Oxford Handbook of Midwifery (70 page)

position for suturing until all preparations are in hand to commence the procedure.

Procedure

but dimmed lights otherwise may help to create a more relaxed environment.

• Infiltration of the wound with 1% lidocaine—up to 20mL maximum dose within an hour and inclusive of the amount used for infiltration prior to episiotomy.
  
• Epidural if
  in situ
  can be topped up to provide analgesia for the
  

  procedure.
  

• Additionally the woman may like to use inhalational analgesia to
  

  assist if she is anxious.
  

• The needle should be inserted into the wound at the fourchette, passing superficially up the vagina; withdraw the plunger to ensure
  

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  Normal labour: third stage
  

  296
  

  the needle is not in a blood vessel, then infiltrate as the needle is slowly withdrawn.
  

  • Using the same site of entry pass the needle into the perineal body and infiltrate. The perineal skin is then infiltrated in the same way.
    
  • While waiting for the anaesthesia to take effect, you can check that you have everything ready for the repair and ensure the woman is comfortable and warm.
    
    • Suturing: repair is usually undertaken in three layers, this ensures that the repair is performed in a logical way and nothing is missed (Fig. 15.1). The layers are the vaginal epithelium, the perineal muscle, and the perineal skin. Care should be taken to align the edges of the
      

      tissues as accurately as possible throughout the repair, to ensure a neat symmetrical result. Sutures should not be pulled too tight as oedema and bruising to the site will cause pain and slow healing.
      

      • A taped vaginal tampon should be inserted into the vault of the vagina prior to the procedure to prevent blood oozing from the uterus obscuring the operator’s view. The tape of the tampon should be secured to the draped towels with a pair of forceps, so that it is removed following the procedure. On no account should loose cotton wool or gauze be used.
        

• • • • Absorbable suture material usually recommended is polyglycolic acid (Dexon), polyglactin 910 (Vicryl) or Vicryl Rapide, dependent on local provision.
        
      • Vaginal epithelium: identify the apex of the tear/episiotomy and secure the first suture, not going too deep as the rectum is in close proximity. Proceed using a continuous locking stitch, becoming a little deeper nearing the fourchette. Ensure good approximation of the edges and secure with a knot at the fourchette.
        
      • Perineal muscle: interrupted sutures (Fig. 15.1b) are used to achieve haemostasis and reduce dead space, thus helping to prevent haematoma formation. Identify the torn edges of the muscles and feel with the fingertips to judge the depth of suturing required. The first sutures are put into the deep tissues to bring the perineal body together, more sutures may be placed more superficially to bring the skin edges together (Fig. 15.1c).
        
      • Perineal skin: the perineal skin edges should be almost together at this stage. Various techniques may be used to aid healing; interrupted transcutaneous sutures, apposing the superficial
        

        edges and allowing natural healing and more commonly the use of continuous subcuticular sutures (Fig. 15.1d).
        

      • There is some debate regarding non-suturing of perineal skin—a large trial found no significant differences between sutured and non- sutured groups of women with regard to short-term pain.
        ¹
        

        • Alternatively, a continuous method of suturing may be used for all layers (Fig. 15.1a).
        

      • On completion of the suturing the tampon should be removed and the vagina inspected to ensure there are no bleeding points. The vagina and introitus should admit two fingers.
        

    ASSESSING AND REPAIRING THE PERINEUM
    

    297
    

    

    1. Continuous suture to vaginal wall
       
    2. 3-4 interrupted sutures to fascia and muscle of perineum
       
    3. Interrupted sutures to the skin (d) Subcuticular skin suture
       

    Fig. 15.1
    Repairing an episiotomy.
    

1
Gordon B, Mackrodt C, Fern E,
et al
. (1998). The Ipswich Childbirth Study: 1. A randomized evaluation of two stage postpartum perineal repair leaving the skin unsutured.
British Journal of Obstetrics and Gynaecology
105
, 435–40.

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298‌‌

Examining the placenta and membranes

Appearance of full-term placenta

The placenta is approximately 18–20cm in diameter, about 2.5cm thick in the centre and progressively thinner towards the outer edges. It is round or oval in shape and weighs approximately one-sixth of the weight of the fetus. It has two surfaces—the fetal and the maternal.

The maternal surface is deep red in colour and attached to the uterine decidua, it is indented with deep grooves, or sulci, into 15–20 lobes, known as cotyledons. The fetal surface lies to one side of the fetus and is attached by the umbilical cord. From the insertion of the cord at the placental site, blood vessels radiate to the periphery, forming subdivisions of the blood vessels that burrow into the substance of the placenta. Each cotyledon has its own branch of the umbilical artery and vein. The surface is covered with the amnion.

Examination

• Examine the placenta and membranes as soon as possible after birth to detect any abnormalities that may have a direct influence on the neonate or provide information about intrapartum events.
  
• Wear protective clothing and gloves.
  
• Wash the placenta in running water to remove any clots. Retain the clots to estimate maternal blood loss.
  
• Hold the placenta firmly by the cord to check that the membranes are complete—there should just be one hole through which the fetus has passed.
  
• Separate the amnion from the chorion to ensure that both membranes are present.
  
• Turn the placenta over with the fetal surface resting on the hand, and with the membranes hanging down. Carefully examine the maternal surface to see whether all the lobes are complete, there should be no spaces or ragged areas.
  
• Note any areas of infarction on the lobes, recognized as firm, fibrous whitish patches. Gritty areas may also be seen.
  
• Check the edge of the placenta for signs of the blood vessels permeating the membranes, which may be indicative of a succenturiate lobe.
  
• Occasionally one vessel is seen that tracks its way back into the placenta—this is known as an erratic vessel.
  
• Examine the umbilical cord carefully, noting its insertion into the placenta; the length, the number of vessels, and any abnormalities.
  

•
Usually the cord is inserted centrally into the placenta and is about 50cm long and 2cm thick, covered in a jelly-like substance known as

Wharton’s jelly. There should be one large umbilical vein and two umbilical arteries. Occasionally only one artery may be detected, this may be indicative of fetal abnormality and the baby should be examined thoroughly by a paediatrician.

EXAMINING THE PLACENTA AND MEMBRANES

299

Abnormalities of the placenta and umbilical cord

a tear in the membranes at the distal end, this would indicate that the missing cotyledon has been retained in the uterus. Consequently, cautions regarding blood loss and the passage of the products of conception need to be recorded in the woman’s notes and explained to the mother. A doctor also needs to be informed of these findings.