Suturing a mediolateral episiotomy wound
Material [Figure 39]
- Curved cutting suture needle.
- Curved blunt suture needle.
- Suturing thread: Polyglycolic acid-based (Dexon®, Vicryl®).
- Needle guide.
- Scissors.
- Anatomical tweezers.
- Surgical tweezers.
- Haemostatic forceps (Kocher clamp).
- Gauze squares.
- Gynaecological tampon.
Figure 39
A curved cutting needle is needed for skin sutures. The other tissue structures are sutured with a curved blunt needle. For the vagina, subcutis and muscle, a thread diameter of 0 gauge is sufficient. For the skin, Vicryl-Rapide® 00 gauge is recommended.
Procedure
- Ensure good lighting. A good view of the operation area is essential for an optimal suture result and affects the time needed for suturing.
- Disinfect the skin along the edges of the wound with a chlorhexidine solution 1% or a povidone-iodine (Betadine®) solution 10%.
- Always start with a careful inspection of the lacerations.
- Place a suture several millimetres above the top of the vaginal wound to fasten the blood vessels that emerge axially in the wound.
- Approximate the wound edges of the vagina with knotted sutures. Place the sutures about 1 cm apart.
- Restore the hymenal ring on the transition from the vagina and vulva carefully with a suture just inside the remnant of the hymen to prevent dyspareunia.
- Suture the incised muscle bellies of the bulbocavernosus muscle with two knotted sutures. Good approximation prevents weakening of the pelvic floor. The suturing technique with which the bulbocavernosus muscle is repaired with knotted sutures, provides a better anatomical and functional recovery of the vaginal sphincter than the technique in which the entire episiotomy is sutured with a continuous thread.
- Close the subcutis with knotted sutures. Start distally and take the unequal wound edges into account.
- Suture the skin distally to proximally (towards the hymenal ring) with knotted sutures or intracutaneously with a continuous polydioxanone/polyglycolic acid-based thread (Vicryl-Rapide®).