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.
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.
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 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.
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