ice packs. They are hygienic. They don't have sharp edges.
[24:55] Don't insert them into your vagina. They're for the outside, and they defrost in about 20 to 30 minutes. And so they're a really good ice pack, cheap, to be using in the postpartum period to help bring down swelling or tenderness in the postpartum period. So I'd have these frozen ahead of time for your birth, and there's all kinds of fancy little gel packs you can buy. And also people talk about, and this is something that research spoke about, was the sensation of discomfort is different for people who have stitches versus not having stitches, they're both, it's a level of discomfort. You know, like when you get a graze and not that we get them very often, but when you're younger and you get grazes and in the day three or four, when it's starting to heal, they kind of get itchy and a bit stingy and a bit, perineums are the same. Around day three or four, they start to feel a little bit, sort of women describe it as tight or itchy or just a bit different to before. That's just a sign of healing so the ice can be really nice at that point to take just to ease that sensation so however you choose to apply it if there's swelling or some itching or just tenderness with that wound healing you can wrap some paper towel around the condom I wouldn't put it straight on your on your perineum and then yeah but certainly if you haven't got the gel packs or or, you know, padsicles are overwhelming or whatever. Packet of condoms frozen. So some kind of ice and cool for inflammation.
[26:24] And I really advocate the use of homeopathic arnica for swelling for your vulva or if there's any level of bruising. Sometimes your vulva gets bruised. That's okay. Really normal kind of postpartum thing to be experiencing. But homeopathic arnica can bring down the swelling and the bruising. And if you're coming from hospital and you have perineal pain or swelling, they will often recommend a combination of Panadol and Voltaren to help bring down swelling. So that's another option. If you don't want pharmacological assistance, the Arnica and Ice, really nice.
[27:01] Oh, look at that. Arnica and Ice are really nice. But if you're happy to go with some medication, then Panadol, Voltaren seems to be the routine recommendation from clinicians who are working in a hospital. All right. I think that's a pretty good wrap-up on suturing versus not suturing. Basically, for midwives to not panic, if a woman... Either can't be some women just will not tolerate suturing for whatever reason if there's trauma or the discomfort is too much don't worry about it from the research and there's more than one paper again I'll put them in the folders for the mailing list it will heal and so don't worry about it and same thing for women if you're feeling cool about that tear not being sutured the outcome will be the same regardless well yeah and yeah it's just made me think because when I trained my current colleague who I my work wife I affectionately call her my work wife when she started coming out to home births with me and I said oh no that one I don't think that one's going to need suturing she's like what do you mean and yes and she said it wasn't until and even now as we reflect on it wasn't until I went into private practice that I even considered that second degree tears wouldn't need to be sutured. So if you're hearing this for the first time, know that actually the evidence.
[28:19] Supports the option of suturing or not suturing in terms of outcome. There's no difference. And can I just put it out there? I think there's more evidence for not suturing perineums than there is for the use of CTG in labour. If you're comfortable and feel confident that CTGs are a good idea,
[28:36] but you want everyone to have suturing, then that's not evidence-based. So look at the evidence and if you're coming up to the challenge of trying to convince your work colleagues or workplace to be comfortable with women not having sutures have a look in the folders that you will get if you're on the mailing list you can get access to all the research and say actually did you know that the outcomes are the same now there is one other option if you've got a tear and you don't want to leave it to heal naturally and you also don't want to have it sutured. If you've got a private midwife, or if you're somewhere else other than in Australia.
[29:14] You may have access to the option of glue. You know, a lot of parents have experienced, if you take your child to the emergency department, if they fall and hit their head and they split their head open, you know, head wounds bleed so much, even if they're super tiny. And often for smaller kids, they actually won't suture these wounds together. They'll use a glue to hold the wound together. Even if they're on the back of the head or on the forehead and the skin's quite tight and it opens up, it kind of splits and the glue is strong enough to hold those edges together while it heals. And so there was actually a researcher who thought, hey, what if we try and use some kind of glue to hold perineums together? Because as we described through this episode, after you've had your baby, it's a sensitive hormonal time and a super important bonding time for you and your baby. And so anything that we can do to not disrupt this time would be amazing. But also the process of getting stitches can be quite uncomfortable.
[30:20] And I didn't explain it so much at the beginning of the episode, but when you have stitches, the clinician will use a needle to infiltrate your perineum with local anesthetic so that when you're repaired, it doesn't hurt. It shouldn't hurt. If it does hurt, tell them that they haven't put enough local anesthetic in. But obviously that involves putting some needle puncture marks into your perineum. When we infiltrate with the local anesthetic the area sort of swells up and becomes more edematous than it was before which can actually make the repair more difficult to do it can be quite a painful experience because that needle is inserted without the local anesthetic and so the sensation is still there in fact when I was speaking to some colleagues about this one of my colleagues had mentioned that she'd spoken to another midwife who worked in Europe and she said whoa you Australian midwives you guys are barbaric around the perineum because you infiltrate into the perineum and this midwife described how where she was and I can't remember which country it was it may be Sweden or Norway I can't remember what was her location but she said they use a lignocaine.
[31:36] Gel or foam. So lignocaine is the local anesthetic. And that numbs the area before stitching. And so there was a possibility to actually stitch and have good and effective pain relief with just a lignocaine gel or foam before suturing. I'd never heard that before. I certainly have not seen that product here in Australia, but if you're listening elsewhere and that's something that you use, then it seems a lot more humane than the way we do it here in Australia where we use needles to infiltrate the perineum with local anaesthetic. And then there's the wound that's inflicted by the sutures going through. So we're stitching with a needle and that's creating new damage in order to put the suture material in, to put the thread in. And so there is a 2023 paper. It's about the use of surgical glue to repair first and second degree tears. Although in Australia, you won't be able to choose the option of surgical glue in hospital. I've never seen it used in a hospital for perineal repair.
[32:42] If you've got yourself a private midwife, you may have access to this. And actually, after I read this 2023 paper, I did some legwork to find some surgical glue that could be used that I've got in my kit and obviously can offer to women if they would prefer to use the surgical glue and this could also potentially be considered for those labial tears that are very difficult to infiltrate with lignocaine but also often don't need stitches because that would be more of a cosmetic stitch but also if the woman wants different type of healing she could opt to have sutures in her labia, but they're traditionally very difficult to suture. They require a smaller needle and they're hard to get adequate pain relief.
[33:31] And so if it's not done by a very experienced clinician, it can be an uncomfortable repair. But potentially, the use of surgical glue could also assist with these labial tears.
[33:43] And this new research, which it's called the use of surgical glue versus suture to repair perineal tears, and it's a randomized control trial. And they concluded that the use of surgical glue for perineal repair of first and second degree tears and episiotomy in all tissue planes the skin the mucosa and the muscle proved to be as effective as the standard suture method it showed less pain a shorter procedure time and a similar healing process now the only downside from this study is that there was only 70 women in the glue group and 70 in the suture group and they also didn't compare glue suturing to not doing anything at all and so if you're a private midwife out there I have spoken to a few other midwives who are using this surgical glue and their feedback was if you have decided to use it as midwives and clinicians we have access to medical supplies so you can access some topical skin adhesive glues. And the advice is that the applicators that they come in are not really good for precision use. And so you would draw up the glue from inside that applicator into a syringe.
[35:05] And use that to be more precise with where you place the glue. Use the glue really sparingly because that's going to be the last place to heal. The glue will dissolve itself over time. But the place where it's mostly going to heal is where the glue isn't, where the wound is sitting together. And so the suggestion from the midwives that I've spoken to who have used it, again, we're not taught this kind of stuff in our usual midwifery training. But private midwives have got the freedom to find and use recent research and with the consent of the woman after presenting her with all the options if she decides to have the glue used this is a way that you could use it only put just enough to bring the wound together this adhesive glue doesn't work well if the area is very wet and moist and so if you've got a wound that is continuously bleeding, this is not really an effective strategy.
[36:06] So this is where the criteria for suturing versus not suturing might be a good thing to consider. So if the wound is bleeding, that wound might actually need to be sutured. And so I think the glue is better suited to tears that you've deemed don't need to be sutured, but where the woman doesn't really want to leave it to heal on its own. So if you pad it with the gauze and there's no active bleeding and you can get that area quite dry with the use of the gauze then sparingly place the glue in strategic areas that when you hold that wound together it's going to hold the whole wound together and you're not going to have any big pockets so you don't want to create any little button holes that have an airspace where the wound's not put together. So potentially consider the.
[36:57] Gluing the the deeper parts of the wound rather than the upper parts so you don't just want to pin the top parts of the wound together you want to make sure that when it heals it's going to heal from the bottom upwards so that all of the tissues are opposed so you apply small amounts of the glue and you hold the wound together consider doing that for 90 seconds to two minutes to make sure that the glue has adhered to the other side. That's what I know about using adhesive glue in the perineal area. It's certainly a researched area. I know it's done elsewhere overseas especially in light of this other research. It's not part of current practice here in Australia though and so having access to that would rely on you having a privately practicing midwife who is also comfortable to access this product and also be experimenting with its use. So if you're a woman keen to have the glue just know that this is not usually part of our midwifery training but that if your midwife has it it is an option
[38:04] if you're willing to expose yourself to that kind of a treatment.
[38:09] Certainly the research indicates that it's an appropriate management of a second degree tear first degree tear or an episiotomy however it's not part of our usual training and I will also say that I do think that if we're using the surgical glue I would love to see research that compares surgical glue to natural healing because compared to suturing it was considered equivalent and if not suturing is also equivalent to suturing outcomes I'm going to hazard at a guess that using the glue versus not will also have very similar outcomes. So that's what I wanted to add for this episode and in a little summary not all first and second degree tears need suturing. If you're considering not having your perineum sutured the criteria for not suturing from my experience is that if the woman has her legs open when she's getting ready for a perineal check and you can see symmetry and a closed together well-opposed wound, then that's your first step in being able to advise this woman that knot stitching could be appropriate. In addition to this first initial assessment.
[39:25] When you check the wound, confirm that it's a second degree tear. Third and fourth degree tears require specialist obstetric repair. If the wound is not bleeding and the sides are reposed well and there's no big gaping gaps, and when you look at it, there's symmetry and no gaping, you know that this is an appropriate wound that could sit together and heal without stitches. So for women listening, this could be more challenging if you're in a hospital system because they're less familiar and less comfortable with leaving a tear to heal. The other thing that might happen to you is when they see a tear, they'll immediately assume that you would like that repaired. I've seen this happen to my clients where I've transferred into hospital for the birth for some reason or another. And after the birth, when their perineum gets checked, there's a second degree tear or less. And the clinician just starts getting ready to stitch and assumes that that woman is going to want it repaired. So just know that you've got a choice but also that it's going to be outside of the comfort zone of your care provider in a hospital setting usually unless they listen to this podcast episode.
[40:35] But if you want to prepare yourself feel free to go in and have a look at these research papers in the resource folder so that you can feel more confident in your decision whether or not you choose to be glued not sutured at all or sutured for your second degree chair to get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com. And to support the work of this podcast, wear the rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @MelanietheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
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