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To suture or not to suture second degree perineal lacerations: what informs this decision?

INTRODUCTION

The quality of perineal care given to birthing women affects them physically and emotionally, both in the short and longer term (Steen, 2007). Perineal assessment skills and expertise of those who care for the birthing woman can have a considerable effect on her entry into motherhood (Baston, 2004). Thus it is significant that one of the most common clinical decisions midwives are required to make is whether or not to suture perineal lacerations.

The Royal College of Obstetricians and Gynecologists (RCOG) estimate that 85% of women who have a vaginal delivery will have some degree of perineal trauma and that 60 to 70% will require suturing (RCOG, 2004). In New Zealand (NZ) there were 64,160 births in the year to March 2009 (Statistics New Zealand, 2009) and all these births have a midwife in attendance, with the majority (75.3%) having a midwife Lead Maternity Carer (LMC) (Ministry of Health, 2007). In an uncomplicated birth, the responsibility for the assessment and management of perineal tears rests with these midwives (New Zealand College of Midwives [NZCOM], 2005).

Recognition that carefully selected second degree tears can and do heal without suturing or risk of harm to the woman has been tacit midwifery knowledge for many years in the United Kingdom (UK) (Walsh, 2007). This may also be the case in New Zealand, as Christchurch Womens' Hospital in 2004 reported 16 women (from the 409 primiparous women who birthed vaginally) experienced a second degree tear which was coded as 'not sutured' (Soh, 2004). The report noted, "This is surprising, as it is usual practice to suture second degree tears ... this may reflect incorrect classification, a coding error, a data entry error, or clinical practice" (ibid, p.34). Yates (2002) gives an opinion that NZ midwives have tended to leave minor perineal tears to heal spontaneously. She suggests this is because research and clinical practice have shown that women can suffer when sutured. However she also expressed concern that there is little evidence, and some potential negative consequences, with a decision to leave a significant second degree tear unsutured (Yates, 2002).

Walsh (2007) says the debate on not suturing second degree tears was not raised in the UK public arena until the early 1990's. Head (1993) performed an audit describing non-suturing of second degree tears as common midwifery practice with equivalent healing and less pain. Following this, another UK study by Clement and Reed (1999) also found no problems with perineal healing in a one year retrospective audit of women, cared for by independent midwives, who had second degree tears left unsutured.

However it is of some concern that recent research indicates that unless midwives have received additional and specific training in perineal assessment they are not good at accurately assessing and appropriately treating perineal tears (Andrews, Sultan, Thakar, & Jones, 2006; Groom & Paterson-Brown, 2002; Langley, Thoburn, Shaw, & Barton 2006; Smalldridge, 2003; Tohill & Metcalfe, 2005). That being said, just what constitutes best care of the perineal tears is an area that until recently has been subjected to limited examination. Furthermore what information is available can be confusing and contradictory.

This article reviews the research which has examined the influences on midwives decision making on suturing and non-suturing of second degree perineal tears. It looks at the impact on outcomes for both midwives and women. Finally, recommendations to aid in midwifery decision making for perineal care will be presented.

REVIEW OF LITERATURE

A review of the literature was performed with a search strategy to assess the outcome of healing in the population of women who experience second degree perineal tears, with the intervention of non-suturing and the comparison of suturing. There was no minimum length of follow-up. The information being sought also included classification and incidence of second degree perineal tears, risk factors, and current repair practice.

Electronic database searches of the Cochrane Library, Medline, and CINAHL were conducted to identify recent publications. Search terms were initially limited to publication dates in the last 10 years. However where there was an overlap of significant key studies cited within the body of the paper or bibliography over 10 years old, these were also retrieved. Research that was limited to suturing techniques was excluded. The review was restricted to literature available in English.

Articles were sorted according to the RCOG (2004) levels of evidence. The traditional hierarchy of evidence provides an understanding of why one methodology carries more weight over another. This ranking system demonstrated in Table 1 (page 30) is a standard notation for the relative weight carried by different types of study when decisions are made about the effectiveness of clinical interventions. The RCT is the 'gold standard' and represents the only true means of evaluating the effectiveness of an intervention (in this case, non-suturing) in terms of improving outcomes. However where studies had descriptive information that added to knowledge on the subject, despite not meeting the level of evidence standards, these were also included. All identified documents were examined and those that were relevant were retrieved for inclusion in the review. Reference lists of retrieved documents were then scanned to identify any additional articles of interest. Studies and information were assessed for their appropriateness to the NZ maternity setting.

The Cochrane Library and Medline were searched using the relevant MESH terms and imposing the limits of English, female and adult. The terms 'second degree' and 'non-suture' were removed as they were not recognised, leaving search terms of perineum, tear, and suturing. While there were no relevant Cochrane Reviews, three applicable Randomised Controlled Trials (RCT) were found (Fleming, Hagen, & Niven, 2003; Langley, Thoburn, Shaw, & Barton, 2006; Lundquist, Olsson, Nissen, & Norman, 2000). CINAHL located two relevant prospective cohort studies (Leeman, Rogers, Greulich, & Albers, 2007; Metcalfe, Bick, Tohill, Williams, & Haldon, 2006) and a range of other articles (e.g. Cioffi, Arundell, & Swain, 2009; Dahlen & Homer, 2008; Layton, 2004; McCandlish, 2001).

Additional papers were identified, and key papers confirmed, via the evidence-based information website resources of Turning Research into Practice (http://www.tripdatabase.com), National Health Service Evidence Health Information Resources (http://www.library.nhs.uk) provided by National Institute for Health and Clinical Excellence (NICE), and British Medical Journal Clinical Evidence (http:// clinicalevidence.bmj.com). Practice guidelines from NZ, such as NZCOM consensus statements (http:// www.midwife.org.nz/) and the NZ Guidelines Group (http://www.nzgg.org.nz/), did not have information related specially to perineal care. Thus UK RCOG guidelines on perineal treatment (RCOG, 2004), NICE Intrapartum Care guideline (NICE, 2007), and the Royal College of Midwives (RCM) Midwifery Practice Guideline (RCM, 2005) were accessed. Current evidenced based midwifery textbooks from NZ, Australia and the UK also provided relevant information (Crabtree, 2004; Hendry, 2006; Raynor & Bluff, 2005; Walsh, 2007). Reports published by NZ health authorities (e.g. National Women's Hospital, 2007; Soh, 2004) and professional and government sites (e.g. Finn, 2008; Ministry of Health, 2007) further assisted in creating a picture of midwifery perineal tear treatment.

CURRENT PRACTICE

Current practice highlighted in a recent midwifery practice article from the office of the NZ Health and Disability Commissioner advised NZ midwives that there is ongoing debate on the benefit of suturing tears (Finn, 2008). Finn counsels that the decision to refrain from suturing can be appropriate but she precedes this statement with a cautionary tale of a complaints process initiated against a midwife who did not suture a tear.

In Crabtree's (2004) examination of the competing influences on NZ midwives decision making, medicalisation is described as the default mode. Under the default mode, suturing could be considered the appropriate method of treating all perineal tears but also may be a basis of fear for midwives. From a lawyer's perspective, Pearse (2000) suggests that midwives' fear "means that we start doing things for the wrong reasons that can result in harm" (p.10). One of the things we may be doing for the wrong reasons is making a decision about suturing or nonsuturing of second degree perineal tears without true consideration of the significance.

In NZ, there has been a tradition of suturing of second degree tears (Soh, 2004). McCandlish (2001) observes that suturing second degree trauma to the perineum has also been standard practice in the UK for many years. Yet there has been a gradual shift since the 1990's towards midwives leaving second degree tears to heal naturally without suturing. This has been brought to light by information from UK, Sweden, America, Australia and NZ (Clement & Reed, 1999; Dahlen & Homer, 2008; Finn, 2008; Fleming et al., 2003; Head, 1993; Langley et al, 2006; Layton, 2004; Leeman et al., 2007; Lundquist et al., 2000; Metcalfe et al., 2006; Miller, 2008; Soh, 2004).

CLASSIFICATION AND ASSESSMENT OF PERINEAL TEARS

Sultan's (1999) classification of perineal tears into four categories has been adopted as standard by the RCOG (2004). Tears are grouped according to severity and number of tissue layers involved: First degree - injury to skin only, second degree - injury to the perineal muscles but not the anal sphincter, third degree - injury to the perineum involving the anal sphincter (further divided into 3a: less than 50% of external sphincter thickness torn; 3b: more than 50% of external sphincter thickness torn; 3c: internal anal sphincter torn) and fourth degree - injury to the perineum involving the anal sphincter complex and anal epithelium. Second degree tears are the most frequently occurring perineal trauma (Albers, Garcia, Renfew, McCandish, & Elbourne, 1999).

However there is no universal classification system to measure the severity or the grade of second degree perineal tears. This has led to a lack of consensus on evaluation of perineal trauma among doctors as well as among midwives (Jackson, 2000; Metcalfe et al., 2002; Mutema, 2007). This lack of consensus also causes difficulties when trying to assess practice implications as, by definition second degree tears may range from a shallow split in the superficial perineal muscle to an extensive three way vaginal tear involving deep perineal muscles (Metcalfe et al., 2002; Ullman, Yiannouzis, & Gomme, 2004). Variations in perineal length may also affect impressions of severity (Rizk & Thomas, 2000).

A UK survey (Sultan, Kamm, & Hudson, 1995) exposed concerns of junior doctors and midwives about the quality of their training in perineal anatomy and repair. In 2002, a NZ audit of knowledge of superficial perineal muscles revealed that only 7% of midwives and doctors were able to identify the perineal muscles correctly (Robinson & Beattie, 2002). Smalldridge (2003) describes a dramatic increase in the diagnosis of major perineal tears in a large NZ hospital after instigating a programme of every tear being checked by a senior midwife or doctor. Research conducted in the UK demonstrated that major perineal tears, including anal sphincter injuries, were missed on clinical examination by midwives and doctors (Andrews, Sultan, Thakar, & Jones, 2006; Groom & Paterson-Brown, 2002). Certainly UK NICE guidelines (2007) recommend rectal examination if there is any suspicion perineal muscles are damaged, followed by referral to a senior midwife or doctor if there remains any uncertainty.

What is more, detection of perineal tears appears to be enhanced by thorough physical exploration of the extent of the tear (Langley et al., 2006). A measuring and assessment tool, the 'Peri-Rule' (Metcalfe et al., 2002), has been designed to assess the complexity of second degree perineal tears by midwives in the UK but does not appear to be in common use. Unexpected findings of a 2005 study found UK midwives consistently underestimated the degree of trauma when using only a visual examination (Tohill & Metcalfe, 2005). In 2006, Langley et al. had similar concerns, warning that the perception of severity of perineal trauma appeared to be influenced by the more detailed examination required during the act of suturing. Midwives were advised that these findings had important implications for postpartum examination, leading Langley et al. to recommend the damaged perineum is examined closely and carefully.

INCIDENCE

Australian statistics (Laws & Hilder, 2008) gave figures of 23.6% of women sustaining a second degree tear, whereas the American second degree perineal tear rate was estimated at around 20% (Leeman et al., 2007). Interestingly there are no NZ perineal tear statistics in the Ministry of Health Maternity Report (2007). However NZ Midwifery and Maternity Providers Organisation (MMPO) midwives data for 2004 revealed 17.2% of the nearly 10,000 women (16.9% of total NZ births in 2004) who had an MMPO midwife had second degree perineal trauma. Primiparous women experienced the highest rate of second degree perineal tears at 23% (NZCOM, 2008a).

MMPO data did not reveal how many NZ women had their tears sutured or not sutured, and who made this decision, although this data may be available in the future (NZCOM, 2008a). A NZ study of a small group of Wellington LMC midwives (combined caseload of 225 women) in 2008, demonstrated that LMC midwives were doing the majority (82.5%) of perineal assessment and suturing for their clients (Miller, 2008). Miller (2008) also found LMC midwives are more likely to suture perineal tears in a hospital environment (66.7% of tears sutured) as opposed to a home birth setting (50% of tears sutured).

RISK FACTORS FOR PERINEAL TEARS

Risk factors for perineal tears include first vaginal birth, birth weight over four kg, persistent occipitoposterior position in first time mothers, induction of labour, epidural, second stage longer than one hour, shoulder dystocia, midline episiotomy and forceps delivery (RCOG, 2007). Of concern with increasing rates of obesity in our society, is that obese women who gained more than 18 kilograms during pregnancy had elevated rates of genital tract lacerations (Albers, Greulich, & Peralta, 2006). Maternal education at high school level and beyond is associated with increased risk of perineal trauma (Albers, Sedler, Bedrick, Teaf, & Peralta, 2006). Increasing age was also identified as a risk factor for perineal morbidity (Williams, Herron-Marx, & Carolyn, 2007).

Kettle and Tohill's (2007) systematic review of perineal care, advised that continuous labour support compared with usual care, reduces assisted vaginal birth, but overall rates of perineal trauma remain the same. This differs from recent UK research (Symon, Winter, Inkster, & Donnan, 2009) reporting that women who booked under an independent midwife in the UK were more likely to avoid perineal trauma. Furthermore, Miller (2008) found that in the NZ continuity of care model, there were no differences in the number of perineal tears between women who birthed at home or in hospital. Miller's findings contrast with recent Swedish research that concluded women birthing at home were less likely to sustain pelvic floor injuries (Lindgren, Radestad, Christensson, & Hildingsson, 2008).

Research on the anatomy of the perineum and the impact on perineal trauma rates indicates that a short perineum with a reduced distance between anus and perineum (a common variant of the normal anal anatomy) are associated with more perineal trauma (Deering, Carlson, Stitely, Allaire, & Satin, 2004; Rizk & Thomas, 2000). Several studies have concluded that being of Asian ethnic origin is a perineal tear risk factor. They suggest this may be due to shorter perineal bodies, but also may be due to difficulties in communicating effectively. (Dahlen, Ryan, Homer, & Cooke, 2007; Hopkins, Caughey, Glidden, & Laros, 2005; Williams & Chames, 2006; Williams et al. 2007).

NZ maternity statistics demonstrate that Asian women had more risk factors for perineal tears than other ethnic groups. Asian women tended to be older, have less children and more likely to have obstetrician care, epidural, episiotomy and instrumental birth (Ministry of Health, 2007). This has implications for the NZ maternity services; as while Asian women only make up only 9.3% of the birthing population (Ministry of Health, 2009) they are projected to have the largest percentage growth of all ethnic groups, up about 120 percent to 600,000 in 2021 (Statistics New Zealand, 2008).

There are no national figures currently available relating to rates of perineal laceration for Maori women. However, Maori women gave birth at a younger age, with a birth rate second only to Pacific women. They were also more likely to have a normal birth, without induction or epidural, compared with women of other ethnicities (Ministry of Health, 2009). In addition Maori mothers were more likely to register with a midwife (81.9 percent) and less than one percent registered with an obstetrician (Ministry of Health, 2007). This means that they have the lowest risk factors for perineal tears of all ethnicities in NZ.

RESEARCH ON WHETHER TO REPAIR OR NOT

The British Medical Journal performed a systematic review on perineal repair in 2007 (Kettle & Tohill, 2007). One of their questions concerned the effects of non-suturing of muscle and skin in first and second perineal tears. Based on two RCTs, Lundquist et al. (2000) and Fleming et al. (2003), it was reported that there is limited evidence regarding benefits and harms of non-suturing of first and second degree tears. It was also pointed out that it is impossible to blind assessors to the allocated treatment, and this may bias results (Kettle & Tohill, 2007).

Lundquist et al. (2000) from Sweden performed the first RCT on the outcomes of suturing or non-suturing of first and second degree tears. Their results, measured to six months after birth, showed no significant differences in healing. The study used a specially trained team of midwives to care for the women. An unexpected finding was that the unsutured women enjoyed a more positive breastfeeding experience. They concluded that first degree, and small second degree perineal lacerations (no larger than two cm x two cm, well-approximated and not bleeding) can be left to heal without needing suturing. It was noted that a limitation of this study was the small sample size of 80. In addition it did not differentiate between first and second degree lacerations and used non-standardised data collection instruments and procedures, causing difficulty in interpreting validity of results (Fleming et al., 2003; Kettle & Tohill, 2007).

The most cited RCT in this area, the SUNS trial, was undertaken by Fleming et al. in Scotland in 2003. They compared outcomes up to six weeks postpartum, assessing perineal pain and healing of sutured and unsutured first and second degree tears (regardless of size and complexity). Trained midwives collected the data. The Redness Edema Ecchymosis Discharge Approximation (REEDA) tool (Davidson, 1974) was used to assess perineal healing. Pain scores were similar in both groups but there was poorer approximation of the unsutured tears at six weeks. A higher rate of breastfeeding in the non-sutured group was noted throughout the study. Their recommendation was for continuation of suturing due to poorer wound healing in the unsutured group. Kettle and Tohill, (2007) reported that this RCT had 'reasonable methodological quality'. A sample of 340 was needed to detect 20% difference in pain and wound healing with 80% power based on a significance level of 1%. However due to recruitment difficulties it had a small sample size of 74 women in total (of which 56 sustained a second degree tear). A further limitation of this trial was that it included both first and second degree tears and it ceased at six weeks postpartum.

Langley et al. (2006) performed the most recent and the largest RCT to date. The healing of sutured and non-sutured second degree tears (regardless of size and complexity) were assessed by a proforma and questionnaire to four to six weeks administered by the trial midwife, and later via a qualitative postal survey at intervals of six weeks, six months and one year. Long-term healing and pain between the sutured and non-sutured groups was equivalent. There was no difference between the sutured group and the unsutured group in urinary stress incontinence and resumption of sexual activity although the non-sutured group was more likely to practice pelvic floor exercises. Langley et al. (2006) concluded that the benefits of not suturing second degree perineal tears are not straightforward. They comment that suturing produces faster healing in the early stages but not in the longer term when the groups were equivalent. However they advocate initial faster healing in the sutured group must be balanced against the need for more pain relief due to the sutures. They also reported that while infection is argued to be a possible consequence of nonsuturing, the results of their research demonstrate very low rates of infection and no difference attributable to suturing. It was noted that there was a change in suture practice during the study, although comparison of both methods showed no difference in outcome by method. The study was powered to detect a 20% difference in quality of healing with 80% power, based on a significance level of 5% and the sample size was 200 women. In contrast to the RCTs of Lundquist et al. (2000) and Fleming et al. (2003), Langley et al. (2006) looked at second degree tears only.

In 2004, a year long quantitative survey of 80 Welsh women by Layton (2004) found midwives decision for non-suturing of selected first and second degree tears did not affect the incidence of dyspareunia and urinary incontinence. However Layton in critiquing her own survey, observed that it was small with unknown variables. She cautiously concluded that decisions on non-suturing should only be reached after careful consideration of perineal damage.

Metcalfe et al. (2006) performed a prospective cohort study for one year, involving 282 women in the UK. They found that there was no difference in perineal pain, but there was increased self referral for perineal problems and increased Edinburgh postnatal depression scores in the unsutured group. Metcalfe et al. did not advocate a change in practice to nonsuturing due to these findings.

A 2007 American prospective cohort study by Leeman et al. over three months, found that of the 172 women in their study, those in the sutured group used more pain relief during hospital stay, but there was no difference between pain scores and similar healing at six weeks. Despite commonly expressed concerns, at twelve weeks they found no difference in pelvic floor function, incontinence or perineal body measurements between the sutured and unsutured group. Consequently they reported that there was no benefit in suturing second degree lacerations and advised suturing should be deferred because of the pain of suturing. Midwives in this study had received additional specialised training on perineal assessment, repair and pelvic floor function.

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GUIDELINES

While there are no national New Zealand guidelines for midwifery perineal care, many DHB's and individual hospitals have their own policies. However two major UK clinical guidelines, RCOG (2004) and the Royal College of Midwives (RCM) Midwifery Practice Guideline (2005), provide specific perineal treatment instruction. The RCOG (2004) perineal suturing guidelines are now incorporated into the UK NICE guidelines (2007), and these state that women with second degree trauma should be advised that the muscle should be sutured to improve healing. Perineal repair should be with a continuous nonlocked suturing technique for the vaginal wall, muscle and perineal skin as this causes less pain and greater satisfaction with their repair than women who had interrupted sutures. If the perineal skin is opposed following suturing of the muscle, the advice is that there is no need to suture the skin as this results in less pain and dyspareunia, and fewer removals of sutures at three months after birth than women who had perineal skin sutured (NICE, 2007). Non-suturing of second degree tears is not offered as an option in the NICE guidelines and this is based solely on the RCT of Fleming et al. (2003).

The Royal College of Midwives (RCM) Midwifery Practice Guideline (RCM, 2005) advises that studies of non-suturing ofthe perineum have conflicting findings in respect of impact on perineal healing. They base their advice on two RCT's of Lundquist et al. (2000) and Fleming et al. (2003) and suggest that additional research is required. They also recommend that small follow-up studies offer a psychological and social point of view which may assist in informed decision making.

INVOLVEMENT OF WOMEN IN DECISION MAKING

Women need to be actively involved in all decisions regarding their perineal treatment. In a case investigated by the NZ Health and Disability Commissioner in 2002, Yates as an expert midwifery advisor, advocates that it is unsatisfactory to leave a woman's perineum unsutured "without discussing fully all options of repair and possible consequences" (Yates, 2002 p. 34). Frye (1995) suggests that if a woman refuses perineal suturing for extensive tears that she may not fully understand the consequences of her decision. She recommends the midwife use deeper questioning to uncover any negative feelings and beliefs about suturing that may be resolved prior to birth. This would appear to be endorsed by the recommendations of Finn (2008), who reports that there are a small but increasing number of complaints made about midwifery care in NZ. While only a limited number are related to perineal issues, the morbidity is apparent from reports on NZ Health and Disability Commissioners website (Health and Disability Commissioner, 2008).

The best time to provide information to women about perineal treatment is debatable. Langley et al. (2006) reported difficulties in antenatal recruitment for their perineal suturing trial as women were unwilling to be randomised. They found women tended to be certain that either suturing or non-suturing was preferable as result of previous experience or on the advice of others. Clement and Reed (1999) cautioned that the vast majority of women, when offered the opportunity, found it easy to decide not to be stitched. Lundquist et al. (2000) also advised that women described great relief when they know that suturing can be avoided. This fits with the findings of Fleming et al. (2003) who discovered that many women previously informed and consented in the antenatal period appeared to be changing their minds about participating in the study following birth and instead chose not to be sutured. They suggested that the midwife may have influenced the women's decision but they also felt women were obviously capable of making informed decisions about their care immediately postnatally. Certainly postnatal informed consent is an approach that has been used successfully in the past (Davidson, 1974; Metcalf et al., 2006).

DeSouza (2006) suggests it is difficult for midwives to have an appropriate balance between giving enough information to assist the woman to make a choice but not overwhelming her or creating anxiety. She also points out that while midwives are expected to appear neutral in their advice, they may in fact have strong feelings regarding care which will impact on how the advice is offered. This may conflict with the care plan that midwives are advised to complete with the women around 36 weeks of pregnancy (NZCOM, 2005). Women can and do change their minds in their labour and the postpartum period, including their plans for perineal care, and this must always be a consumer's prerogative. This suggests that perineal assessment, discussion and treatment be fully documented, using diagrams if needed (NICE, 2007). Frye (1995) goes a step further, advising midwives to get women to sign a waiver if they refuse suturing of a tear that may potentially result in serious morbidity.

Understandably women prefer to be sutured by the same professional who assisted with the birth. Then they are less likely to have to wait for repair (Ho, 1985) and receive more understanding care (Hulme & Greenshields, 1993). Feedback from women also appears to influence midwives decisions regarding perineal repair and reduce perineal repair rate. One study reported rates of non-suturing rose from 20% to 80% due to midwives being able to reflect upon their practice in relation to the woman's experience (Lewis, 1995). Perhaps, suggest Clement and Reed (1999), this is because women appeared to view having or not having stitches from a holistic perspective and weighed up perceived short and longer term psychosocial and physical factors.

DISCUSSION

According to Raynor and Bluff (2005), midwives have not historically been recognised for making use of evidence to inform decision making. Consequently, it is not surprising that Australian and UK researchers report that when some midwives' make the choice to not suture some second degree tears it is seen as concerning and lacking good evidence (Dahlen & Homer, 2008; Fleming et al., 2003; Metcalfe et al., 2006). However the decision to suture or not suture has historically had little researched evidence for guidance, leaving midwives having to rely on past knowledge and experience (Cioffi, Arundell, & Swain, 2009).

Raynor and Bluff(2005) suggest that in the UK, maternity culture is changing and the expectation is that midwives today will use their professional judgment within evidenced based guidelines to make decisions. A recent study has found Australian midwives see the key to making the suturing verses non-suturing decision as being deep within the experience of a midwife in having the ability to see difference between small, aligned, not bleeding tears and large, ragged, misaligned and bleeding tears (Dahlen & Homer, 2008). From a NZ perspective, Jackson (2002) says it is understandable if a midwife leaves a second degree tear to heal without being sutured at a woman's specific request. She also reminds midwives that visualising the full extent of a second degree tear, and digital rectal examination, is essential to the decision making process (Jackson, 2002). Nevertheless there are valid concerns that while some midwives may describe second degree tears as small or uncomplicated to justify non-suturing, these may be subjective, inconsistent and often poorly informed definitions and decisions (Jackson, 2000; Metcalfe et al., 2002; Mutema, 2007; Robinson & Beattie, 2002; Sultan et al., 1995; Ullman, Yiannouzis, & Gomme, 2004). Furthermore incomplete perineal assessments may lead midwives to state they have very few tears (Frye, 1995).

Cioffi et al. (2009) advise that a full appreciation of cues (such as bleeding and birth trauma), in addition to women-centred factors (such as the ability for self care, cooperation, consent, discomfort, disfigurement, and sexual function) ensures that a more comprehensive perineal assessment occurs. They suggest it is this holistic assessment on which the decision to not suture or suture depends for best practice decisions. Awareness of the sum of these cues appears to be what informs midwives decisions regarding the need to suture or not.

Reassuringly, overseas midwives appear to be keen to get information on perineal care (Dahlen & Homer, 2008; Mutema, 2007). It has also been observed that workshops on perineal issues at NZ midwifery conferences have standing room only, although it has to be said that the information given tends to focus on avoiding episiotomies and on suturing skills. Indeed, the Midwifery Council New Zealand (MCNZ) website places optional workshops on midwifery perineal care under the heading 'Epidurals, Suturing and other Surgical' (MCNZ, 2008). Certainly in the past, perineal repair courses were often sponsored by the companies marketing suture material and perhaps this influence still creates expectations today.

NZ LMC midwives have the advantage over many overseas midwives of seeing the longer term results of their perineal treatment with the provision of continuity of care for six weeks after birth (NZCOM, 2005). This may also include providing care to the same woman in subsequent pregnancies. It could be expected that direct verbal and visual feedback from women on their outcomes as a result of suturing or non-suturing assists to hone midwifery skills and experience. This is aided by the compulsory biennial reflection process of NZCOM Midwifery Standards Review (NZCOM, 2007). Certainly NZCOM (2005) considers perineal assessment and repair to be a requirement for both training and qualified midwives. Unfortunately there are no NZ midwifery guidelines or consensus statement to facilitate how midwives can make best practice decisions in this area. This is also the case in Australia where in the absence of specific guidelines, education on perineal treatment varies between different organisations and models of care (Dahlen & Homer, 2007). On the other hand, the NZ Midwifery Council (MCNZ) incorporated perineal suturing into the first round of compulsory three yearly Technical Skills Workshops (MCNZ, 2008) and awards perineal suturing workshops offered by District Health Boards and educational institutions desired recertification 'Elective Education' points.

The key concepts of this article are summarised in a flowchart (Figure 1 - page 32). The concepts characterise the midwifery practices that are best supported by evidence, and most likely to provide optimal perineal care.

CONCLUSION

From this literature review, it is apparent that studies of non-suturing of second degree perineal tears have conflicting findings in respect of impact on perineal healing based findings from a systematic review, three RCT's, two large prospective cohort studies, UK guidelines, and a variety of other evidence. This would not be surprising to NZ midwives as what constitutes a second degree tear varies from a shallow skin and muscle abrasion right through to cavernous, forked perineal wounds just short of a third degree tear. It is also apparent that midwives are influenced by the environment in which they practice, whether home or hospital. In addition the views and needs of the women are an important consideration for midwives, especially in the continuity of care model where the midwifery partnership and women's feedback is a fundamental and required component of practice.

Of fundamental importance for midwives in NZ today is that our midwifery care continues to be safe, effective, efficient, culturally appropriate, holistic, and in partnership with women (NZCOM, 2005). Our constant challenge is to not just identify when this does and does not occur, but to make changes that improve midwifery practice through integration of experience and research. Most NZ midwives would agree that second degree perineal tears should be sutured if they need it. The critical skill is the assessment of the tear to determine 'need'. To enable midwives to achieve this critical skill requires quality midwifery education and information to be readily available. In addition, legitimising practice by some midwives of non-suturing of uncomplicated second degree perineal tears by continuing and specific research in the NZ midwifery context is vital.

NZ midwives are uniquely placed within our continuity of care LMC model to assemble data on the realities of perineal care for NZ birthing women, looking at both day to day clinical practice and longer term outcomes. Using an appropriate sample size across a spectrum of midwifery 'ways of being' and experience would genuinely reflect the views and experience of NZ midwives and women. Furthermore the information would allow further shaping and evaluating of NZ midwifery knowledge and ultimately be to the benefit of women and normal birth.

Wickham's (2000) challenge is that birthing women may well have different individual needs for protection and treatment of the perineum and the midwife should find answers to suit her practice and the needs of the women she is with. This midwifery experience should be informed by past and present practice, evidenced based research and perhaps most importantly, the views and needs of the women who are the recipients of the care. The final word rests with Frye (1995); who reminds us that women will be depending on the midwife's assessment of their perineum to make an informed choice but that ultimately the decision rests with the woman.

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Accepted for publication August 2009

Cronin, R., Maude, R., (2009) To suture or not to suture second degree perineal lacerations: What informs this decision? New Zealand College of Midwives Journal 41, 29-35.

Authors:

* Robin Cronin RCpN, RM, IBCLC, BA, PGDipMid

LMC Midwife, Tauranga

robincronin@xtra.co.nz

* Robyn Maude RN, RM, MA (Midwifery), PhD candidate

Lecturer Graduate School of Nursing, Midwifery and Health

Victoria University of Wellington

Midwife Leader, C&CDHB

Robyn.Maude@vuw.ac.nz
Table 1: Traditional Hierarchy of Evidence
(Greenhalgh, 1997, p. 48)

1     Systematic reviews and meta-analyses.

2     Randomised controlled trials with
      definitive results (that is, a result
      with confidence intervals that do not
      overlap the threshold clinically
      significant effect).

3     Randomised controlled trials with
      non-definitive results (that is, a point
      estimate that suggests a clinically
      significant effect but with confidence
      intervals overlapping the threshold for
      this effect).

4     Cohort studies.

5     Case-control studies.

6     Cross sectional surveys.

7     Case reports.
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Title Annotation:PRACTICE ISSUE
Author:Cronin, Robin; Maude, Robyn
Publication:New Zealand College of Midwives Journal
Article Type:Report
Geographic Code:8NEWZ
Date:Oct 1, 2009
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