Secondary suturing compared to non-suturing for broken down perineal wounds following childbirth

BACKGROUND

Each year approximately 350,000 women in the United Kingdom and millions more worldwide, experience perineal suturing following childbirth. The postpartum management of perineal trauma is a core component of routine maternity care. However, for those women whose perineal wound dehisces (breaks down), the management varies depending on individual practitioners preferences as there is limited scientific evidence and no clear guidelines to inform best practice. For most women the wound will be managed expectantly whereas, others may be offered secondary suturing.

OBJECTIVES

To evaluate the therapeutic effectiveness of secondary suturing of dehisced perineal wounds compared to non-suturing (healing by secondary intention, expectancy).

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2013) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials of secondary suturing of dehisced perineal wounds (second-, third- or fourth-degree tear or episiotomy), following wound debridement and the removal of any remaining suture material within the first six weeks following childbirth compared with non-suturing.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion. Two review authors independently assessed trial quality and extracted data. Data were checked for accuracy.

MAIN RESULTS

Two small studies of poor methodological quality including 52 women with a dehisced and/or infected episiotomy wound at point of entry have been included.Only one small study presented data in relation to wound healing at less than four weeks, (the primary outcome measure for this review), although no reference was made to demonstrate how healing was measured. There was a trend to favour this outcome in the resuturing group, however, this difference was not statistically significant (risk ratio (RR) 1.69, 95% confidence interval (CI) 0.73 to 3.88, one study, 17 women).Similarly, only one trial reported on rates of dyspareunia (a secondary outcome measure for this review) at two months and six months with no statistically significant difference between both groups; two months, (RR 0.44, 95% CI 0.18 to 1.11, one study, 26 women) and six months, (RR 0.39, 95% CI 0.04 to 3.87, one study 32 women). This trial also included data on the numbers of women who resumed sexual intercourse by two months and six months. Significantly more women in the secondary suturing group had resumed intercourse by two months (RR 1.78, 95% CI 1.10 to 2.89, one study, 35 women), although by six months there was no significant difference between the two groups (RR 1.08, 95% CI, 0.91 to 1.28).Neither of the trials included data in relation to the following prespecified secondary outcome measures: pain at any time interval; the woman's satisfaction with the aesthetic results of the perineal wound; exclusive breastfeeding; maternal anxiety or depression.

AUTHORS' CONCLUSIONS

Based on this review, there is currently insufficient evidence available to either support or refute secondary suturing for the management of broken down perineal wounds following childbirth. There is an urgent need for a robust randomised controlled trial to evaluate fully the comparative effects of both treatment options.

Drainage water reuse: biological, physical, and technological considerations for system management

Previous reviews of drainage water reuse have discussed principles of water reuse and disposal; provided examples of reuse practices; offered reuse criteria for salinity, for trace elements, and for bacteria; discussed mitigation of dissolved trace elements in reuse strategies; and summarized the California experience with a focus on discussion of salinity, sodicity, B, Mo, and Se issues. This review emphasizes recent literature contributing to understanding physical and biological constraints to drainage water reuse. The potential for drip irrigation and, particularly, low-flow/high-frequency systems to enhance the use of drainage water while minimizing the deleterious effects on yield and on water and soil resources is examined using the numeric HYRDUS-2d model. Additionally, an analytical model is used to illustrate physical and biological limitations to drainage water management that result from the self-regulating nature of the soil-plant-water system. The models suggest that crop, soil, irrigation frequency, and delivery systems might be manipulated to reduce the quantity of drainage water, but they also suggest that the nature of the system may seriously constrain the amount of reduction that might be achieved.

Environmental implications of adopting a dominant factor approach to salinity management

Additive or multiplicative models of crop response on which salinity management theory have been developed may lead to an erroneous perception regarding compensative interaction among salinity and other growth factors. We present results from studies of biomass production and transpiration of corn (Zea mays L. cv. Jubilee), melon (Cucumis melo L. subsp. melo cv. Galia), tomato (Lycopersicon esculentum Mill. cv. 5656), onion (Allium cepa L. cv. HA 944), and date palms (Phoenix dactylifera L. cv. Medjool) under salinity combined with water or nitrate (growth promoters) or with boron (growth inhibitor). The measured crop responses were to the more severe stress rather than to combinations of the individual effects of the various stresses. Consequences of shifting management of saline water to a dominant factor approach include reduction of environmental contamination and conservation of water resources.

The effects of oxalates produced by Salsola tragus on the phosphorus nutrition of Stipa pulchra

Oxalic acid is produced by some species of plants and mycorrhizal fungi and it may solubilize unavailable soil phosphorus (P) bound by cations (Ca⁺⁺, Al⁺⁺, Fe⁺⁺⁺). Field and greenhouse experiments were conducted to show whether oxalate produced by the annual Salsola tragus or added oxalic acid would solubilize P from the inorganic-bound soil P pool, making it available for uptake by Stipa pulchra. Oxalate could be leached in the laboratory from the senescent canopy of Salsola, and leaching by rainfall was hypothesized to be a source of potential increased soil P under the Salsola canopy. Both oxalate leached from the canopy of Salsola and added oxalic acid increased the availability of soil P in greenhouse experiments. The source of the increase in available soil P in the greenhouse experiment was shown to be the inorganic-bound P pool, as the total P concentration of the soil decreased with increasing oxalate. There were significant increases in Stipa shoot P in response to Salsola leachates and in response to added oxalate in the greenhouse studies. These results suggest an important role for oxalate in P cycling. On disturbed sites where Salsola invades it may act to facilitate the establishment of later seral species like Stipa by creating a nutrient island of available P.

Soil solution phosphate, root uptake kinetics and nutrient acquisition: implications for a patchy soil environment

The importance of increased root phosphate (P) uptake kinetics, root proliferation and local increases of soil solution P (P₁) for P acquisition from fertile soil microsites was explored with a simulation model and calculated uptake was compared with experimental data. Based on the partitioning of added P in microsites to P₁ and P adsorbed on soil particles and the results of a dual-isotope-labeling experiment (Caldwell et al. 1991a), acquisition of P from the fertile microsites was some 20 X that of uptake from an equal volume of soil which received only water. Simulations were in general agreement and also showed that elevation of root P uptake kinetics could contribute more to the increased acquisition than did root proliferation under these circumstances. Although increased physiological uptake capacity for P has generally been considered to be of little benefit because of diffusion limitation, in patchy soil environments selective elevation of P uptake kinetics in fertile microsites may be of considerable benefit. These tests were conducted in calcareous soil which releases much less P into the soil solution than do many other soils. In many noncalcareous soils the benefits of selective elevation of root uptake kinetics would likely be greater.