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

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Abstract

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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 (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.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Plain language summary

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

Continuous stitching causes less pain than interrupted stitches when used for repairing the perineum after childbirth

When women give birth the perineum (the area between the vaginal opening and back passage) sometimes tears or it may be necessary to have an episiotomy (surgical cut) to increase the size of the outlet. Episiotomies and tears that involve the muscle layer (second degree) need to be stitched. In the UK alone, approximately 1,000 women per day will experience perineal stitches following vaginal birth and millions more worldwide. A midwife or doctor will stitch the episiotomy or second degree tear in three layers (vagina, perineal muscle and skin). Traditionally the vagina is stitched using a continuous locking stitch and the perineal muscles and skin are repaired using approximately three or four individual stitches, each needing to be knotted separately to prevent them from dislodging. Researchers have been suggesting for more than 70 years that the 'continuous non‐locking stitching method' is better than 'traditional interrupted methods'. This review looked at 'continuous stitching methods' compared with 'traditional interrupted stitching methods' and identified seven trials involving 3822 women. Results from the trials showed that stitching just underneath the skin (subcutaneous) was associated with less pain; however, when the 'continuous stitching method' is used for repair of all three layers, this is associated with even less pain. Other research is needed to assess perineal repair training programmes. In addition, research is needed to look at interventions that may reduce the incidence of perineal trauma during childbirth.