Repair of 2nd degree tear - is it standard to leave muscle layers unsutured?

[cardamomginger]

Morning everyone. Hoping someone out there can give me a bit of information.

I sustained significant birth injuries when I gave birth to DC1 last year and wrote a letter of formal complaint to the hospital about various aspects of my care. I obtained a copy of my notes and the surgeon who will be doing the reconstructive surgery (not at this hospital) flagged a couple of issues to do with the way I was sutured. The hospital have replied that their actions in my case are adequate and in no way substandard.

I would like some clarification and I'm hoping that a friendly MW out there might be able to give me some information and what is/is not usual suturing practice for second degree tears.

I sustained a tear to the puborectalis muscle. The hospital say that this "would not routinely need to be repaired". Is this true and why? Is it therefore the case that not all the layers of muscle torn are sutured? Which ones do? Which ones don't? And why? I've had a quick look at NICE and their guidance on Intrapartum Care states at 1.9.25 that in cases of second degree tear the muscle should be sutured. So I am confused.

They used a suture called Vicryl Rapide, which my surgeon says does not provide enough support to muscle tears. The manufacturer's website states that it provides short term wound support to skin and musoca. I understand using it for the final layers of skin, but the hospital used it for ALL suturing, including whatever muscle layers were stitched (although maybe they didn't stitch any!). Again, the hospital state that this is standard. Is this true? There's an absorbable suture that is suitable for muscle and hangs around in the body a bit longer. Is this ever used? When?

Thank you!

[laluna]

Hello! Friendly midwife here!

Re suturing muscle as part of a second degree tear, the NICE guidelines confirm the answer I would give - I would personally always suture muscle - whichever one it is. I may occasionally leave the skin depending on the anatomy and nature of the tear but would never recommend that the muscle is left.

We always use the same suture material throughout (even the obstetricians repairing third degrees) and use vicryl rapide.

[gushofbloodtothefloor]

I was sutured after a second degree, but they came out within a day. The rest of the healing was completed 'open', which looked horrific and was painful - but it naturally closed within 2 weeks and was fully healed by 6.

[cardamomginger]

Thanks laluna! That's helpful . Wonder why they have a different policy.
Does seem odd to me to use vicryl rapide for all layers, when it only holds for 10 days and muscle takes longer than this to heal and there is a disolvable suture specifically for muscle.
Glad you are OK gush.

[ratprincess]

I'm not a midwife, nor can I answer your question re: whether muscle is normally sutured. However, I can tell you about my sutures -I happened to be looking through my notes today. I had a 3b tear (repaired at Kings College Hospital in 2010).

For the external sphincter repair, the obs used 3 o PDS sutures.

For the repair to the vagina she used 2 o Vicryl rapide.

I remember her telling me that one set of sutures were quick dissolving and the other took longer to dissolve (?3-4 weeks maybe).

Hope this helps.

[cardamomginger]

Thanks! I think I still have some questions....!

[first1]

I have nothing insightful to say other than whatever they used for the first attempt of repairing my 3a tear were crap and all poked out so I was sitting on a million knives

[breatheslowly]

I had vicryl rapide both for my initial stitching and for the second attempt at stitching. I was told that I would need a repair after my epi reopened as otherwise the muscle wouldn't come together - so I think that stitching of the muscle is pretty much always required.

[cardamomginger]

Thanks guys!