Typically, perineal repairs are deferred until the placenta has been delivered. his policy permits undivided attention to the signs of placental separation and delivery. A further advantage is that the repair is not interrupted or disrupted by placenta delivery. his is especially true if manual removal must be performed. The major disadvantage is continuing blood loss until the repair is completed. Direct pressure from an applied gauze sponge will help to limit this volume.
For suitable repair, an understanding of perineal support and anatomy is necessary and is discussed in Chapter 2 (p. 19). Adequate analgesia is imperative, and women without regional analgesia can experience high levels of pain during perineal suturing. Again, locally injected lidocaine can be used solely or asia supplement to bilateral pudendal nerve blockade. In those with epidural analgesia, additional dosing may be necessary.
First-degree lacerations do not always require repair, and sutures are placed to control bleeding or restore anatomy. Here, few data guide suture selection, and ine-gauge absorbable or delayed-absorbable suture or adhesive glue is suitable.
Second-degree laceration correction as well as midline and mediolateral episiotomy repairs include similar steps. Namely, these close the vaginal epithelium and reapproximate the bulbospongiosus and supericial transverse perineal muscles during restoration of the perineal body (Figs. 27-15 and 27-16). For this, most studies support a continuous
FIGURE 27-16 Midline episiotomy repair. A. An anchor stitch is placed above the wound apex to begin a running, locking closure with 2-0 suture to close the vaginal epithelium and deeper tissues and reapproximate the hymeneal ring. B. A transition stitch redirects suturing from the vagina to the perineum. C. The superficial transverse perineal and bulbospongiosus muscles are reapproximated using a continuous, non locking technique with the same length of suture. This aids restoration of the perineal body for long-term support. D. The continuous suture is then carried upward as a subcuticular stitch. The final knot is tied proximal to the hymeneal ring. (Reproduced with permission from Kenton K, Mueller M: Episiotomy and obstetric anal sphincter lacerations. In Yeomans ER, Hoffman BL, Gilstrap LC III, et al (eds): Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hili Education, 201•7.) suturing method, which is faster than placing interrupted sutures and, with few exceptions, yields less pain (Grant, 2001; Kettle, 2012; Kindberg, 2008; Valenzuela, 2009). Blunt needles are suitable and likely decrease the incidence of needle-stick injuries (El-Refaie, 2012; Mornar, 2008). Commonly used suture materials are 2-0 polyglactin 910 (Vicryl) or chromic catgut. With the former, a decrease in postsurgical pain and lower risk of wound dehiscence are cited as major advantages Qallad, 2016; Kettle, 2010). Closures with traditional polyglactin 910, however, occasionally require removal of residual suture from the repair site because of pain or dyspareunia. This disadvantage may be reduced by using a rapidly absorbed polyglactin 910 (Vicryl Rapide) (Bharathi, 2013; Kettle, 2002; Leroux, 2006).