Let’s think about why it’s necessary for midwives in Slovenia to learn how to suture episiotomy wounds and minor perineal tears, what benefits this brings for the woman giving birth, and the midwife supporting her, if we know that their core task is to protect the perineum during the pushing stage and keep interventions as low as possible?

Differences between doctors and midwives in performing episiotomies and suturing them?

The author wanted to answer the following research questions:

• In which countries are midwives allowed to suture episiotomy wounds and perineal tears independently? What degrees of perineal tears are they allowed to suture?
• Do midwives learn suturing during their studies, and which teaching aids do they use?
• Are any quality indicators tracked later in clinical practice that could be used to assess the quality of the work performed?
• Do midwives abroad believe that this type of knowledge contributes to greater recognition and autonomy of the midwifery profession?
• Did the registered midwives at the Maribor maternity hospital gain sufficient theoretical and practical knowledge during their midwifery studies in suturing episiotomy wounds and minor perineal tears?
• If not, the author was interested in whether the registered midwives at the Maribor maternity hospital are willing to learn how to suture episiotomy wounds and minor perineal tears, transfer this knowledge into practice and take full responsibility for the work performed, and whether they believe that this type of knowledge contributes to greater recognition and autonomy of the midwifery profession.

During her midwifery studies, the author of the thesis found that since 2008 the study programme has included a theoretical introduction to performing and suturing episiotomy wounds, as well as the option of practical suturing practice on a model. However, for now students cannot transfer this knowledge into clinical practice in any way (except for performing an episiotomy in later years of study). Even later in their professional careers, after completing their studies, they do not have the opportunity to practise suturing episiotomy wounds and minor perineal ruptures, and therefore do not build on their theoretical knowledge with practical experience in this area. In Slovenia, midwives in maternity hospitals do not have these competencies, which reflects the fact that they still do not have the autonomy to manage low-risk births completely independently. Perinatal care in Slovenia is still a hierarchically organised, medicalised process (Furlan, 2010).

Difference in performing and suturing episiotomy between doctors and midwives

• Tincello (2003) and Karimi and Khadivzadeh (2011) state that there are some differences between midwives and doctors in performing and suturing episiotomies. Differences are observed especially in the length of the episiotomy, the distance from the sagittal plane, and the size of the angle from the longitudinal axis of the perineum in mediolateral episiotomy. They investigated possible differences in clinical practice between doctors and midwives regarding the size and location of the episiotomy. It was found that doctors often make a longer incision that is further away from the longitudinal axis of the perineum. This can be explained by the fact that doctors manage instrumental births (vacuum extraction, forceps, vaginal breech birth, etc.). They suture more tightly (pull the stitches tighter). Midwives make shorter incisions that are closer to the longitudinal axis of the perineum. They often do not suture minor ruptures if they are not bleeding (labia, vagina).

Why should midwives learn suturing?

• A strong argument for learning suturing in midwifery practice is the WHO (2003) guidelines, which state that the professional who performs an episiotomy should also repair it. In Slovenia, episiotomy is performed by midwives in most births, so they should also know how to suture it.
• The EMA (European Midwives Association) calls for home birth to be enabled and legalised in Slovenia, and for midwives to be trained accordingly, proving their competence by obtaining a licence and certificates of additional training and education, which also includes competence in suturing.
• The competency of suturing episiotomies and perineal tears (along with other competencies) is defined in Slovenia in the document “Professional Activities and Competencies in Nursing and Midwifery Care” (Železnik et al., 2008) and should therefore be transferred into clinical practice.
• Fleming (2006) argues that midwifery education and practice must be aligned. Midwifery education must be focused on acquiring competencies for practice, which represent the basic standard for obtaining a licence to work.
• Better establishment and delivery of the continuity of midwifery care model for women and newborns.
• According to some authors, Slovenian midwives’ knowledge of suturing would also contribute to reducing the number of traumatic birth experiences and thus postpartum depression.
• Good interprofessional collaboration with representatives of the medical profession and the introduction of reflective practice in midwifery, which would enable midwives to think more critically, evaluate their own work, and take responsibility in cases of professional errors (Mivšek, 2012).
• Greater autonomy for midwives and a faster professionalisation process in midwifery.
• A more rational allocation of financial costs in healthcare.
• It enables better employment opportunities and greater mobility for Slovenian midwives within the EU (Čelhar et al., 2010). One of the EU principles is the free movement of labour among its member states (Zakšek, 2007).

HOW DO MIDWIVES SUTURE ABROAD?

Italy

• Since 2005, suturing training has been included in the study programme
• Most midwives DO NOT SUTURE
• IF THEY DO SUTURE: it depends on the doctor, whether they allow it, and on the maternity hospital where they work
• First- and second-degree tears, NO EPISIOTOMIES!

Sweden

• A four-year university midwifery programme – they learn suturing on animal tissue, by reading theory, watching videos, and learning about instruments and suture materials.
• Midwives suture first- and second-degree tears, minor episiotomies
• Every newly employed midwife must demonstrate their knowledge and experience in suturing by being observed while suturing (the number of wounds sutured is not prescribed), and once they are assessed as capable of suturing independently, they are granted a licence/permission to suture.
• Suturing contributes to the autonomy of the midwifery profession

The Netherlands

• With a midwifery diploma, every midwife is allowed to suture first- and second-degree tears, episiotomies, vaginal tears, and labial tears. Midwifery studies last 4 years. If a woman has a third- or fourth-degree perineal injury and gives birth at home, she must be transferred to a maternity hospital, where a doctor sutures it.
• AUTONOMY? Why are we even asking this? They are already autonomous in their field!

New Zealand

• Midwifery in this country is at a high professional level. In New Zealand, midwives are competent and fully independent in suturing episiotomies and perineal tears, except for third- and fourth-degree tears, which are sutured by doctors. Suturing is standard midwifery practice in this country.
• The College of Midwives organises many training workshops – including on suturing episiotomies and perineal tears – intended also for already registered midwives in the country.
• Students suture when the opportunity arises and always in the presence of their mentor. After graduation, midwives initially always suture under their mentor’s close supervision, and when the mentor assesses that they are sufficiently trained to suture, and when the midwife herself also feels confident, she can work independently.
• Each midwife keeps her own statistics (number of births, episiotomies, tears, possible complications …). These statistics are reviewed once a year by so-called supervisory experts. In this way, quality indicators are also tracked – each midwife receives a detailed insight into her work during the annual review. Every midwife in the country must know and follow the competencies and standards of midwifery work. Every two years midwives must defend midwifery standards (Midwifery Standards Review – MSR) to renew their licence (registration).

Slovenia

• Since 2008, suturing training has been a mandatory part of midwifery care
• Learning on a sponge
• February 2016: the first training workshop at the Faculty of Health Sciences – Department of Midwifery – suturing training for midwives from clinical practice – training on chicken thighs
• The theoretical part of the training was led by midwives
• The practical part by obstetricians (1 UKC Ljubljana, 2 UKC Maribor)
• DESPITE TRAINING, MIDWIVES DO NOT SUTURE IN PRACTICE!

Maribor

• Midwives with shorter work experience (up to five years) mainly gained theoretical knowledge in suturing episiotomy wounds during their studies.
• For midwives with more than five years of work experience, suturing episiotomies and minor perineal tears was in most cases not covered during their studies, and for midwives with more than ten years of experience, not at all.
• 75% of midwives would like to gain suturing knowledge and 25% would not.

Arguments they cited AGAINST gaining this knowledge were:

1. More important than suturing is that midwives are recognised for providing antenatal care for healthy (low-risk) pregnant women and managing normal births, with the wish that this would not be only on paper but actually carried out in practice.
2. This area is exclusively the responsibility of doctors, as they gained the appropriate practical knowledge during their specialisation, which midwives in Slovenia do not have at all.
3. For Slovenian midwives, knowing how to suture would be an additional burden in terms of taking on extra responsibility without receiving appropriate pay. Doctors already shift too much of their work onto registered midwives, and suturing skills would only make midwives’ work harder, especially at night.

Conditions for transferring into practice and taking responsibility

• More midwives employed in the labour ward, with each midwife caring for a maximum of 2–3 women in labour at the same time, appropriate pay, truly solid prior theoretical and practical knowledge in suturing.

To define, adopt, introduce, and implement competencies in midwifery, including suturing episiotomy wounds and minor perineal tears, personal motivation is needed from both midwives and users of midwifery services, support from representatives of other professional groups, support from the professional association of midwives, political support, and a clear definition of goals and a vision for the midwifery profession. Every profession needs a vision for development so it does not decline. A vision is a realistic and clear idea of how the profession will progress, and where and what it will be in a few years’ time. First, midwives in Slovenia need to be recognised for managing normal births, and appropriate standards and clinical pathways should be developed accordingly. First and foremost, the competency of suturing episiotomy wounds and minor perineal tears should be clearly defined and specified: what knowledge/education must be obtained beforehand, who may suture them, and under what conditions.

The role of the Faculty of Health Sciences and, of course, the Department of Midwifery is very important in introducing the suturing competency. In the author’s opinion, the school is the most competent to organise training workshops and invite qualified lecturers to participate (including from abroad, if needed). It is also extremely important that representatives of the school work well and in a coordinated way with representatives of the Chamber of Nursing and Midwifery Care and the Section of Nurse Midwives, because this brings unity, alignment, and strength to the midwifery profession. Before introducing the competency of suturing episiotomy wounds and minor perineal tears into clinical practice in the Republic of Slovenia, it is necessary to ask what benefits the introduction of this competency in midwifery would bring the most. Therefore, before implementing this competency in practice, it would make sense to carefully examine the wishes and demands of Slovenian women, and above all clarify whether suturing performed by a doctor really means greater medicalisation of birth for them than if the same service were performed by a midwife. It is right that Slovenian midwives follow the research results of other countries, but it is even better if in the future they undertake their own research on the Slovenian population of women giving birth, which contributes to building solid foundations for the Slovenian midwifery profession. Despite possible suturing knowledge, Slovenian midwives must not forget their basic mission. Their core goal must still remain an intact perineum, supported by good antenatal preparation for birth, proper management of the second stage of labour, and appropriate perineal protection. All of this will require a fundamental change in midwives’ thought patterns in how they do their work in the future.

Conclusion

• Introducing and implementing the competency of suturing episiotomies and minor perineal tears (along with other competencies) in midwifery is an opportunity for Slovenian midwives to prove that they are an important, invaluable, and integral part of the mosaic of Slovenian healthcare. This requires a great deal of additional knowledge, courage, perseverance, inner strength, willpower, and the development of a vision.
• Midwives in Maribor have a vision. And most often it is this vision that gives them the strength to keep going despite fatigue, stress, and strain. They are ready to step onto a new path of autonomous midwifery, ready for new challenges and to gain the necessary knowledge through close and strong partnership collaboration with women and their families as well as with obstetricians.
• They are guided to this way of thinking by the fact that only in this way will Slovenian midwives regain the millennia-old wisdom that has been taken from them throughout the history of midwifery.

Source: Rosemarie Franc’s thesis (2013); Suturing an episiotomy wound and minor perineal tears under the mentorship of Assist. Prof. Dr Ana-Polona Mivšek, BMid.

Read also:

• Preparing the perineum for birth
• Perineal injuries
• Episiotomy
• Techniques and procedures that help preserve the perineum

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