Perineal Repair

Perineal repair Opener & Procedure 1.jpeg

This module describes how to repair an episiotomy or a first or second degree perineal tear postpartum. Third and fourth degree repairs are often repaired in theatre.


  1. Episiotomies or first or second degree perineal tears


  1. First degree tears where the tissue is well-apposed and not bleeding

  2. For third and fourth degree tears, call a senior to assist with anal sphincter repair


Always verify your patient’s identity and obtain informed consent before proceeding.

How do I explain this procedure?

“You have a cut or tear in your vagina after you gave birth. I need to put a few stitches in so that it will heal well.”

What can my patient expect?

“I am going to give you an injection that will prevent you from feeling pain, but it will sting a little. Then I will put in the stitches. The stitches will dissolve by themselves while the wound is healing, so you don’t have to have them taken out.”

What is my patient’s role?

“Let me know if you have any allergies. Let me know if anything is painful, and let me know if you feel faint while I put in the stitches. When you go home, keep your stitches clean and dry. You can sit in a bath of cool water for up to 20 minutes at a time to help ease the pain. Wait for 6 weeks before resuming sexual intercourse. If the wound becomes more painful, appears to be gaping open, or has a discharge, go for a wound check. Do not pull at the stitches.”


Perineal repair Equipment

Prepare a trolley with equipment. Ensure a female chaperone is present. Ensure you have adequate lighting—general ward lighting is not enough.

Documentation

  1. Patient notes

Equipment

  1. Non-sterile and sterile gloves

  2. Alcohol-based hand rub

  3. A suture pack

    1. Needle holder
    2. Artery forceps
    3. Thumb forceps
    4. Dental syringe
    5. Scissors
    6. Bowl for cleaning solution
    7. Drapes
    8. Sterile gauze
  4. Sutures of the appropriate

    (you may need two packets)

  5. Lignocaine cartridges for dental syringe

  6. Dental needle

  7. Irrigation supplies

    1. Bottle of normal saline
    2. Large-bore IV cannula
    3. 20 ml syringe


Position the patient in lithotomy.

Perineal repair Site.jpeg


Follow medical asepsis with sterile gloves; however, due to the nature of vaginal tears, complete sterility may not always be achievable.

  1. Perform hand hygiene.

  2. Don non-sterile gloves and

    the tear to determine the grade. Doff gloves.

  3. Open the suture pack and create a sterile field. Pour skin cleaning solution into the bowl. Open syringe, IV cannula, sutures, and

    onto the field. Drop non-sterile lignocaine cartridges into the iodine solution. Open a bottle of normal saline and place it beside the field.

  4. Don sterile gloves.

  5. Load the dental syringe and anaesthetise the wound edges. Wait 5-10 minutes.

  6. Use gauze and iodine solution to clean the skin around the wound, but not inside the wound.

    the wound with saline if contaminated. Drape the area.

  7. Start by making a knot 5 mm above the apex of the wound in the vagina.

  8. Approximate the edges of the vaginal wound up to the edge of the posterior fourchette using a

    suture.

  9. At the edge of the fourchette, insert the needle back into the skin, to exit at the deepest point of the perineal muscle tear.

  10. Approximate the muscles using a continuous suture, working from the vagina

    the anal end.

  11. Working from posterior (interior) to anterior, close the skin using continuous

    up to the posterior fourchette.

  12. At the posterior fourchette, tie an

    .

  13. Bury the knot by placing a stitch through the wound, into the adjacent skin, and then cutting the suture material flush with the skin.

  14. Perform a rectal exam to confirm that no sutures have penetrated the rectum.

  15. Cover the wound with a sanitary pad.

  16. Dispose of medical waste safely.

  17. Record the completion of the procedure in patient notes, and prescribe analgesia.


My needle is bending and losing its curve as I suture through the tough perineal skin.

Make sure you are using a thick enough needle and that you are using a wrist motion that follows the curve of the needle. Good lighting helps with your technique. Losing the curve of your needle makes it harder to put in the next stitch and could result in the tip breaking off. If this happens, contact a senior for help.


  1. Chronic pain & dyspareunia

  2. Uneven approximation with poor cosmetic result

  3. Penetration of the rectum/missed 4th degree tear with rectovaginal fistula

  4. Missed third degree tear with fecal incontinence

  5. Sharps injury to healthcare personnel


  1. Kettle C, Dowswell T, Ismail KM. Continuous and interrupted suturing techniques for repair of episiotomy or second-degree tears. Cochrane Database Syst Rev. 2012;11(11):CD000947. doi:10.1002/14651858.CD000947.pub3

  2. Marty N, Verspyck E. Déchirures périnéales obstétricales et épisiotomie : aspects techniques. RPC prévention et protection périnéale en obstétrique CNGOF [Perineal tears and episiotomy: Surgical procedure - CNGOF perineal prevention and protection in obstetrics guidelines]. Gynecol Obstet Fertil Senol. 2018;46(12):948-967. doi:10.1016/j.gofs.2018.10.024.