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Katlyn Carter

8.2 1st & 2nd Degree Repair

1st & 2nd Degree Repair Guide


(Frye, 2010, p. 503-525)

Complete a thorough exam and assessment. Plan the repair. Always start with the deepest, most
internal, hard-to-reach damage. In the event of a cervical tear, internal, and external anal
sphincters, transfer for complete repair.

Anchor Stitch

 Placed 1 cm above the internal apex of the tear to ligate any retracted blood vessels (helps
prevent hematomas)
 If tear is not bleeding and the upper end is hard to reach, it is acceptable to place this
stitch less than 1 cm above the apex.
o Never guess the location of the internal apex of a tear; it must be accurately
identified before you proceed with the repair.
 Tie the anchor stitch using a surgical knot
Constructed with:
o 3 throws for chromic
o 4 for braided synthetic
o Trim only free end
 Check to confirm knot is secure against the tissue and slightly moveable
 Anchor stitch should not pucker on either side of tissue

Posterior vaginal wall

 Use 3-0 chromic gut or 2-0 braided synthetic on a CT-1 or T-12 taper point needle for
most repairs
 For shallow tears, a small taper point needle (SH or T-5) is sufficient
 Use 2-0 multifilament synthetic if the introitus requires repair or reconstruction
 Shallow stitch
o Use a smaller half circle needle
 Large, deep stitch
o Use heavier suture
o Muscles tend to pull away from the midline
o Stronger suture material needed to ensure edges stay together under stress.
o You can use 2-0 chromic gut or 1-0 absorbable synthetic swagged to a standard
(CT-1, T-12) taper point needle for these repairs.
o Use assistant to help maintain sterile field when more items are needed
o Spacing- stitches should be approximately, but no greater than 1 cm apart (avoids
creating dead spaces
o Never sew hymenal tags
o If in doubt, err on the side of too few stitches (as long as they are equally spaced)
Katlyn Carter
8.2 1st & 2nd Degree Repair

o What kind of stitch?


o A simple, half-circle basting stitch is ideal
o A locked blanket stitch may be used for a wound that is seeping more blood
o If the tear is jagged or complex, a locked stitch may better align the tissues
 However, limit the use of locked stitches because they tend to shorten as
they heal and may run the risk of creating a too-tight line that can impair
healing

Deep layer stitches

Typically, one or two interrupted stitches (two-bite technique may be necessary) in deep
will bring tissue together (to avoid dead space), followed by continuous, basting stitches down
the perineum to complete the closure.

 Tear less than 1.5 cm deep


o Encompass to depth or nearly with one pass of the needle using a half-circle
stitch, two-bite technique
 Inserting the needle on one side of the tear
 Removing the needle from the tissue,
 Taking a mirror-image bite on the opposite side
 Making sure the needle enters the opposite side just above the trough of
the wound
 Tears of an intermediate depth (between 1.5 and 2.5 cm deep)
o Close using a buried circle stitch
o If you cannot encompass the depth of a tear using a CT-1 or T-12 needle and a
buried circle stitch, the tear is more than about 2.5 cm deep in that area.
o Deep tears that do not involve the rectal mucosa can occur when the perineal body
is quite long
o If tear is only a little more than 2.5 cm deep, you can usually get away with
closing it using only one layer of buried circle stitches
o If closure is not possible with a buried circle stitch
 Place a second, deeper layer to close the dead space
 Evenly spaced stitches promote circulation and healing
 Begin repair at the internal apex of tear in the posterior vaginal wall
 Take as deep a bite as possible when you place your first few stitches to assess how many
deep stitches you actually need.
 Close the deepest and hardest to reach part of a tear first, even if the tear itself is shallow.
o Use single layer of buried circle stitches in the posterior vaginal wall
o If anorectal mucosa is damaged
 Start this repair first, to ensure you can reach the depth of the tear
 If repair of anal sphincters is needed, transfer
Perineum

 Most often suture down the perineum with same strand used to repair the mucosa of the
vaginal floor
Katlyn Carter
8.2 1st & 2nd Degree Repair

 With a continuous unlocked stitch in the vaginal floor, place your last stitch at the level
of the hymenal ring
o Move to the vertical plane of the tear and continue with a basting stitch
 With a locked stitch complete the last locked stitch
o Insert your needle just outside the lock of the last stitch in the vaginal floor
o Bring the needle out where you want to begin closure of the perineum

Subcutaneous Closure (continuous)

 Helps to control capillary bleeding and prevents the more shallow parts of the wound
from becoming disrupted during the healing process
 Have your assistant hold the edges of the tear apart
o If you have no assistant, hold the edges of the tear apart with thumb and middle
finger of nondominant hand from below or above
o Begin closure by starting a row of basting stitches in the perineal body, beginning
about 0.5 cm below the introitus
o Entry and exit points for these stitches should be at least 8 to 10 mm from the skin
edge
o Depth of stitches can vary to close the depth of the tear at each level
o Remove the needle from tissue with thumb forceps
o Do NOT bring the needle through the skin surface; keep the suture inside the
external apex

If skin tags are present:


o If there are skin tags near the vaginal opening, you may need to put some stitches around
the introitus
o You may need to repair skin tags with another packet of synthetic suture on a small
needle before going back inside to tie off the main part of the repair

Finishing up
o Trim the ears
o Remove the gauze tampon
 Check to be sure no clots have collected behind the tampon while you
have been suturing
o Remove debris from the area
 Be sure that everything (needle, gauze, suture fragments, etc.) is
accounted for and properly discarded
 Sharps in the sharp container

Reference
Frye, A. (2010). Healing Passage. A midwife’s guide to the care and repair of the tissues

involved in birth. (6th ed.). Portland, Oregon: Labrys Press.