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TrustedAdult t1_izt18gv wrote

Hi! I'm an ob/gyn.

I don't have an answer to your question, but I have commentary on the current state of perineal laceration suturing that I want to share here to keep some harmful misinformation from spreading.

First off, perineal lacerations are very common. It is very common to have lacerations with one's first vaginal delivery.

They get measured in "degrees." 1st-degree is very superficial, 2nd-degree involves the underlying structure of the "perineal body," and 3rd and 4th degree involve some or all of the anal sphincter.

That's an assessment of perineal lacerations that's very geared towards their significance for future pelvic organ prolapse (having the vagina bulge outward) and dysfunction with defecation. It doesn't include labial lacerations, lacerations that involve the clitoris or clitoral hood, or periurethral lacerations -- those all lack a grading system, and in my experience, get described subjectively.

/u/illraceyou96, /u/Fearless_Reaction592, /u/Snakandahalf -- non-perineal pelvic lacerations are understudied. It's recent that we have good data on what we can do to reduce the risk of perineal lacerations (perineal massage, for example), and I think non-perineal lacerations will be next. I'm going to talk a little bit about why.

Although misogyny is a constant force in our world, there are things that medicine likes and doesn't like to study. Medicine likes studies with clear differences between groups and outcomes: people either did or didn't get a medication, and you look at hospitalization rates after. Clitoral and labial lacerations are tricky because they are soft-tissue injuries happening after the very unpredictable interactions between a fetus/newborn and a vulva... and then the intervention is also very randomized right now, because there's a wide range of how aggressively physicians repair these kinds of lacerations.

So I think/hope that over the next 20-30 years, we'll see development of better ratings to measure labial/clitoral lacerations, which will be followed by proving that they correlate with subsequent risk of pain or sexual dysfunction, and then that will be followed by studies to see if interventions reduce their risk and/or if we can standardize management of them.

(This kind of standardization happened for cesareans in the last decade, for context.)

I've had the privilege of taking care of a lot of people who had unattended deliveries without repair of lacerations. I'd like to say without a doubt that repairing perineal lacerations is good. People who have unrepaired lacerations are at high risk of going on to have pelvic organ prolapse, which can cause issues with discomfort with activity, sexual dysfunction, incontinence, and constipation.

/u/biRdimpersonator brings up the "husband stitch." I've had the good fortune of only training in places with a high degree of compassion and patient-centered care, and during the ongoing takeover of ob/gyn by women. Medicine is becoming less patriarchal and paternalistic. I have never seen a "husband stitch." I have never seen anybody do anything more than was needed to return the vulva (close) to the state it was in before the delivery.

Most of my work is in abortion care. Some urogynecologist might come through here and correct me on the current state of research!

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Kabloozey t1_iztcay3 wrote

This is gold. Med Student here. I was never sure how to broach the husband stitch matter with my OBGYN attendings, usually during deliveries the perineal repairs have made perfect sense! For all the reasons you mentioned. Where it's gotten a bit more grey for me is where I was a part of a particular vaginal reconstruction+prolapse repair surgery (the former was an add on by the patient) with an awesome urogyn I've learned under (she is a great surgical educator, actually let's me cut and stitch and enjoys teaching) , but I still remember one comment of "don't worry about how the tissue looks here, it'll feel the same and neither will notice, it doesn't have to be aesthetically pleasing. Her husband and her are gonna love this." It was very frank and I enjoy that about her sense of humor. I was at a bit of a loss though about what to make of that on a grand scale as it did remind me of the "husband stitch." At this point I'm interpreting it as something the patient wanted for their own sake? Kind of like how some men opt for penile lengthening/entension surgery? (Although that's less common) I'm no expert on this topic I'm just trying to parse the situation with the now very negative, rightfully so, perception of the husband stitch. I understand a major difference here is of course the patient being the one to make this choice. Ie there's a respect for autonomy here. (At least from what's visible on our end)

I should clarify too, I only participate in procedures or surgical operations with patient permission as to how exactly I'm participating*

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TrustedAdult t1_izthwdg wrote

Hi there! Glad you're engaging with this.

> but I still remember one comment of "don't worry about how the tissue looks here, it'll feel the same and neither will notice, it doesn't have to be aesthetically pleasing. Her husband and her are gonna love this."

Yeah, that comment makes me wince a bit, too. I'm trying to picture a posterior repair surgery and where somebody might say that and really mean it. Maybe a bit of puckered vaginal mucosa? It might have been a surgical situation where she had sorted the underlying support structures and it left the mucosa looking a little odd...? I'm making this up.

I think that if your impression of this urogyn was otherwise positive, and she was otherwise compassionate and patient-centered, you can forgive a comment that didn't land right and we can give her the benefit of the doubt.

I remember a very sweet 60-year-old patient whose husband was absolutely doting. They were such a sweet couple in pre-op, and he was so warm and positive... and then as we were about to wheel her away he said "va a estar coma una quinceñera, si?" (And it'll be like it's her sweet sixteen, right?) (Except fifteen not sixteen.) And we all winced and groaned... but she laughed! And when I checked how she felt about it, said she was happy for him and looking forward to that, too.

So it's important to remember that, even if you're trying to have perfectly feminist and respectful language, your patient might not... and that's okay! Meet them where they are. Don't reflect negative ideas back at them, but engage with the positive in what they're saying.

> At this point I'm interpreting it as something the patient wanted for their own sake?

I think so. Or something that your attending has heard many times from patients. No urogyn wants to do a repair that winds up uncomfortably tight. Even if the doctor isn't compassionate, that's a miserable patient that keeps coming back unhappy! Who wants that? We're surgeons. We like to get things done right once and have them be fixed and that's it.

> (she is a great surgical educator, actually let's me cut and stitch and enjoys teaching)

I think that it's good for you to keep in mind in public forums that people are reading your words without an understanding of supervision in medical teaching.

Like, I know that we're talking, say... putting a single stitch in the exit site of a retropubic sling in an incontinence surgery... not doing the imbricating stitches of a posterior repair. And I suspect that the cutting is the trimming the excess mucosa once it's been freed up from the underlying tissue, not making the opening incision on a cesarean. i.e., appropriate times for uncertain hands, where errors can be easily guarded against or corrected.

But how will your words sound to somebody who has their surgery next week and is really nervous?

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eeveeyeee t1_izu6o6a wrote

> But how will your words sound to somebody who has their surgery next week and is really nervous?

For what it's worth, I understood what they meant. Not necessarily the particulars but I knew that they meant under full supervision, after years of rigorous teaching and with very minor and routine procedures.

If you're never given the opportunity to practice, you'll never learn. I'd rather trainee doctors practice during their placements rather than only ever observe and then be thrown in the deep end when they qualify.

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Kabloozey t1_izuvng4 wrote

I'm not familiar with how to do specific sections of your comment as quotes, so sorry is a bit disjointed! I firstly totally agree that it may have been some non optimal word choice. She's truly awesome and her patients love her!

I know I suffer from some occasional wicked "foot-in-the-mouth-itis" we all do.

And I should clarify now that you mention it... this isn't r/medical school.

I'm not doing the surgery or anything high stakes during the procedure. We're talking closing laparscopic port sites, parts of open incisions (after the attending has got them started or gotten the key bits done) and certainly not doing anything major with knife. And all under active guidance from the surgeon. Not to worry anyone 😅. We start with watching and work our way up gradually as we prove ourselves competent as patients would, as I imagine, hope.

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Original_Amber t1_iztnzd6 wrote

It doesn't matter how it looks, neither will notice it. That's fine for vaginal intercourse. What about if the couple routinely partake in cunnilingus?

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Kabloozey t1_izuwj4o wrote

Fair point, I'm not sure! But I should mention It wasn't actually that profound. You'd kind of have to be looking for it and that was DURING the surgery. I'd imagine with healing it would be neglible. Possibly some scarring? It's not my area of expertise, but I imagine it would improve with time and be worth it from the patients perspective the vast majority of the time.

It could have been purely poor word choice? However I do think there was truth to it in that it would be hard to notice in the first place.

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PrettyChrissy1 t1_izvbo4h wrote

TrustedAdult, thank you for taking the time to put this information together. It's very insightful and extremely informative.

Some things referenced in your response I wasn't even familiar with, so I did some research and I'm now way more educated. Once again thanks.😊

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hotcookin53 t1_izvk92i wrote

Is there a term for lacerations that happen inside the vagina during child birth? Is that part of the scale or not because it's not the perineum?

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