A randomized comparison of suturing techniques for episiotomy and laceration repair after spontaneous vaginal birth

Risk Factors for Perineal Wound Breakdown in Early Postpartum: A Retrospective Case-Control Study

We conducted a retrospective case-control study in patients presenting a perineal tear (second degree or higher) or episiotomy complicated by wound breakdown during maternity stay to identify risk factors associated with wound breakdown in early postpartum with a view to improving the quality of care. We collected ante- and intrapartum characteristics and outcomes at the postpartum visit. In all, 84 cases and 249 control subjects were included. In univariate analysis, primiparity, absence of history of vaginal delivery, a longer second phase of labour, instrumental delivery, and a higher degree of laceration emerged as risk factors for early perineal suture breakdown postpartum. Gestational diabetes, peripartum fever, streptococcus B, and suture technique did not emerge as risk factors for perineal breakdown. Multivariate analysis confirmed that instrumental delivery (OR = 2.18 [1.07; 4.41], p = 0.03) and a longer second phase of labour (OR = 1.72 [1.23; 2.42], p = 0.001) were risk factors for early perineal suture breakdown.

Benefits of continuous suture of perineal injury in adaptation to motherhood

OBJECTIVE

To assess the effect of the continuous suture technique of the perineal wound on the capacity and functional recovery of women when carrying out their self-care routine, the care of the newborn (NB), breastfeeding (BF) and Activities of Daily Living (ADLs), both basic activities of daily living (BADL) and instrumental (IADL), during the postpartum period.

METHODS

Non-randomised clinical trial with blinding allocation to study groups, carried out at the Arnau de Vilanova tertiary hospital in Lérida. The intervention group received continuous suture for perineal repair and the control group discontinuous suture. The study population was women with eutocic delivery and second-degree perineal tears or episiotomy. Three postpartum assessment were performed (48 h, 7-10 days and one month).

RESULTS

126 women with eutocic delivery and second degree perineal tears or episiotomy participated (n = 126); 64 sutured with continuous technique (intervention group) and 62 with discontinuous technique (control group). At 48 h postpartum, 85% of women from the continuous suture technique group were able to perform their self-care and 46,7% of them had recovered functionally. At 7-10 days, 96,7% of women with continuous suturing had acquired the ability to perform instrumental activities of daily living and 60% had recovered functionally compared to 68,3% and 15% respectively of women with discontinuous suturing (p < 0.001). At 7-10 days, 100% of women with continuous suturing achieved functional recovery for newborn care and 80% for breastfeeding and in the control group 81,7% and 30% respectively (p < 0.001 and p < 0.001).

CONCLUSIONS

Women who undergo the continuous suture technique restore their ability and functional recovery to perform activities of daily living earlier and with less pain than women with discontinuous suturing, adapting more quickly and satisfactorily way to motherhood.

Postpartum Dyspareunia Following Continuous Versus Interrupted Perineal Repair: A Systematic Review and Meta-Analysis

Research evaluating optimal repair techniques for the reduction of postpartum dyspareunia following obstetric laceration is severely limited. Prevailing guidelines from the American College of Obstetricians and Gynecologists (ACOG) are reliant on data from just nine clinical trials conducted from 1980 to 2012. While the literature on this topic is still limited today, this review aims to synthesize data from past and present studies to ensure that standing clinical recommendations are supported by current literature.

A review was conducted per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Medical Literature Analysis and Retrieval System Online (MEDLINE), Cochrane Library, and Google Scholar were searched. Included articles (1) compared continuous with interrupted repair techniques for subjects with episiotomies and/or second-degree tears, (2) were available in full length, and (3) reported dyspareunia as an outcome variable. Excluded articles were those (1) inclusive of first-, third-, or fourth-degree tears; (2) comparing suture material rather than technique; and (3) not available in English. A meta-analysis was conducted for both acute dyspareunia (<3 months) and chronic dyspareunia (>3 months) utilizing Meta-Essentials Microsoft Excel (Microsoft Corp., Redmond, WA) workbook. Bias was evaluated via Egger regression and Begg and Mazumdar rank correlation tests.

Twelve articles met inclusion and exclusion guidelines, seven for acute dyspareunia and eight for chronic dyspareunia. All publications were randomized controlled trials and were inclusive of a total of 4,081 patients. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using a random effect model. Analysis revealed no statistically significant difference between continuous and interrupted suture groups for acute dyspareunia (RR: 0.98; 95% CI: 0.89-1.08) or chronic dyspareunia (RR: 0.96; 95% CI: 0.83-1.12). Egger regression test (p-value=0.534) and Begg and Mazumdar rank correlation test (p-value=0.570) indicated minimal publication bias. Compiled data does not indicate a preferential suture technique for the reduction of postpartum dyspareunia. These findings are congruent with the ACOG guidelines; therefore, there is no supporting evidence for ACOG's recommendation of continuous suturing to be overturned.

Health care workers' perceptions of episiotomy in the era of respectful maternity care: a qualitative study of an obstetric training program in Mexico

BACKGROUND

Episiotomy in Mexico is highly prevalent and often routine - performed in up to 95% of births to primiparous women. The WHO suggests that episiotomy be used in selective cases, with an expected prevalence of 15%. Training programs to date have been unsuccessful in changing this practice. This research aims to understand how and why this practice persists despite shifts in knowledge and attitudes facilitated by the implementation of an obstetric training program.

METHODS

This is a descriptive and interpretative qualitative study. We conducted 53 pre and post-intervention (PRONTO© Program) semi-structured interviews with general physician, gynecologists and nurses (N = 32, 56% women). Thematic analysis was carried out using Atlas-ti© software to iteratively organize codes. Through interpretive triangulation, the team found theoretical saturation and explanatory depth on key analytical categories.

RESULTS

Themes fell into five major themes surrounding their perceptions of episiotomy: as a preventive measure, as a procedure that resolves problems in the moment, as a practice that gives the clinician control, as a risky practice, and the role of social norms in practicing it. Results show contradictory discourses among professionals. Despite the growing support for the selective use of episiotomy, it remains positively perceived as an effective prophylaxis for the complications of childbirth while maintaining control in the hands of health care providers.

CONCLUSIONS

Perceptions of episiotomy shed light on how and why routine episiotomy persists, and provides insight into the multi-faceted approaches that will be required to affect this harmful obstetrical practice.

Patient-reported outcomes and outcome measures in childbirth perineal trauma research: a systematic review

INTRODUCTION AND HYPOTHESIS

In evaluating the effectiveness of interventions in perineal trauma research, outcomes reported by patients should have a prominent focus. There is no international consensus regarding the use of either patient-reported outcomes (PROs) or tools used to determine these outcomes (patient-reported outcome measures, PROMs). The objective was to evaluate the selection, reporting and geographical variations of PROs and PROMs in randomised controlled trials (RCTs) on perineal trauma.

METHODS

We performed a systematic review of RCTs in perineal trauma research evaluating outcome and outcome measure reporting. We identified PROs and PROMs and grouped PROs into domains and themes, a classification system based on a medical outcome taxonomy.

RESULTS

Of 48 included RCTs, 47 reported PROs. In total, we identified 51 PROs. Outcome reporting consistency was low, with 27 PROs reported only once. Nine PROs were reported more than five times, the most frequent being perineal pain, with no geographical variation in reporting. Four themes encompassing 12 domains were identified. The most frequently reported theme was "Clinical", with 25 PROs grouped within four domains. "Resource use" and "Adverse events" themes were rarely reported, with only five PROs. PROMs also exhibited variation. Most common were visual analogue scale (VAS; 100 mm), Cleveland Clinic Continence Score, The Faecal Incontinence Quality of Life scale, VAS (0-10) and the McGill Pain Questionnaire.

CONCLUSIONS

Significant heterogeneity in PROs and PROMs was observed among RCTs. Despite inconsistency, PROs are the most prevalent outcome in perineal trauma research. Patient-reported adverse events are underreported. Their use in determining the effectiveness and safety of interventions makes their integration important in perineal trauma core outcome sets. Identification and grouping of outcomes will assist future core outcome consensus studies.

Dispareunia en mujeres después de parto vaginal. Prevalencia en dos clínicas de Armenia, Colombia, 2012-2017

Se realizó un estudio de corte transversal que tuvo como objetivo determinar la prevalencia de la dispareunia en mujeres con parto vaginal, evaluar posibles factores de riesgo y la asociación con la episiotomía. Ingresaron mujeres atendidas por parto vaginal entre 2012 y 2017 en dos clínicas de alta complejidad en Armenia (Colombia). Se utilizó el cuestionario Índice de Función Sexual Femenina (IFFS-6) para evaluar la función sexual. Los resultados reportan una prevalencia de dispareunia del 59,37%, siendo más prevalente en mujeres sometidas a episiotomía (OR: 68,17; IC95 %: 60,57-79,15). Respecto a la asociación de la episiotomía con la presencia de dispareunia se encontró asociación significativa con la episiotomía medio-lateral (OR: 8,17; IC95%: 2,15-56,32), lesión del esfínter (OR: 7,32; IC95%: 4,86-12,75) y dehiscencia de la sutura (OR: 6,48; IC95%: 4,92-14,28). Se observaron como factores de riesgo: antecedente de endometriosis (OR: 11,6; IC95 %: 9,15-17,52), dolor pélvico crónico (OR: 3,56; IC95%: 2,21–6,32) e ITS (OR: 2,67; IC95%: 1,54–5,14), p=0,003). Se concluye que la prevalencia de dispareunia en mujeres con parto vaginal, atendidas en Armenia, varía en función de la realización de episiotomía, asociándose tanto a las complicaciones de esta como a otros antecedentes.

Suture type used for perineal injury repair and sexual function: a randomised controlled trial

The type of suture used to repair perineal injury may be associated with this healing process and subsequent sexual function. This study aims to assess whether the suture technique used (continuous or interrupted) has an impact on a woman's sexual function following childbirth. A single-blind randomised clinical trial was conducted with primiparous women who had experienced a perineal injury during childbirth. A computer-generated random number table was applied to allocate women to each group. Data were collected on sociodemographic variables, variables associated with childbirth, and outcomes during the 3 months after childbirth. Mean difference was used to assess the influence of the suture type on outcomes. Multivariate analyses were carried out to adjust for unbalanced variables after randomisation. Seventy women participated in the intervention group (continuous suture) and 64 women in the control group (interrupted suture). The women in the intervention group scored high for sexual desire, adjusted mean difference (aMD) = 1.8, 95% CI = 1.1-2.6 (p < 0.001); the same happened with arousal (aMD = 1.7, 95% CI = 0.8-2.5, p < 0.001). In the intervention group, orgasm was more easily reached, aMD = 0.8, 95% CI = 0.4-1.1 (p < 0.001). Women who received a continuous suture indicated they felt less discomfort (p < 0.001). Women who had a continuous suture reported better postpartum sexual function.Trial registration: ClinicalTrials.gov NCT03825211 posted 31/01/ 2019.

Perineal repair of media-lateral episiotomies and 2nd degree tears by midwives: A randomised controlled trial comparing three suture techniques

BACKGROUND

Perineal trauma pain is associated with perineal repair and its subsequent healing. New evidence is required concerning perineal repair techniques that cause less pain and favour healing.

OBJECTIVE

To compare three perineal repair suturing techniques after episiotomy or second degree tearing during a normal birth with respect to reducing pain and improving the perineal healing process.

DESIGN

A randomised controlled trial.

SETTING

A large public university hospital in Madrid, Spain.

PARTICIPANTS

Full term pregnant women older than 18 years-of-age, who required perineal repair after episiotomy or second degree tearing and were attended for normal birth by midwives.

METHODS

One hundred and eighty-three women were randomly assigned to three groups: the Continuous Suture Group (n = 58), Interrupted Cutaneous Suture Group (n = 53), or the Interrupted Subcutaneous Suture Group (n = 57). The study participants and data collectors were blinded to group allocations. Principal outcome: perineal pain 10 days after birth. Other outcomes: short (2 and 48 h) and long term (3 and 6 months) perineal pain after birth; short term healing; suture time.

RESULTS

At 10 days postpartum, the presence of spontaneous pain, pain when walking or moving in bed, was almost nonexistent in the 3 suture groups. The median (P25-P75) perineal pain on palpation was similar in the 3 groups, with values of 2 (1-4) in the Continuous Suture Group, 3 (2-5) in the Interrupted Cutaneous Suture Group and 2 (1-4) in the Interrupted Subcutaneous Suture Group; also were similar the perineal pain on sitting: 1 (0-3) in the Continuous Suture Group, 1 (0-2) in the Interrupted Cutaneous Suture Group and 1 (0-3) in the Interrupted Subcutaneous Suture Group. There were no statistically significant differences between the groups. Pain measurements throughout the follow-up period only showed statistically significant differences in 2 out of 22 evaluations: pain when sitting 48 h after birth and spontaneous pain at 3 months. The mean times (standard deviation) to carry out suturing were 12.86 (4.9) minutes in the Continuous Suture Group, 13.54 (5.6) in the Interrupted Cutaneous Suture Group, and 15.59 (6.9) minutes in the Interrupted Subcutaneous Suture Group (p < 0.05).

CONCLUSIONS

The three suturing methods described for perineal repair after episiotomy or second degree tearing after normal birth are comparable with respect to short, medium and long term perineal pain and the healing process. Use of the continuous suturing technique involved less time than interrupted suture methods. Tweetable abstract: proper the suturing methods for perineal repair after episiotomy or second degree tearing prevent postpartum perineal pain.

Continuous versus discontinuous suture in perineal injuries produced during delivery in primiparous women: a randomized controlled trial

BACKGROUND

The technique used in the repair of a perineal injury resulting from childbirth could avoid discomfort and morbidity during the postpartum period. Recent studies show inconsistent results and support the need for new research with the inclusion of new health parameters not yet studied. Therefore, this study aims to evaluate if the suture technique (continuous or interrupted) has an effect on pain and other postpartum problems, incidence of incontinence (urinary and/or fecal), and the restart of sexual relations.

METHODS

A single-blind randomized clinical trial was conducted in five hospitals in south-east Spain. The participants were primiparous women who had experienced a perineal injury during delivery (second-degree tear or episiotomy). Data was collected on sociodemographic variables, variables associated with pregnancy, labor and delivery, and the postpartum period, and outcomes during the 3 months after delivery: pain, incontinence, and restart of sexual relations. Odds ratios (OR) were calculated by binary logistic regression to assess the influence of the suture type on binary outcomes and t-test used for comparing continuous outcomes. Multivariate analyses (using logistic regression -adjusted (aOR)- and analysis of covariance) were carried out to adjust for unbalanced variables after randomization.

RESULTS

A total of 70 women were included in the intervention group (continuous suture) and 64 in the reference group (interrupted sutures). A negative association was observed (aOR = 0.39; 95% CI = 0.18-0.86) between a continuous suture and the need for analgesia at 24 h postpartum. Pain experienced by the women at 24 h postpartum was assessed as 4.4 ± 0.3 compared with a score of 3.4 ± 0.3 in the group with continuous sutures (p = 0.011). At 15 days postpartum, women in the intervention group experienced less pain (aOR = 0.38; 95% CI = 0.18-0.80) (p = 0.019). Urinary sphincter incontinence was also evaluated at 15 days, with 4.3% (n = 3) of the women in the intervention group presenting with urinary incontinence compared with 18.8% (n = 12) in the control group (aOR = 0.11; 95% CI = 0.03-0.47) (P = 0.003).

CONCLUSIONS

The women who had a continuous suture repair showed lower levels of pain from delivery to 3 months after delivery and had a lower incidence of urinary incontinence at 15 days postpartum.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03825211 posted January 31, 2019 (retrospectively registered).

Perineal suture practices. Are they up to date with the evidence based medicine data: A local experience into a university maternity?

OBJECTIVES

To investigate the prevalence of perineal suture techniques then to identify the factors influencing suturing technique choices.

METHODS

Prospective, observational, monocentric study over 20 weeks in a university hospital. A personal questionnaire was completed by medical practitioners performing perineal sutures: years of experience, training attendance, suturing techniques usually used for degrees 1 and 2 tears/episiotomies. For each delivery with perineal tear/episiotomy, the professional answered on the type of suture performed and the reasons for choosing this technique. We distinguished discontinuous sutures (several stitches/continuous locking stitch) from continuous sutures (single thread, single continuous locking stitch). We evaluated the prevalence of the techniques used in our center as well as the factors associated with the choice of technique, then we described the characteristics of the professionals who responded to the survey and their suturing habits.

RESULTS

Among the 401 perineal sutures, 45.4% of them were continuous (n = 182), discontinuous sutures were more performed. Discontinuous sutures were more common in 1st and 2nd degree tears. Residents/obstetricians performed significantly more continuous sutures than midwives. Whatever the type of suture technique used (continuous or discontinuous), professionals sutured in the way they felt most suitable to the degree of tearing/episiotomy. Fifty-one percent of midwives are trained in continuous technique, compared with 81% of residents/obstetricians. Midwives required training in 70% of cases and 64% of residents.

CONCLUSIONS

It appears necessary to disseminate continuous suture techniques and to promote their training in order to improve our practices.

Incidence of perineal pain and dyspareunia following spontaneous vaginal birth: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Perineal pain and dyspareunia are experienced by women undergoing a vaginal birth that can have short and longer term physical and psychological morbidities. This review aimed to determine the incidence of perineal pain and dyspareunia following spontaneous vaginal birth (SVB) with intact perineum, first and second-degree perineal trauma or episiotomy.

METHODS

Searches of MEDLINE, EMBASE, CINAHL, AMED and MIDIRS (inception - December 2017) were undertaken with selection criteria of any study evaluating the effect of intact perineum, first- or second-degree perineal trauma on perineal pain or dyspareunia in women with SVB.

RESULTS

Eighteen studies (8 RCTs and 10 NRSs) were included. Fourteen and 12 studies were undertaken to assess perineal pain and dyspareunia after SVB, respectively. Meta-analysis of 16 studies (3133 women) demonstrated that women at 2 days postpartum experienced nearly the same incidence of perineal pain whether perineal trauma existed or not. At 4-10 days postpartum there was a significant reduction in the incidence of perineal pain for both presence and absence of any perineal trauma. Episiotomy was associated with the highest rate of perineal pain. The incidence of dyspareunia was high at resumption of sexual intercourse following SVB with an intact perineum. At 12 months, women still experienced dyspareunia whether perineal trauma existed or not.

CONCLUSIONS

Women experience perineal pain and dyspareunia regardless of the presence or absence of perineal trauma after SVB; nonetheless, the reported incidence is higher if perineal trauma occurred.

Do we need a core outcome set for childbirth perineal trauma research? A systematic review of outcome reporting in randomised trials evaluating the management of childbirth trauma

BACKGROUND

Selecting appropriate outcomes to reflect both beneficial and harmful effects is a critical step in designing childbirth trauma trials.

OBJECTIVE

To evaluate the outcomes and outcome measures reported in randomised controlled trials evaluating interventions for childbirth trauma.

SEARCH STRATEGY

Randomised trials were identified by searching bibliographical databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE.

SELECTION CRITERIA

Randomised trials evaluating the efficacy and safety of different techniques in the management of perineal lacerations.

DATA COLLECTION AND ANALYSIS

Two researchers independently assessed studies for inclusion, evaluated methodological quality, and extracted the relevant data. Spearman's ρ correlation and multivariate linear regression analysis using the backward stepwise model were used for analysis.

MAIN RESULTS

Forty-eight randomised trials, reporting data from 20 308 women, were included. Seventeen different interventions were evaluated. Included trials reported 77 different outcomes and 50 different outcome measures. Commonly reported outcomes included pain (34 trials; 70%), wound healing (20 trials; 42%), and anorectal dysfunction (16 trials, 33%). In the multivariate analysis, no relationship was demonstrated between the quality of outcome reporting and year of publication (P = 0.31), journal impact factor (P = 0.49), and methodological quality (P = 0.13).

CONCLUSION

Outcome reporting in childbirth trauma research is heterogeneous. Developing, disseminating, and implementing a core outcome set in future childbirth trauma research could help address these issues.

TWEETABLE ABSTRACT

Developing @coreoutcomes for childbirth trauma research could help to reduce #research waste.

Techniques for Repair of Obstetric Anal Sphincter Injuries

Importance

Obstetric anal sphincter injuries (OASISs) complicate up to 11% of vaginal deliveries; obstetricians must be able to recognize and manage these technically challenging injuries.

Objective

The aim of this study was to share our approach for management of these challenging complications of childbirth based on a multidisciplinary collaboration between general obstetrician-gynecologists, maternal fetal medicine specialists, and female pelvic medicine and reconstructive surgeons established at our institution.

Evidence Acquisition

A systematic literature search was performed in 3 search engines: PubMed 1946-, EMBASE 1947-, and the Cochrane Database of Systematic Reviews using keywords obstetric anal sphincter injuries and episiotomy repair.

Results

Identification should begin with an assessment of risk factors, notably nulliparity and operative vaginal delivery, consistently associated with the highest risk of OASISs, and proceed with a thorough examination to grade the degree of laceration. Repair should be performed or supervised by an experienced clinician in an operating room with either regional or general anesthesia. The external anal sphincter may be repaired using either an overlapping or end-to-end anastomosis. Providers should be comfortable with both approaches as the degree of laceration may necessitate one approach over the other. We advocate for use of monofilament suture on all layers to decrease risk of bacterial seeding, as well as preoperative antibiotics and postoperative bowel regimen, which are associated with improved outcomes.

Conclusions and Relevance

Long-term sequelae, including pain, dyspareunia, and fecal incontinence, significantly impact quality of life for many patients who suffer OASISs and may be avoided if evidence-based guidelines for recognition and repair are utilized.

The development and validation of a new postpartum sexual function and dyspareunia assessment tool: The Carol Scale

OBJECTIVE

The aim is to develop a new tool to evaluate postpartum sexual function and dyspareunia which will facilitate better evaluation of perineal pain in woman after vaginal delivery.

DESIGN

The development and validation of the Carol Postpartum Sexual Function and Dyspareunia Assessment Scale.

SETTING

The Obstetrics and Gynecology Service of a University Hospital in central Spain.

PARTICIPANTS

102 women after being attended for vaginal birth, and 5 midwife assessors.

FINDINGS

81women reinitiated sexual activity (with vaginal intercourse) during the first three months postpartum. The Carol Postpartum Sexual Function and Dyspareunia Assessment Scale (Carol Scale) was internally reliable with a Cronbach-α value of 0.79 (95%CI0.72-0.85). Cronbach-α coefficients for Carol Scale domains were: preparation for the sexual activity 0.69 (95%CI0.55-0.79), pain or discomfort on caressing the vulval area 0.86 (95%CI0.79-0.91), pain or discomfort related to vaginal intercourse 0.93 (95%CI0.90-0.95) and pain or discomfort after vaginal intercourse 0.86 (95%CI0.78-0.91).

CONCLUSIONS

The Carol Postpartum Sexual Function and Dyspareunia Assessment Scale is valid and reliable for measuring sexual function and postpartum dyspareunia in women after being attended for vaginal birth.

IMPLICATIONS FOR PRACTICE

The Carol Scale could be used both clinically and in research to improve the quality of care for the mother after childbirth. The scale could help to identify problems in the reinitiation of postpartum sexual activity and, therefore, could contribute to widening the clinical information about these women and help in decision making.

Continuous versus interrupted sutures for facial surgery repair: a randomized prospective study

BACKGROUND

The cosmetic appearance of a facial scar is a concern for patients undergoing Mohs micrographic surgery (MMS). Although suturing technique may influence scar cosmesis, few studies have been published comparing suturing methods for MMS repair.

OBJECTIVE

To compare the cosmetic appearance of facial MMS scars sutured with either continuous or interrupted percutaneous nylon sutures.

MATERIALS AND METHODS

Patients with facial MMS defects were randomized to have half their scar sutured with interrupted 5-0 nylon stitches, whereas the other half of the scar was closed with running 5-0 nylon stitches. The appearance of each half of the scar was assessed at 1 week, 8 weeks, and 6 months by the principal investigator. Blinded photographic evaluation at 1 week and 6 months was completed by a plastic surgeon and general dermatologist.

RESULTS

A total of 105 patients were entered into the trial, and 101 completed all time point assessments. There was no statistically significant difference in scar outcome using each of the 3 scar assessment scales, at any time point, for any assessor (blinded and nonblinded).

CONCLUSION

Interrupted and continuous 5-0 nylon sutures result in an equivalent final cosmetic appearance of facial MMS scars. Given its advantages, running sutures may be the preferred closure technique for facial repair.

Nonsuturing or Skin Adhesives versus Suturing of the Perineal Skin After Childbirth: A Systematic Review

BACKGROUND

Suturing of perineal trauma after childbirth can cause problems such as pain, discomfort because of tight sutures, the need for suture removal, and dyspareunia. It is unclear whether leaving the perineal skin unsutured or using skin adhesives might prevent these problems.

METHODS

CENTRAL, MEDLINE, EMBASE, CINAHL, and prospective trial registers until January 2013 were searched for (quasi-)randomized controlled trials comparing nonsuturing of the perineal skin or skin adhesives versus suturing of the skin when repairing a second-degree perineal tear or episiotomy. Primary outcome measure was short-term and long-term pain and need for analgesic medication.

RESULTS

Four randomized and two quasi-randomized controlled trials (involving 2,922 women) with heterogeneity in contexts, designs, and methodological quality were included. Nonsuturing of the skin leads to less short-term and long-term pain compared to suturing and an increased rate of skin separation. Skin adhesives lead to less short-term pain without an increased rate of skin separation. Nonsuturing or skin adhesives lead to less complaints and there are no other adverse effects.

CONCLUSIONS

Nonsuturing of the skin or the use of skin adhesives appears preferable in terms of pain. Nonsuturing could lead to more short-term skin separation when no adhesives are used, but there is no evidence for the clinical importance of skin separation. There is a need for studies with a follow-up of at least 6 months, in which pain is measured homogeneously and for studies comparing the use of skin adhesives with nonsuturing of the skin with the focus on long-term cosmetic results.

Continuous and interrupted suturing techniques for repair of episiotomy or second-degree tears

BACKGROUND

Millions of women worldwide undergo perineal suturing after childbirth and the type of repair may have an impact on pain and healing. For more than 70 years, researchers have been suggesting that continuous non-locking suture techniques for repair of the vagina, perineal muscles and skin are associated with less perineal pain than traditional interrupted methods.

OBJECTIVES

To assess the effects of continuous versus interrupted absorbable sutures for repair of episiotomy and second-degree perineal tears following childbirth.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 January 2012).

SELECTION CRITERIA

Randomised trials examining continuous and interrupted suturing techniques for repair of episiotomy and second-degree tears after vaginal delivery.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial quality. Two of the three authors independently extracted data and a third review author checked them. We contacted study authors for additional information.

MAIN RESULTS

Sixteen studies, involving 8184 women at point of entry, from eight countries, were included. The trials were heterogeneous in respect of operator skill and training. Meta-analysis showed that continuous suture techniques compared with interrupted sutures for perineal closure (all layers or perineal skin only) are associated with less pain for up to 10 days' postpartum (risk ratio (RR) 0.76; 95% confidence interval (CI) 0.66 to 0.88, nine trials). There was an overall reduction in analgesia use associated with the continuous subcutaneous technique versus interrupted stitches for repair of perineal skin (RR 0.70; 95% CI 0.59 to 0.84). There was also a reduction in suture removal in the continuous suturing groups versus interrupted (RR 0.56; 95% CI 0.32 to 0.98), but no significant differences were seen in the need for re-suturing of wounds or long-term pain.

AUTHORS' CONCLUSIONS

The continuous suturing techniques for perineal closure, compared with interrupted methods, are associated with less short-term pain, need for analgesia and suture removal. Furthermore, there is also some evidence that the continuous techniques used less suture material as compared with the interrupted methods (one packet compared to two or three packets, respectively).

The effects of continuous and interrupted episiotomy repair on pain severity and rate of perineal repair: a controlled randomized clinical trial

INTRODUCTION

Perineal pain is the most common complaint after episiotomy. It imposes extra pressure on mothers who attempt to adapt to their new conditions. Therefore, the present study was performed to compare pain severity and perineal repair in two episiotomy repair methods.

METHODS

In this clinical trial, 100 primiparous women who referred to hospitals of Tabriz (Iran) for delivery were randomly allocated into two groups of 50 to undergo either continuous or interrupted episiotomy repair. A visual analogue scale (VAS) was used to evaluate pain severity 12-18 hours after episiotomy repair and also 10 days after delivery. Perineal repair rate was also assessed using the REEDA (redness, edema, ecchymosis, discharge, and approximation) scoring scale. The obtained data was analyzed in SPSS15.

RESULTS

Statistical tests did not show significant differences between the 2 groups in pain severity variations or REEDA scores at 12-18 hours and the 10th day after delivery. However, the mean required time for repair and the number of used threads were significantly lower in the continuous repair group (p < 0.001).

CONCLUSION

The results of this study showed that pain severity and episiotomy repair rate were similar in the two methods. Nevertheless, shorter time of repair and fewer threads were required using the continuous repair method. Therefore, this method would provide better services for mothers and reduce the required time, energy, and costs.

Continuous versus interrupted episiotomy repair with monofilament or multifilament absorbed suture materials: a randomised controlled trial

PURPOSE

To compare different repair techniques and different suture materials for episiotomy.

METHODS

160 women having vertex delivery with right-mediolateral episiotomy were randomly allocated to four groups. In the groups where continuos technique was performed, vaginal mucosa, perineal muscles and the skin were sutured continuously. In the groups of interrupted technique, vaginal mucosa was sutured with continuous sutures, then muscle layers and skin were closed by interrupted sutures. Two different types of synthetic absorbed suture material were used: monofilament type is in form of polyglycolide-co-caprolactone and multifilament one is polyglactin 910-Rapide. Perineal pain during different activities on the first and tenth day postpartum and also during sexual intercourse 6 weeks after the delivery was questioned by visual analogous scale (VAS). Furthermore, repair time, amount of suture and episiotomy complications were investigated in each groups.

RESULTS

On the first day after delivery, the perineal pain scores, the repair time, the amount of suture were statistically less in the continuous technique groups. The differences between the pain at tenth day and during sexual intercourse 6 weeks after the delivery were statistically same.

CONCLUSIONS

The continuous suturing techniques for episiotomy closure, compared to interrupted methods, are associated with less short-term pain, are quicker and also need less suture material.

Postpartum perineal repair performed by midwives: a randomised trial comparing two suture techniques leaving the skin unsutured

OBJECTIVE

To compare a continuous suture technique with interrupted stitches using inverted knots for postpartum perineal repair of second-degree lacerations and episiotomies.

DESIGN

A double-blind randomised controlled trial.

SETTING

A Danish university hospital with more than 4800 deliveries annually.

POPULATION

A total of 400 healthy primiparous women with a vaginal delivery at term. METHOD Randomisation was computer-controlled. Structured interviews and systematic assessment of perineal healing were performed by research midwives blinded to treatment allocation at 24-48 hours, 10 days and 6 months postpartum. Pain was evaluated using a visual analogue scale and the McGill Pain Questionnaire. Wound healing was evaluated using the REEDA scale and by assessment of gaping wounds >0.5 cm. Analysis complied with the intention-to-treat principle.

MAIN OUTCOME MEASURES

The primary outcome was perineal pain 10 days after delivery. Secondary outcomes were wound healing, patient satisfaction, dyspareunia, need for resuturing, time elapsed during repair and amount of suture material used.

RESULTS

A total of 400 women were randomised; 5 women withdrew their consent, leaving 395 for follow up. The follow-up rate was 98% for all assessments after delivery. No difference was seen in perineal pain 10 days after delivery. No difference was seen in wound healing, patient satisfaction, dyspareunia or need for resuturing. The continuous suture technique was significantly faster (15 versus 17 minutes, P = 0.03) and less suture material was used (one versus two packets, P < 0.01).

CONCLUSION

Interrupted, inverted stitches for perineal repair leaving the skin unsutured appear to be equivalent to the continuous suture technique in relation to perineal pain, wound healing, patient satisfaction, dyspareunia and need for resuturing. The continuous technique, however, is faster and requires less suture material, thus leaving it the more cost-effective of the two techniques evaluated.

Continuous versus interrupted sutures for repair of episiotomy or second degree tears

BACKGROUND

Millions of women worldwide undergo perineal suturing after childbirth and the type of repair may have an impact on pain and healing. For more than 70 years, researchers have been suggesting that continuous non-locking suture techniques for repair of the vagina, perineal muscles and skin are associated with less perineal pain than traditional interrupted methods.

OBJECTIVES

To assess the effects of continuous versus interrupted absorbable sutures for repair of episiotomy and second degree perineal tears following childbirth.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (June 2007).

SELECTION CRITERIA

Randomised trials comparing continuous versus interrupted sutures for repair of episiotomy and second-degree tears after vaginal delivery.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial quality. Two of the three authors independently extracted data and a third author checked them. We contacted study authors for additional information.

MAIN RESULTS

Seven studies, involving 3822 women at point of entry, from four countries, have been included. The trials were heterogeneous in respect of operator skill and training. Meta-analysis showed that continuous suture techniques compared with interrupted sutures for perineal closure (all layers or perineal skin only) are associated with less pain for up to 10 days postpartum (relative risk (RR) 0.70, 95% confidence interval 0.64 to 0.76). Subgroup analysis showed that there is a greater reduction in pain when continuous suturing techniques are used for all layers (RR 0.65, 95% CI 0.60 to 0.71). There was an overall reduction in analgesia use associated with the continuous subcutaneous technique versus interrupted stitches for repair of perineal skin (RR 0.70, 95% CI 0.58 to 0.84). Subgroup analysis showed some evidence of reduction in dyspareunia experienced by participants in the groups that had continuous suturing for all layers (RR 0.83, 95% CI 0.70 to 0.98). There was also a reduction in suture removal in the continuous suturing groups versus interrupted (RR 0.54, 95% CI 0.45 to 0.65), but no significant differences were seen in the need for re-suturing of wounds or long-term pain.

AUTHORS' CONCLUSIONS

The continuous suturing techniques for perineal closure, compared to interrupted methods, are associated with less short-term pain. Moreover, if the continuous technique is used for all layers (vagina, perineal muscles and skin) compared to perineal skin only, the reduction in pain is even greater.