18.16 Injuries of the birth canal

Primary Mother Care describes the repair of episiotomies and first-degree tears; here we describe the repair of more serious injuries. You can nearly always avoid third-degree tears by ‘controlled pushing’, and by making an episiotomy when this is needed. They follow instrumental deliveries more often than normal ones. Almost all obstetricians meet them sometimes: so recognize this, and don’t blame the midwife. She will be upset anyway, and will be tempted to conceal such a tear if you are harsh.

Suture second- and third-degree tears, either within 24 hours of delivery, or after several months, when a tear has epithelialized and is no longer infected. With a recent third-degree tear: (1) Start by stitching the edges of the patient’s rectum together. (2) Cover these stitches with a layer of fascia. (3) Suture her anal sphincter with two or three interrupted sutures. (3) Close her vaginal and perineal skin. If a tear is old, you will first have to incise and reflect the skin which has grown over it.