A clinician’s review of perineal tear repair in the UKLeave a Comment
Where have we come from and where are we going?
Author: Darya Kozlyk, Midwife at University College of London (UCLH) Hospital. PhD Candidate in Maternal Medicine at UCL. Qualified midwife since 2015.
Around 85% of women who have a vaginal birth will sustain some degree of birth-related perineal trauma and of these around 70% will need perineal suturing, usually within an hour of the birth1. Critically, perineal trauma requires accurate examination, classification and adequate repair to avoid lifelong adverse consequences for the woman’s physical, sexual and psychological health2.
2003 Milestone Moment
The NHS supports approximately 350,000 women who sustain perineal trauma every year2. Yet despite this perineal repair via perineal suturing was not systematically incorporated into routine clinical practice in the U.K3 until the results of a seminal randomised control trial in 20034 were published which found that repair leads to improved healing. This, along with Cochrane systematic reviews recommending continuous suturing using absorbable sutures (which don’t need to be removed postnatally), has seen the practice of perineal repair firmly incorporated into the National Institute for Health and Care Excellence (NICE) guidelines5.
Today: Room for Improvement
Despite the significant improvements new guidelines have led to, there remains significant areas for improvement. For example, second degree perineal tear repair is the most common intrapartum surgical procedure yet studies have shown considerable gaps and disparities in the methods used in clinical practice6. Studies of UK-based qualified midwives show that only 39% feel that their training was adequate, that 37% had no hands-on training prior to undertaking their first repair7 and only 6% of midwives used evidence-based suturing methods to repair all layers of the perineum6. To address this knowledge gap the Perineal Assessment and Repair Longitudinal Study (PEARLS)1 provides an interactive educational package that aims to improve evidence-based practice and is available to all Midwives through the Royal College of Midwives’ I-learn platform7.
Despite the advances in training, current standard practice for postpartum suturing inherently limits every clinicians’ ability to comply with evidence-based best practice. Today’s standard guidelines require the suturing clinician to digitally retract vaginally tissue to locate the apex, classify the degree of trauma and maintain this position for the duration of the procedure. This puts the clinician at high-risk of needle stick injury, hinders the quality of repair and increases the risk of inadequate repair.
The Future of Perineal Repair
The Hegenberger Retractor for perineal repair is the next step in suturing best practice for clinicians and their patients.
Designed to work in conjunction with PEARLS Training Package, Obstetric Anal Sphincter Injuries (OASIs) Two Bundle8 and NICE clinical guidelines5, it allows suturing clinicians to perform repairs according to evidence-based practice and using both hands for the duration of the procedure. Emerging international data from clinicians shows the retractor improves exposure and access for the suturing clinician, provides a safer, more ergonomic environment to perform routine repairs and complex OASIs and aids compliance with evidence-based suturing practice.
- Ismail KM, Kettle C, Macdonald SE, Tohill S, Thomas PW, Bick D (2013). Perineal Assessment and Repair Longitudinal Study (PEARLS): a matched-pair cluster randomized trial. BMC Medicine 11(209). https://doi.org/10.1186/1741-7015-11-209 [Accessed 14 June 2022].
- NHS Digital. NHS maternity statistics, England 2019-20. 2020. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/nhs-maternity-statistics/2019-20 [Accessed 15 June 2022].
- Lundquist M, Olsson A, Nissen E, Norman M. Is it necessary to suture all lacerations after a vaginal delivery?. Birth. 2000 Jun;27(2):79-85. Available at: https://doi.org/10.1046/j.1523-536x.2000.00079.x [Accessed 20th July 2022].
- Fleming VE, Hagen S, Niven C. Does perineal suturing make a difference? The SUNS trial. BJOG: an international journal of obstetrics and gynaecology. 2003 Jul 1;110(7):684-9. Available at: https://doi.org/10.1016/S1470-0328(03)02353-X [Accessed 20th July 2022].
- National Institute for Health and Care Excellence (NICE) (2014). Intrapartum care for healthy women and babies [Last updated 21 February 2017]. https://www.nice.org.uk/guidance/cg190 [Accessed 25 May 2022].
- Bick DE, Ismail KM, Macdonald S, Thomas P, Tohill S, Kettle C. How good are we at implementing evidence to support the management of birth related perineal trauma? A UK wide survey of midwifery practice. BMC pregnancy and childbirth. 2012 Dec;12(1):1-0.
https://doi.org/10.1186/1471-2393-12-57 [Accessed 14 June 2022].
- Royal College of Midwives (RCM). MaternityPEARLS; Perineal Repair and Suturing. 2018. Available at: (Accessed 2nd August 2022).
- Royal College of Obstetricians and Gynaecologists (RCOG). OASI Care Bundle Project. 2020. Available at: https://www.rcog.org.uk/oasicarebundle [Accessed 20th July 2022].