March 30, 2012 | 859 Comments

Can’t suture? Apply homebirth midwifery stupidity instead.

It’s hard to beat homebirth midwives when it comes to stupidity. Consider this bit of midwifery “wisdom” shared by Denise Gilpin-Blake and Summer Elliott in “A Natural Alternative to Suturing,” Sharing Midwifery Knowledge, Tricks of the Trade, Vol. IV:

Upon examination, I found a second-degree tear and told the couple that suture repair would be necessary. The couple refused suturing on the basis that they believed the tear should heal naturally. … While on an Indian reservation, I had studied with a shaman and observed the use of seaweed to heal burns and deep lacerations. … I [took] a piece of seaweed that was twice the length of the width of the tear, folded it in half and moistened it with sterile water. I placed it down the center of the tear and brought the edges of the tissue together, carefully aligning them. I also covered the entire length of the tear with a second patch of moistened seaweed. Before departing, I included in my postpartum care plan instructions to replace the outer patch of seaweed each time she used the bathroom. … Upon my arrival 24 hours later for the first postpartum check, all was well with mom and baby. … I discovered the tissue had healed miraculously well. … Ever since that birth in 1986, I have been using seaweed patches with great success as an alternative to suturing.

Why is it incredibly stupid? Consider the rationale for suturing the perineum> As I explained in a recent post on vaginal tears:

As you can see, this tear extends into the muscles that surround the vagina. The tear can be short in length or it can extend the entire distance between the bottom of the vagina and the top of the anal sphincter. A median episiotomy produces a second degree tear like this.

Putting the muscles back together makes sense if you want to preserve the natural shape and anatomy of the vagina. If it is not repaired, the opening to the vagina will gape, but there are usually no serious consequences of failing to repair it. Theoretically it is possible that the muscles will be able to heal back together on their own, but it is extremely unlikely. With the exception of very tiny tears, there are no circumstances under which a second degree heals “better” if it is not stitched.

Generally, when muscles are severed, their fibers retract to either side, and no longer meet in the middle. They will not heal together unless they are brought together by stitches. The overlying tissue (what you see when you look at the perineum) will almost always heal regardless of whether or not it is stitched. It’s like a cut. The skin heals by itself.

According to the homebirth midwives, the patient declined suturing, but the real reason the midwives didn’t suture is almost certainly tripartite:

1. they didn’t know how to suture
2. they didn’t understand the consequences of not suturing
3. they didn’t understand that healing of the overlying tissue is completely independent of healing the underlying muscle.

What are the consequences of not suturing a second degree tear? To understand, it helps to analogize to an elastic waistband in a pair of pants. Imagine that you tore through the overlying fabric right through the complete thickness of the elastic. Then imagine that you “repaired” it by closing the hole in the fabric without sewing the ends of the elastic back together. It might looked “fixed” from the outside, but those pants are not going to stay up and therefore, it isn’t fixed at all.

Similarly, if you do not suture the vaginal muscles back together, they will no longer meet in the middle. The patient may suffer a gaping vagina, and is at risk for an enterocele or rectocele, where the outer wall of the intestine or rectum pushes into the vagina. It’s not a fistula; there’s no hole between the vagina and rectum, but the large bulge into the vagina can be very uncomfortable and interfere with intercourse.

What did the seaweed contribute in this case? Absolutely, positively NOTHING. The overlying, outermost tissue was going to heal anyway. It didn’t need to be “treated” with seaweed, and I’m not aware of any scientific evidence that seaweed has any beneficial effects on wound healing of perineal lacerations. The seaweed did not heal the torn muscles together since they are too far apart to heal together. Only sutures could have preserved normal vaginal structure and the midwives didn’t suture. It’s difficult to imagine that if the midwives told the mother that her vaginal anatomy was likely to be severely compromised in the absence of sutures, she would have refused the sutures. They almost certainly didn’t tell her because they didn’t know and because they didn’t know how to suture at all.

So they screwed up in a major way, and the mother wil have to live with the consequences. That’s the worst part. However a close second is the fact that they have no idea that they screwed up and are actually proud of themselves for using a completely inane, totally useless “treatment.”

Author:Amy Tuteur, MD

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