Making Sense of What You See

A critical midwifery skill is to prevent (to the greatest extent possible) and repair the damage that can occur to a woman’s body when a baby is born. Sometimes, even if a laceration (“tear”) occurs in the genitalia or perineum, the best thing to do is to let the body heal on its own. At other times, suturing (stitching) of the damaged skin or muscle is required. While the hand skills of administering local anesthesia and suturing are not very difficult, learning to identify the relevant structures of the body in their damaged state and learning how to use one’s judgment as to where and what to repair is difficult and intimidating for any student. Here I recount a complex laceration repair that I observed early in my midwifery training. The woman’s personal details have been changed to protect her privacy.

*****

I have been on the unit for two minutes, and have forgotten to eat breakfast. I have missed a birth by a hair — I arrived early, but not early enough — and have had time to change and take a breath before entering Alba’s room. Her baby has been taken away (“Smelly baby,” the nurse whispers to me); its fever and odor indicate chorioamnionitis, an infection of the membranes surrounding the baby in the uterus. Alba is propped up with her legs open as the midwife finishing 24 hours on the L&D unit investigates her vaginal laceration.

It is not the worst laceration I have ever seen, but it is the most unfathomable. Is it a “2nd degree”? A “3rd degree”? How many muscle groups will need to be brought back together? The midwife has begun suturing but Alba bleeds and bleeds — she has already lost 600cc of blood, and has received misoprostol to stop the hemorrhage. I enter with the midwife coming on for the day, her bright pink lipstick meant to inspire energetic confidence. After being awake for nearly 30 hours, the midwife repairing Alba’s laceration is showing signs of exhaustion; the repair is seeming unmanageable to her. She has missed the deepest point of the laceration, and is now wondering aloud if what she has done needs to be removed so that we can start over. The new midwife relieves her, and tells her not to worry. She positions herself at Alba’s perineum and adjusts her glasses.

Sitting by the midwife’s side, what I see is: lacerated tissue on the right, lacerated tissue on the left. Blood: rivulets, seeping, the occasional tiny spurt. Swelling. Interlocking stitches and a suture hanging from the vagina onto a clean towel. I am allowed to insert one sterile hand into the deepest part of laceration to feel the tunnel it forms under the existing suture; I am thankful for the epidural placed during labor that allows me to do this without Alba feeling pain. I am allowed to offer my opinion on how to repair it — a few deep, interrupted stitches, followed by further interlocking stitches — and I am permitted to wonder aloud how to perform such a deep repair when stitches have already been placed. (Repair on the horizontal plane, I’m told, not the vertical.)

Alba continues to bleed. I feel lightheadedness creeping over me and think about the granola bar in my bag, wishing I had stuffed it into my mouth before coming into the room.

The midwife stitches, I blot and retract labia. She instructs me: Suture like to like, and I attempt to identify any two pieces of tissue that actually look alike to me. I watch her deftly place interrupted stitches deep into the wound, and she points out the borders of the intact anal capsule; a deep 2nd degree laceration, then.

And as she slowly repairs, the bleeding stops and the muscle and skin come together — seemingly by magic, although I know very well that it is no such thing. After two midwives, nine packets of suture, 30 gauze sponges and an hour and a half, Alba’s body looks almost as if no damage had been done at all. I tell her how brave she has been, and how we will make sure that she heals properly with no infection. I am sweating.

The midwife turns to me and narrates my thoughts in a low voice: When I was a student, I was sure I would never be able to do this.

 

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