ArticlesContinuous versus interrupted perineal repair with standard or rapidly absorbed sutures after spontaneous vaginal birth: a randomised controlled trial
Introduction
85% of women who have a spontaneous vaginal birth will have some form of perineal trauma, and up to 69% will need to have sutures.1, 2, 3 In the UK, about 350 000 women yearly need perineal repair after normal childbirth. Most of these women will have perineal pain in the period immediately after delivery, and about a fifth will continue to have long-term problems, such as superficial dyspareunia. If repairs are done perfunctorily or inadequately, women could have continued perineal pain, which has been described as being far worse than the pain of childbirth.4 This pain can be very distressing, and can interfere with the new mother's daily activities such as walking, sitting, lying in bed, passing urine, and opening bowels, and could affect her ability to cope with the 24-h demands of parenthood.5 The extent of trauma, skill of the operator, technique of repair, and type of suturing material used all contribute to perineal pain.6
Results of a systematic review of four randomised controlled trials,7 consisting of 1864 primiparous and multiparous women, showed that continuous subcutaneous techniques of perineal skin closure were associated with less short-term pain than interrupted transcutaneous stitches. However, these four studies were heterogeneous in terms of the specific components of training and details of gauge of material and methods used. Only two studies specified a period of training before recruitment of participants.8, 9 Data were presented in a suitable format for meta-analysis in three studies, but results of only one study8 showed any significant difference between the intervention groups. This finding was weakened by the number of participants who were excluded from early follow-up (n=98). Meta-analysis of the published data showed no difference in terms of dyspareunia at 3 months after delivery.
Grant,10 recognising the technical difficulty of continuous subcuticular perineal skin closure, suggested that the interrupted method is easier than this technique to learn and could cause fewer problems for inexperienced or novice operators. A telephone survey in 1995 revealed that of 21 hospitals contacted within the West Midlands region of the UK, most were instructing midwives to undertake perineal repair with the interrupted method (C Kettle, unpublished).
In 1990, Fleming11 reported her findings after use of a simple, non-locking, loose, continuous suturing technique for all layers, with subcutaneous stitches placed well below the perineal skin surface. She reported that the continuous technique was straightforward to do and could be easily taught to inexperienced operators. Women reported low levels of pain after repair with this technique, and good cosmetic results were seen on clinical examination 6 weeks after delivery.11
There is also evidence that perineal repair with an absorbable synthetic material, such as standard polyglactin 910 (Vicryl; Ethicon, Edinburgh, UK) or polyglycolic acid (Dexon; Davis and Geck, Gosport, UK) reduces shortterm pain.12 The long-term effects of these materials are less clear, and there are some concerns about the need to remove absorbable synthetic material up to 3 months after delivery.13 A polyglactin 910 suture material (Vicryl Rapide; Ethicon) is now available for perineal repair, which is more rapidly absorbed than standard polyglactin 910 material. This material has all the properties of other synthetic sutures, but because of changes in the manufacturing process, its tensile strength is lost by day 10–14, and it is totally absorbed by 42 days.14
One possible risk associated with early absorption might be an increase in wound breakdown. Results of an observational study undertaken in France,15 of 2000 women undergoing episiotomy repair with the more rapidly absorbed polyglactin 910 suture material, recorded no short-term adverse effects, apart from a 2% rate of wound dehiscence at day 3 after delivery. Data from a small (n=308) randomised controlled trial undertaken in Denmark,16 which compared standard polyglactin 910 suture material with the more rapidly absorbed polyglactin 910 material, showed no difference in the overall amount of short-term and long-term pain. There was a substantial reduction in pain when walking at day 14 for women in whom the more rapidly absorbed polyglactin 910 suture material was used compared with those in whom the standard material was used (33·3% vs 48·5%), but no difference in wound dehiscence was seen. The authors concluded that a large study was needed to look at these results further.
We thus aimed to compare the continuous technique with the interrupted method of perineal repair, and the more rapidly absorbed suture material with the standard polyglactin 910 material.
Section snippets
Participants
Our study was undertaken in a UK district general hospital with more than 5000 deliveries per year. The static population of this district includes a wide range of socioeconomic classes, and is predominately white. The local research ethics committee approved the study.
Hospital and community midwives gave written information leaflets about the study to all women during routine antenatal visits. These leaflets were produced in collaboration with the lead investigator (CK), the National
Patients
Analysis of data recorded in the birth register showed that, during the randomisation period, 2273 mothers were eligible for the study (figure 2). 731 mothers did not take part, and the main reasons were that the woman did not want to enter the trial (358), supervision was not available (154), and the midwife responsible for the suturing did not ask the woman if she would like to take part (98). Other reasons included postpartum haemorrhage, the tear was too small, or placenta was retained
Discussion
For every six women in our study who were sutured with the continuous technique there was one less who complained of pain at day 10 than in the interrupted method group. This benefit of the continuous technique was seen consistently, whether we looked at pain associated with daily activities, suture material, or skill of operator. Results of our secondary analysis showed the absence of any effect of operator bias or confounding variables in the early phases of the study. Most of the
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