Suturing

[veganmamma]

What are your philosophies on suturing? The technique I am learning has sub cutaneous on the perineum so moms don't see frankenstein in their yoni, with two deep muscle stitches and some stitches in the vagina. Otherwise my instructor's philosophy is to not suture unless the muscle has been torn. I agree with her. Skin tears will heal better on their own with less drama and trauma to the area. So my question is, when people say "minor tear," are they meaning skin tears? I hear a lot of people talking about being sutured for minor tears and I wonder if they're so minor, why are they being sutured? Does that make sense? Are they minor tears to the muscle, or is there really no way to tell? I just feel like women don't really know what they're being sutured for or what's torn, etc. I also feel like there is no telling unless you ask, what a MW's or OB's policiy on suturing is. So what is your philosophy on the whole thing?
Thanks,
L

[pamamidwife]

I hardly ever suture. Well, once in three years. The only reason why I did suture this once is that the skin did not come together well and I knew that it probably wouldn't heal right, and I knew that things like this mattered to this mama. I talked with her about it, showed it to her and I sutured.

If it involved muscle, I'm not sure that I'd suture. I would definitely call in another mw with more extensive suturing experience or even my friend who is a doc. I just don't feel like I do it often enough to be messing with it all that much. I'd feel much better having someone more experienced doing it.

(This from my own experience with poor healing after an epis)

Still, I find that most women do not tear into muscle. It's very rare and I like it like that. :)

[veganmamma]

My instructor said the only way to get experience is to watch at the hospital b/c if you try to learn from midwives it won't happen often enough for you to learn. The suturing we learned was for when a muscle band is either completely or mostly torn through. This was for a pretty extensive tear. I'm glad to hear she was right about MWs not having to suture often. :)

[Malama]

Aloha!
The Midwife I work with pretty much sutures most tears.... she likes to see those perineums or yoni's come together as they should be and she was taught that suturing is the way to do that.

I've only seen a few bad tears and she sews them so beautifully that at their 6 week check up they usually look intact.

However.... I don't know that i'm all that thrilled about suturing-- partly because I've read about how the body recognizes those sutures as foreign and it causes a localized reaction (swelling and stuff). So.... i'm interested in other alternatives-- glue, herbs, doing nothing, etc....

One woman i know who refused to have her tear stitched complained forever about how her yoni was just not the same.... she regretted it....
So it's interesting that pamamama doesn't barely ever suture. Hmmmm

karen

[pamamidwife]

yeah, I guess my belief is if our bodies were meant to birth, why, if a woman is left to push on her own, with her body leading, would we tear so badly the majority of the time that we wouldn't heal right?

I think the vagina is the most forgiving place on our bodies. There is an old obstetric saying, "put two sides of a vagina together in a forest and they'll find each other". This is so true -

I find that I have to really weigh suturing vs not. With each suture, there are two new wounds and entrances for possible infection. For many women, chromic gut or even synthetic vicryl make for a very uncomfortable postpartum.

I haven't seen any postpartum vulvas that I would have thought would be better with sutures. On the other hand, I talk alot about my philosophy and discuss it with women right after the birth. Surely, if they felt like they really wanted it sutured, I would definitely oblige.

I think that resting in the first week postpartum (not running off to Target, etc), some nice herbal baths and kegels are all that is needed.

What is interesting is my preceptor sutured alot. So, I was trained with someone who sutured for most first degree tears. I think things like glue or nori sheets are interesting, but if it's minor enough for those treatments, then it's minor enough to heal on its own. I have tried glue before and I just didn't like it...it crystallized and had to be reapplied often. Medical grade glue is expensive and clearly states in the package that it's not for mucus membranes.

There's some great new studies from the UK on not suturing first degree tears vs suturing - and the healing rates for both camps were pretty even. It's reassuring.

I like comfrey leaf infusions in the peri bottle, as well as soaked on the sanitary pad to encourage cell regeneration and tissue growth postpartum.

[loved]

For me, I want to know how to prevent those tears first and then to really 'see' what has happened. So often I have looked at a torn yoni and I can't make out hide nor hair (o.k. bad pun, I'm sorry!).
I think suturing is a skill I really want to know how to do, but will do rarely. I love Pamamidwife's description and belief. I also know lots of midwives that do it pretty often.
I worked with a midwife who wanted to suture those little first degree labial tears because of the pain women experience on urinating. She also would wait for the swelling to go down to do repair for up to a day...sure makes a difference in how those tissues look and how they take repair.
I think, more importantly, we need to listen to the experiences of these mamas with tearing, with suturing and how they view themselves afterwards. This is where we will learn the most.

Peace and love,
Lesley

[Malama]

I hear you Lesley, on preventing those tears. I don't know if you've seen Midwifery Today's whole issue on preventing tears (recent one) but there are so many opinions on how to do that.
I have seen women who are following their bodies completly tear as well as women who have extensive perineal massage by the MW tear.... tears just happen some time.

I like that idea of waiting til the next day to see how the tear looks. When the moms are so swollen, it's hard to tell what's going on sometimes.

I think that when I start practicing, I'll figure out what seems most comfortable for me in terms of suturing.

I just want to be able to serve moms and have the walk away from their births feeling good (and with comfy yonis)

karen

[veganmamma]

I agree, Pam, anything minor enough for glue is minor enough to heal fine on it's own. I feel like if we naturally birth babies on our own it can't be common to have tears that require suture. What do women in tribal cultures worldwide do? What have we done for hundreds of thousands of years? If most tears require stitches and minor tears happen fairly frequently, then that means that we aren't perfect birthing creatures, kwim? And I think we are perfect. I agree that if a woman wants sutures she should get them. Frankly, I had a small labial tear, like a little nothing, really, so it didn't affect my vagina at all, and barely affected my labia, save for some stinging on urination. My vagina doesn't feel the same. It never will! An almost 8 pound baby passed through it! I think it's hard to say if it is suturing or not suturing that changes it, though I completely agree we learn best from birthing women.

I just feel like every suture is more trauma and drama and risk of infection to the area, so don't cause more damage if it's not really necessary.

Also, I've recently learned that comfrey is contraindicated where there is infection because it heals so quickly it can cause healing over the infection. I never knew that, though I use TTO on all infections in my personal life and then comfrey after they are cleared up anyway. Dunno if it was intuition or what, but I was glad for the knowledge. I used comfrey in my peri bottle. I used warm water from the sink each time and added comfrey extract. I healed so quickly!

One last thing. Many OBs and some MWs suture things together that don't go. When there is pardon me, but hamburger looking flesh that they are trying to sew together, even before real swelling, it can be very difficult to put things together correctly. I think waitin guntil the next day may be a great idea, better than immediate suturing, but more importantly, I think waiting to assess if there is a need for suturing is even better. Mucosa tissue heals so well on it's own and the body knows the vagina just passed a baby so it is sending healing energies that way. I dunno, I have faith in its ability to heal it self in almost all cases. :)

[lorijds]

But, in regards to waiting a day, wouldn't that tissue already be begining the process of granulating in? I would think that that would lengthen the healing time, and weaken the tissue, as you are trying to suture together something that has already begun to heal over.

Thoughts?

[loved]

I apolagize for the long interlude here - y/know life!
Anyway, Yes the tissues do begin to heal - shortly after the birth. So repair would happen either over the healing if it is happening correctly or the itssues would need to be roughed-up in order to heal well. In my limited experience, I saw that these bottoms healed well, and in the same amount of time. And the mother was given good uninterrupte bonding time and exhausted midwife time to recuperate.
I know it is frowned upon. I also saw that it worked.
Anne Frye says don't wait longer than 6 hours. The longest we waited was nearly 24 hours...

Peace,
Lesley