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Taylor Rackey, CPM Candidate 

Midwifery Documents 
Revised: April 19th, 2020 
 
Midwifery Documents: 
Second Degree Perineal Laceration Repair 
 
Anchor Stitch:  
● If there is ​no active bleeding​ coming from the wound, start the repair at 
the level of the internal apex 
● If there is active bleeding, place an anchor stitch 1 centimeter above the 
internal apex of the tear to ligate any retracted blood vessels  
○ It is ​NEVER​ acceptable to guess where the location of the internal 
apex of a tear; it must be accurately identified before continuing 
with the repair! 
● Tie an anchor stitch using a square knot 
○ Use 4 throws if using braided synthetic material 
○ Use 3 throws if using chromic material 
● Cut the short, free end, as you will continue on with the side attached to 
the needle 
 
Posterior Vaginal Wall: 
● If the tear is deep, use the two bite technique to place the first stitch. 
● After taking the first half of the first bite, while the needle is still in place, 
perform a digital rectal exam and make sure that you have encompassed 
the full depth of the tear. 
○ If the space is found to be larger than the tip of your finger, use a 
two-bite or buried circle stitch. 
○ If the first stitch was too shallow , use buried circle stitches to 
complete the repair of the vaginal floor 
○ If a buried circle stitch still leaves a significant gap below the first 
layer of stitches, you may need to place one or deep stitches 
● Place two or three stitches in the vaginal floor, and d/c repair before 
reaching the hymenal ring 
 
If a deep layer is not needed, skip straight to ​repairing the perineum --------- 
 
Deep layer stitches: 
● Use either interrupted stitches or basting stitches 
● Palpate to locate the the last suture loop placed in the vaginal mucosa 
and palpate for the trough near the tear 
○ This will help you to position a deep stitch 
● Insert the needle into one side of the tear and bring the tip out just in front 
of the trough of the tear 
● Remove the needle completely and reinsert it opposite its exit point. 
Taylor Rackey, CPM Candidate 
Midwifery Documents 
Revised: April 19th, 2020 
○ Keeping the point of the needle visible in the center helps to prevent 
the needle from penetrating the bowel wall 
● If only one stitch is needed, cut both ears and tie it off.  
● If more stitches are necessary, use this stitch as your anchor and place 
additional continuous stitches, as needed. 
 
Repairing the Perineum:  
Using the same suture material that was used to suture the vaginal floor- 
● To do so when continuous unlocked stitches have been used in the vaginal 
floor, place the last stitch at the level of the hymenal ring.  
● Direct the neele segment of the suture down the perineal portion of the 
tear by dropping the strand down towards your dominant side between 
the edges of the tear; keep the strand loose. 
● Now the needle is where it should be to begin basting down the perineum. 
 
Continuing the repair when a new pack of suture material is required- 
● Finish the strand that was used to close the mucosal layer in 1 of 3 ways: 
○ Use a three-strand knot to tie off your last stitch. 
○ Insert the mucosal needle beside the last exit point and come up on 
the opposite side, parallel with your insertion point. 
○ Leave a long loop on the non-dominant side and, using that one as 
thread, tie and trim your suture.  
○ Start a new pack of suture material by placing an anchor stitch at 
the top of the perineal body.  
 
Subcutaneous Closure: 
 
*If the tear is very shallow and does not necessitate a subcutaneous layer of 
sutures, move your needle to begin outer closure by inserting the needle 
behind the hymenal ring, running it through the tissue all the way down to 
the bottom of the perineal tear and bringing it out just inside the external 
apex of the tear. 
 
● Holding the edges of the skin apart, begin closure by starting a row of 
basting stitches in the perineal body --- beginning about 0.5cm below the 
introitus.  
○ Keep the entry and exit points of these stitches at least 8-10mm from 
the skin edge.  
● This layer is placed parallel with the surface of the perineum, making sure 
to encompass the depth of the tear. 
○ Remember, these stitches are not locked. 
● Continue these stitches down to the external apex of the tear.  
Taylor Rackey, CPM Candidate 
Midwifery Documents 
Revised: April 19th, 2020 
○ Most tears are deepest at the introitus, forming an increasingly 
shallow wedge as you approach the external apex 
■ Therefore, these stitches will be increasingly superficial as you 
near the external apex of the tear (the end above the anus). 
● Once you have gotten to the point that your basting stitch will be less than 
a quarter inch from the skin edge, run your needle under the tissue and 
bring it out inside the posterior apex of the tear so that you can begin 
outer closure. 
 
Closing the skin layer: 
● Once the basting stitch is placed, a deep “subcuticular” running mattress 
stitch is placed beneath the skin to hold the edges closer together.  
○ Running mattress is ideal for closing the outer layer because they 
eliminate the irritation caused by interrupted stitches since none of 
the strand is exposed. 
● Place the running mattress stitch parallel with but 2-3mm below the skin’s 
surface, in the subcutaneous fascia 
● *If a subcuticular stitch is not to be used, tie the stitches off at the external 
apex of the tear using a triple-strand square knot. 
 
Finishing the repair: 
● After finishing the subcuticular layer, you will again be at the vaginal 
introitus.  
● Use the same technique to tie off, regardless of the stitch type: 
○ Begin by inserting the needle between the edges of the skin tear and 
passing it back inside the vaginal for one last stitch.  
○ Bring the needle out of the tissue near the hymenal ring. 
○ The last stitch may be placed either in front of or behind the 
hymenal tags, use judgement of what seems best. 
 
Resources: 
 
Frye, A. (2010) Healing Passage - A​ Midwife’s Guide to the Care and Repair of the 
Tissues Involved in Birth​. Labrys Press. Portland, Oregon. 

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