Evidence‐Based Suturing Education for Midwives

Abstract

Perineal repair is a skill that student nurse‐midwives must achieve competency in before graduating and entering practice. Students and new midwives often express a lack of confidence in their ability to undertake perineal repair. This article aims to share one public university nurse‐midwifery program's experience developing and implementing a suturing education program with an interprofessional approach. We designed a workshop that optimized student confidence and competence in suturing by incorporating the best evidence. Components of this workshop included interprofessional education, leveraging of technology, online preparatory materials for students to reference and practice before attending, allowing time for in‐person practice and return demonstration with instructor feedback, and evaluation of student competence at the end of the session. The lack of evidence for best practices in suturing education for student midwives highlights interprofessional suturing education—where midwives, medical students, and obstetric interns learn together—as a promising area for future research. Optimizing student competence through interprofessional education enhances new midwives’ skills and confidence and fosters collaboration and trust among professions with shared clinical responsibilities, ultimately improving outcomes for providers and patients.

BACKGROUND

Nurse‐midwifery students learn to provide care for patients across their life span. Midwifery programs prioritize learning the skills necessary to care for patients during and after birth. Midwifery students are required to become proficient in repairing perineal lacerations sustained during vaginal birth, and students often express that they find this experience of learning to suture stressful. Some midwives, especially students and new midwives, commonly lack confidence in their suturing skills. ¹ , ² , ³ , ⁴ Carroll et al suggest that this lack of confidence may interfere with the continuity of care if a more experienced midwife or obstetric colleague subsequently performs the repair. ⁴ Methods of instruction on suturing technique vary across universities, but all midwifery programs accredited by the Accreditation Commission for Midwifery Education include introductory suturing education in their curriculum.

Nature and Significance of the Problem

According to the American College of Obstetricians and Gynecologists, an estimated 53% to 79% of patients giving birth vaginally sustain perineal injury. ⁵ The morbidity of poorly healing perineal lacerations is significant. Infection and dehiscence following perineal laceration occur in up to 23.6% and 24.6% of cases, respectively. ⁶ The cost to patients experiencing wound complications is significant, including the financial cost of follow‐up care, as well as lingering pain, aesthetic or body image effects, incontinence, dyspareunia, and disruption of breastfeeding and childcare activities. Competent repair reduces the risk of complications such as bleeding, infection, and wound breakdown. ⁶

The American College of Nurse‐Midwives (ACNM) establishes the core competencies that represent the foundational knowledge and skills necessary for the safe practice of nurse‐midwifery. Graduates of midwifery and nurse‐midwifery training programs must be able to recognize and repair first‐degree and second‐degree perineal lacerations and to consult with a collaborating physician for the repair of third‐ and fourth‐degree lacerations. ⁷

  

Continuing education (CE) is available for this article. To obtain CE online, please visit http://www.jmwhce.org. A CE form that includes the test questions is available in the print edition of this issue.

A REVIEW OF THE LITERATURE

Students and new midwives anecdotally report feeling anxious or lacking confidence when learning to suture and applying these skills in practice—an experience well‐documented in the literature. Dahlen and Homer found that inexperienced midwives were significantly more likely to self‐assess as “not at all confident” and to feel concerned with their performance of suturing repair “all of the time.” ¹ Surveys consistently show low confidence among midwives in performing perineal repair: only 21% of more than 400 midwives in the study by Bick et al felt “very confident” all the time, dropping to just 4% when focusing solely on inexperienced midwives. ² Similarly, East et al found that 44% of 69 midwives felt “very confident,” ³ and Carroll et al reported that 20% of 52 midwives felt “not at all confident,” ⁴ with confidence levels varying by experience across all studies. ¹ , ² , ³ , ⁴

QUICK POINTS

• ✦Repairing first‐degree and second‐degree perineal lacerations is a core competency for midwifery education.
• ✦Student midwives and new midwives express a lack of confidence in perineal repairs.
• ✦Multimodality education incorporating online preparatory learning materials followed by live demonstration and observation by suturing experts with iterative feedback may improve competence and confidence in suturing ability.
• ✦Suturing education from an interprofessional teaching team with at least one expert midwife and one expert surgeon or obstetrician‐gynecologist may improve suturing skills.

Several studies highlight midwives’ desire—and researchers’ recommendations—for additional or continuing education in evidence‐based perineal repair. Investigations into current training for novice clinicians and new midwives have also identified key opportunities for improving this education.

A literature review identified key best practices in suturing education, including interprofessional learning, multimodal content delivery that incorporates technology, opportunities for repeated review, direct faculty feedback, and repeated hands‐on practice with return demonstrations. Repetition of skills practice under faculty guidance increases student confidence, which may transfer to increased confidence in the clinical setting. ⁸ , ⁹ Incorporating best practices into suturing education can enhance students’ confidence and competence in perineal repair, ultimately contributing to improved outcomes for their future patients. ¹⁰ , ¹¹ , ¹² , ¹³

A prospective randomized controlled trial conducted during the COVID‐19 pandemic evaluated the acceptability and effectiveness of basic suturing in novice learners, comparing face‐to‐face classroom teaching with an online, synchronous format. ¹⁴ The authors concluded that both approaches were equally effective and acceptable to the students. In another study, Bradford and colleagues found that when paired with regular home practice, remote instruction can boost students’ confidence and competence in suturing skills. ¹⁰

Technology and Blended‐Modality Learning

Technology can enhance learning by allowing students to practice remotely from the educational institution. Blended‐modality learning, with the opportunity to first practice skills at home over time, followed by an in‐person demonstration with feedback from faculty, positively impacts student learning. ⁹ , ¹¹ Reusable learning objects, including PowerPoint lectures, didactic learning modules, and demonstration videos, help students prepare for hands‐on sessions in advance. ¹¹ Students’ preparation before attending a skills session enhances their confidence and makes the time spent in the skills laboratory more efficient. ¹⁵ For this reason, students are encouraged to come to in‐person workshops already able to tie a surgical knot, to allow faculty to focus on demonstrating laceration repair techniques.

High‐Fidelity and Low‐Fidelity Simulation

Simulation activities have been shown to improve student confidence in clinical skills. ⁸ Suturing can be taught using both high‐fidelity and low‐fidelity models. Students can practice instrument handling and knot‐tying techniques at home using materials such as cloth or craft sponges. Others prefer materials resembling human tissue, like chicken breast or beef tongue. Kits, including demonstration sutures and mock tissue, are readily available online for students to purchase. Researchers have even created lifelike perineal models for practice, and these can be used in suturing workshops to prepare students for the reality of practice. ¹⁶ Realistic simulation has been shown to increase confidence in suturing. ¹²

Return Demonstration and Evaluation

After engaging in blended‐modality learning materials, students demonstrate their suturing skills with faculty observation. Faculty can correct student mistakes iteratively until students achieve competency. ¹⁴ Faculty can assess student competence before sending them to their clinical practicum sites, enhancing safety as they begin performing the skill with patients. Using an objective structured clinical examination (OSCE) is a traditional method to evaluate student mastery of skills. In this model, students demonstrate their ability to complete a second‐degree laceration repair while faculty observe and evaluate their ability to complete distinct aspects of the task. The standardized format allows students to demonstrate their ability to perform clinical tasks in a simulated setting. ¹⁷

Interprofessional Collaboration in Suturing Education

Interprofessional collaboration between experts in suturing education allows midwifery students to learn skills from surgical experts and midwifery experts, fostering interprofessional trust and cooperation. ¹⁸ A pilot study conducted in Australia brought together nursing students enrolled in their midwifery course and fourth‐year medical students to attend a program that taught gynecologic surgical skills, including suturing, aseptic gowning and gloving, intrauterine device insertion, and urethral catheterization. Workshop facilitators consisted of nursing and medical educators. The authors report a statistically significant increase in confidence scores in students from both disciplines, and confidence in interprofessional behaviors such as communication and teamwork improved. ¹⁸ Interprofessional education can improve patient care by enhancing collaboration between midwives and physicians. ¹⁸ , ¹⁹ Avery et al demonstrated that after completing interprofessional education activities, learners reported an improved understanding of each other's roles and greater clarity regarding areas of disciplinary overlap. ²⁰

A Gap in the Evidence

This article begins to fill a gap in the nursing and midwifery literature. In the United Kingdom and Europe, most low‐risk births are attended by midwives as the standard of care. In contrast, in the United States, only 11% of births are attended by a midwife. ²¹ , ²² A search of PubMed and CINAHL revealed that the US literature contains significantly more information about training medical students and surgical interns in suturing than training midwives. Recent research in interprofessional education has highlighted the benefits of sharing expertise and instruction across disciplines. ¹⁸ , ¹⁹ However, additional research is needed to identify how to meet all learners’ needs in an interprofessional education setting.

REDEVELOPMENT OF AN EDUCATIONAL SUTURING WORKSHOP

Faculty aimed to improve students’ experience and learning outcomes by revamping the suturing workshop offered each semester as part of a Clinical Skills Intensive session. By incorporating evidence from the literature into the current workshop, faculty aimed to improve student confidence and competence. To pilot these changes, 15 students who participated in the educational suturing project were enrolled in an online nurse‐midwifery program at a level 1 research University in the Midwestern United States. The students were at the beginning of their second nurse‐midwifery practicum course, focused on intrapartum skills. During the first week of this course's semester, students must attend an on‐campus, 2‐day workshop to learn about and demonstrate competency in intrapartum skills using simulation. Four hours of this workshop are devoted to hands‐on, faculty‐led education and training on perineal laceration repair using sutures, instruments, and high‐density sponges to simulate human tissue.

Using a survey, the faculty assessed students’ perceived confidence 4 weeks before and immediately after the workshop. Additionally, after the workshop, faculty assessed student competence using an adapted OSCE, a performance examination that evaluates the student's clinical competence. ²³ , ²⁴ The rationale for not including a preworkshop competence score was that suturing is not a nursing task, so Bachelor of Science in Nursing (BSN)‐prepared students were not expected to enter the workshop with significant knowledge or skill in suturing.

The Evidence‐Based Workshop

To prepare students for attending, the faculty compiled a suite of resources for student use that included new lectures and videos from internet sources and placed these in Canvas, a web‐based learning management system. ²⁵ Faculty created a new PowerPoint lecture on the anatomy and physiology of the perineal body, principles of wound repair, suture selection, and a step‐by‐step guide to the repair of second‐degree perineal lacerations. Additionally, demonstration videos depicting knot‐tying and perineal repair were created, mirroring what the students would see during the on‐campus workshop. The faculty communicated to the students that they must practice and try to master 2‐handed and instrument tying before the on‐campus experience.

The interprofessional teaching and evaluation team comprised 2 community‐practicing certified nurse‐midwives (CNMs), 2 faculty CNMs, one obstetrician‐gynecologist, and an educational technology expert. At the front of the classroom, the physician stood at a high‐top table equipped with sutures and a simulated foam model, demonstrating the repair of a second‐degree perineal laceration in real time. A camera focused closely on his hands, and the live feed was projected onto Apple iPads at each student's desk, set up by the technology expert to ensure optimal visualization. The iPad also allowed students to access the preparatory materials located in Canvas to review as needed. The midwifery faculty demonstrated skills up close and assisted students at their desks during the demonstration. During the demonstration, the faculty also showed realistic perineal models so that students could identify anatomic structures in both models.

Students practiced knot‐tying and suturing on individual foam models with faculty guidance. At the end of the workshop, students demonstrated the repair in the presence of faculty who verified student competency using the developed OSCE format. After the workshop, students repeated the preworkshop confidence survey. All surveys were completed anonymously via Microsoft Forms integrated within Canvas, and the data were exported to Excel for analysis. Group means were calculated to assess preworkshop and postworkshop confidence, as well as postworkshop competence. Individual responses were not identifiable, and all data were used for project evaluation.

Challenges

Creating an innovative skills development workshop that meets student needs often entails a significant financial investment. Institutional cost is dependent on the use of high‐fidelity or low‐fidelity models. Supplies include perineal models or sponges, sutures, needle drivers, scissors, and pick‐up forceps with teeth. Other associated institutional expenses include physical space and faculty time. Student costs include home practice supplies and kits, time off from work, and travel expenses if in a distance learning program. Additionally, it takes time to develop educational workshops outside of standard faculty teaching assignments. Even given the time, space, and funding to offer a suturing program, students may still present with a wide range of background experience or exposure to perineal laceration repair. Educators must find creative solutions to address these and other obstacles.

Successes

This program's outcomes support the use of multimodal education delivered by interprofessional teams to enhance nurse‐midwifery students’ confidence and competence in perineal suturing. The preintervention confidence assessment indicated an average self‐rating of “not very confident,” aligning with existing literature suggesting that students and novice midwives often begin training with limited confidence in performing perineal repairs. Following the intervention, the average posttest confidence rating increased to “very confident,” supporting the effectiveness of targeted instruction in enhancing student confidence in suturing ability. Additionally, the average postintervention competence score reflected a level of suturing skill consistent with that of an advanced beginner. Our goal was to equip students with the knowledge and skills to begin performing perineal repair under the supervision of their preceptors at an advanced beginner level. Students will continue progressing toward competence in perineal suturing throughout their program.

Technology can be used in educational settings to enhance learning. In this program, faculty demonstrated suturing techniques using a camera focused on the instructor's hands, with the live feed streamed to iPads positioned at each student's desk. Bringing the demonstration directly to the student's desk successfully increased student‐faculty ratios, as more students could view the instructor's hands simultaneously despite being in a larger room (Figure 1). The iPads also allowed students to review previous videos, speed up or slow down demonstration videos, and even record their own hands for later viewing (Figure 2).

Figure 1.

Suturing Demonstration by a Surgical Expert

Video footage of a live demonstration is viewable on student iPads during the suturing workshop.

Figure 2.

Student View of Suturing Demonstration, as Displayed on iPads

Importantly, nurse‐midwives are experts in low‐risk intrapartum care and the management of common perineal lacerations. Midwives consult their obstetrician colleagues collaboratively when a patient's clinical picture necessitates medical intervention. Midwifery faculty are well‐qualified to teach perineal repair techniques to their students. Including obstetrician‐gynecologist colleagues allows for sharing expert teaching and demonstrating ideal surgical techniques. This co‐teaching approach also models effective interprofessional communication for students preparing to work in multidisciplinary settings.

NEXT STEPS

The evidence supporting interprofessional education is clear. In recent sessions, this program has invited family practice residents and fellows to participate in introductory suturing workshops. We hope to expand the sessions to include medical and midwifery students. Learning together builds trust and allows for the sharing of techniques. By tapping into the midwifery faculty's expertise as clinicians and teachers, other disciplines engaged in pregnancy and birth work can better understand the scope of midwifery practice and expertise. Student midwives can observe positive interactions between midwives and their obstetric colleagues, which has the potential to enhance collegiality.

The authors found significantly more literature on suturing in medical education than in midwifery education. This gap highlights the need for future research to evaluate and improve midwifery students’ confidence and competence in suturing and perineal laceration repair.

Any educators teaching suturing skills can implement the evidence‐based educational workshops described here. Evidence shows that many midwives lack confidence in perineal repair skills. Because confidence improves with experience and regular practice supports skill retention, ACNM state affiliates may consider offering recurring suturing workshops using these modalities.

CONFLICTS OF INTEREST

The authors have no conflicts of interest to disclose.