Jan wasn't going to miss the Royal Wedding for anything, not even the birth of her second child. I remember her saying ‘I’m watching it, even if I’m up in stirrups.’

Which made me smile. She had a very determined 15-minute second stage and her baby was born just before Kate arrived at Westminster.

Jan sustained a fiddly second-degree tear and so I asked for help with suturing, from an extremely experienced midwife who was running the birth center that day. We wheeled in a TV and Jan fed her baby while watching the service.

It was a great distraction for her as we ensured haemostasis and that everything was aligned.

Everything went well for Jan, despite her tear.

But did you know 12% of women say having a tear sutured is 'the worst thing’ that happened to them during birth?

That's quite a statement.

In this post, we’ll do a quick round-up of the most important suturing topics.

Why Women Tear

85% of women will tear during birth. That seems odd, doesn’t it? It might be that current birth practices of encouraging women to do 'directed pushing', rather than letting things progress naturally, might cause this.

Though at least one trial I know of suggests directed pushing makes no difference. It could just be that nature isn’t very kind to perinea.

It would make evolutionary sense for women following their own instincts not to tear as much (Does Jan's instinct to not miss the wedding count as directed pushing? I'm not sure.  She was a lady on a mission 😉 )

Preventing Tears

There's quite a bit of research on tearing prevention, and it's unclear whether midwives being hands on or hands off the perineum during crowning makes a difference. A slow, controlled birth is what midwives aim for.

There's evidence to suggest waterbirth helps prevent tears, wahey, love those. Being physically active also helps, possibly because it increases smooth muscle tone everywhere.

I've also read some fascinating anecdotal evidence about an obstetrician who practiced in a nudist community. He hypothesised the women who spent more time naked didn't tear as much because their perinea were tougher, having been out of clothes and exposed more.

 One to try?

Anatomy

Have a look at this video for the basics.

When you come across your first tear if you're anything like me, you'll feel like you've been plonked down in a new city without a map. It'll just look like a bit of a red mess - though keep things women-centered by not saying this out loud!

Keep practicing and you'll soon be able to navigate all on your own.

Look at diagrams and perhaps get one of these anatomy and physiology colouring books (I like colouring in, it's soothing).

The pelvic floor is a big bunch of muscles stretching off in different directions, supporting the weight of the organs. Then you’ve got the vaginal wall, and the skin, both of which can be torn.

Ideally, the damage won’t gone high enough to involve the urethra (which can cause problems passing urine), or the clitoris (ouch).

Finally, you don't want the tear to go too low. If it involves the anal sphincter you'll need an experienced obstetrician to suture under excellent light and with pain relief, in theatre.

You suture by matching the colours and shapes of tissues. Ongoing bleeding can make this rather tricky.

You get different kinds of tears. 1st degree are just to the skin. 2nd degree are to the skin and some muscle. 3rd degree are to the skin, muscle, and a bit (or a lot of) the anal sphincter.

We suture to stop bleeding or in medical language 'achieve haemostasis', and to put the tissue of the vagina and muscle back in the right place so the woman won’t suffer from painful sex or other issues.

A Cochrane review in 2011 found there wasn’t enough evidence to say one way or another whether we should suture…but there also wasn't enough evidence to say we should stop, if you see what I mean. It’s a bit confusing, but the RCM suggests we should be cautious about leaving 2nd-degree tears to heal on their own.

As always, it’s the woman’s choice.

Ensuring Kindness

My mentors who taught me to suture when I was newly qualified were so gentle.

Lots of other midwives I know have a kind of ‘let’s get it over with’ attitude, but my mentors went slowly, used lots of local anaesthesia and gas and air.

The way of numbing (lidocaine injection) is similar to what's used when you're at the dentists. But it's a more intimate and potentially more painful procedure so make sure you take your time, go slowly and gently.

I always told women the truth: that there's often no way of making things 100% comfortable without spinal anaesthesia - and that comes with much higher risks, a delay, and possibly a trip to theatre.

After suturing, midwives tend to give a suppository of paracetamol and/or diclofenac, as this helps a lot with targeted pain relief.

One of my mentors used to give this first so it would start kicking in as she sutured, which seemed to do the trick.

If you’re a student it's great to observe suturing as often as possible – but do support breastfeeding too as this can be a great way of distracting Mums if you haven’t got a Royal Wedding to hand.

Essentially, suturing is one of those skills that you build through experience and muscle memory, like learning to drive. Keep asking questions and doing little bits here and there and it'll fall into place.

Now I'd love to hear from you:

• Do you have a personal or professional story about suturing that we could benefit from?
• Any tips for learning to suture?

As always, thanks so much for reading. If you know someone who could benefit from this post, it'd be great if you could share it.

I hope everything is good for you in midwifery and life.

Don't forget to be good to yourself even when you have huge responsibilities. Napping is basically a requirement of caring for others some days 🙂

Ellie x