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BMJ Clinical Evidence logoLink to BMJ Clinical Evidence
. 2015 Mar 10;2015:1401.

Perineal care

Julie Frohlich 1,#, Christine Kettle 2,#
PMCID: PMC4356152  PMID: 25752310

Abstract

Introduction

More than 85% of women having a vaginal birth suffer some perineal trauma. Spontaneous tears requiring suturing are estimated to occur in at least one third of women in the UK and US. Perineal trauma can lead to long-term physical and psychological problems.

Methods and outcomes

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of different methods and materials for primary repair of first- and second-degree tears and episiotomies? What are the effects of different methods and materials for primary repair of obstetric anal sphincter injuries (third- and fourth-degree tears)? We searched: Medline, Embase, The Cochrane Library, and other important databases up to November 2013 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

Results

We found 33 studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

Conclusions

In this systematic review, we present information relating to the effectiveness and safety of the following interventions: conventional suturing; different methods and materials for primary repair of obstetric anal sphincter injuries; non-suturing of muscle and skin (or perineal skin alone); and sutures (absorbable synthetic sutures, catgut sutures, continuous sutures, interrupted sutures).

Key Points

More than 85% of women having a vaginal birth suffer some perineal trauma.

  • Spontaneous tears requiring suturing are estimated to occur in at least one third of women in the UK and US.

  • Risk factors for severe perineal trauma include first vaginal delivery, large or malpositioned baby, older mother, abnormal collagen synthesis, and forceps delivery.

Perineal trauma can lead to long-term physical and psychological problems such as long-term perineal pain, dyspareunia or urinary problems, and faecal incontinence.

Non-suturing of all layers in first- and second-degree tears (perineal skin and muscles) may be associated with reduced wound healing at 6 weeks after birth. However, leaving the perineal skin alone unsutured (vagina and perineal muscles sutured) reduces dyspareunia and may reduce perineal pain at 14 days to 6 weeks after delivery.

Perineal gaping may be more likely for up to 3 months after delivery, when the skin is left unsutured; although, further studies are required. There is no evidence about longer-term outcomes when the skin is left unsutured.

Absorbable synthetic sutures for repair of first- and second-degree tears and episiotomies may be less likely to result in perineal pain and dyspareunia than catgut sutures. Rapidly absorbed synthetic sutures reduce the need for suture removal. Continuous sutures reduce short-term pain and analgesic use.

We don’t know how primary overlap repair for third- and fourth-degree anal sphincter tears and end-to-end approximation compare with each other at reducing perineal pain or faecal urgency or incontinence.

Clinical context

General background

More than 85% of women having a vaginal birth suffer some degree of perineal trauma. It is estimated that at least one third of women in the UK and US require perineal suturing following birth. Perineal trauma can lead to long-term physical and psychological problems for women. This review looks at the effects of different methods and materials for primary repair of perineal trauma in all classifications including obstetric anal sphincter injury (OASI).

Focus of the review

To increase the likelihood of a good outcome following repair of perineal trauma sustained during vaginal birth, clinicians must ensure that the suturing techniques they employ, and the materials they use, are supported by the best available evidence. We reviewed the effects and different methods and materials for the primary repair of first- and second-degree tears and episiotomies, the trauma most often sustained during vaginal birth. We also reviewed the effects of different methods and materials for primary repair of OASI (third- and fourth-degree tears), the trauma most likely to have longer-term consequences for women both physically and psychologically.

Comments on evidence

We found no high-quality evidence in any of the areas reviewed. With regard to perineal trauma and adverse effects, we found moderate-quality evidence when comparing different types of absorbable synthetic suture materials; however, there was some statistical heterogeneity between studies. We also found moderate-quality evidence with regard to continuous versus interrupted sutures for perineal repair; again, there was statistical heterogeneity between studies and the results were analysed at different time points. The remaining studies were assessed as being of low- or of very low-quality using a GRADE evaluation.

Search and appraisal summary

The update literature search for this review was carried out from the date of the last search (March 2010) to November 2013. For more information on the electronic databases searched and criteria applied during assessment of studies for potential relevance to the review, please see the Methods section. Searching of electronic databases retrieved 100 studies. After deduplication and removal of conference abstracts, 37 records were screened for inclusion in the review. Appraisal of titles and abstracts led to the exclusion of 27 studies and the further review of 10 full publications. Of the 10 full articles evaluated, two systematic reviews and five RCTs were added at this update.

Additional information

Given that perineal trauma sustained during vaginal birth is so prevalent, it is disappointing that there is a lack of high-quality evidence concerning primary repair.

About this condition

Definition

Perineal trauma is any damage to the genitalia during childbirth that occurs spontaneously or intentionally by surgical incision (episiotomy). Anterior perineal trauma is injury to the labia, anterior vagina, urethra, or clitoris, and is usually associated with little morbidity. Posterior perineal trauma is any injury to the posterior vaginal wall, perineal muscles, or anal sphincter. Spontaneous tears are defined as first degree when they involve the perineal skin only; second-degree tears involve the perineal muscles and skin; third-degree tears involve the anal sphincter complex (classified as 3a where <50% of the external anal sphincter is torn; 3b where >50% of the external anal sphincter is torn; 3c where the internal and external anal sphincter is torn); fourth-degree tears involve the anal sphincter complex and anal epithelium.

Incidence/ Prevalence

More than 85% of women having a vaginal birth sustain some form of perineal trauma, and 60% to 70% receive stitches. In England from 2012 to 2013, perineal tears during delivery were reported in 42% of deliveries for women aged 15 to 24 years, and 31% of deliveries for women aged 40 to 49 years. There are wide variations in rates of episiotomy: 8% in the Netherlands, 14% in England, and 50% in the US. Sutured spontaneous tears are reported in about one third of women in the US and the UK, but this is probably an underestimate because of inconsistencies in both reporting and classification of perineal trauma. The incidence of anal sphincter tears varies between 1% in Finland, 2% in the UK, and 17% in the US. The incidence of obstetric anal sphincter injuries in primiparous women in the UK is reported to have risen to 6% over the past decade.

Aetiology/ Risk factors

Perineal trauma occurs during spontaneous or assisted vaginal delivery, and is usually more extensive with the first vaginal delivery. Associated risk factors also include bigger baby, mode of delivery (especially forceps), and malpresentation and malposition of the fetus, position of the mother during birth (especially birthing stools), and prolonged pushing. Other maternal factors that may increase the extent and degree of trauma are ethnicity (Asian women in the UK have been shown to be at greater risk of obstetric anal sphincter injury), age older than 25 years, abnormal collagen synthesis, poor nutritional state, and higher socio-economic status. Clinicians' practices or preferences in terms of intrapartum interventions may influence the severity and rate of perineal trauma (e.g., use of ventouse v forceps or ‘hands-on’ v ‘hands-off’).

Prognosis

Perineal trauma affects women's physical, psychological, and social wellbeing in the immediate postnatal period as well as in the long term. It can also disrupt breastfeeding, family life, and sexual relations. In the UK, about 23% to 42% of women continue to have pain and discomfort for 10 to 12 days postpartum, and 7% to 10% of women continue to have long-term pain (3–18 months after delivery); 23% of women experience superficial dyspareunia at 3 months; 3% to 10% report faecal incontinence; and up to 24% have urinary problems. Complications depend on the severity of perineal trauma, and on the effectiveness of treatment.

Aims of intervention

To reduce the rate and severity of trauma; to improve the short- and long-term maternal morbidity associated with perineal injury and repair.

Outcomes

Incidence and severity of perineal trauma: psychological trauma; short- and long-term perineal pain; blood loss; infection; wound dehiscence; superficial dyspareunia; urinary incontinence or retention; faecal incontinence; quality of life; adverse effects.

Methods

BMJ Clinical Evidence search and appraisal November 2013. The following databases were used to identify studies for this systematic review: Medline 1966 to November 2013, Embase 1980 to November 2013, and The Cochrane Database of Systematic Reviews 2013, issue 10 (1966 to date of issue). Additional searches were carried out in the Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA) database. We also searched for retractions of studies included in the review. Titles and abstracts identified by the initial search, run by an information specialist, were assessed against predefined criteria by an evidence scanner. Full texts for potentially relevant studies were then assessed against predefined criteria by an evidence analyst. Studies selected for inclusion were discussed with an expert contributor. All data relevant to the review were then extracted by an evidence analyst. Study design criteria for inclusion in this review were: published RCTs and systematic reviews of RCTs in the English language, at least single-blinded, and containing more than 20 individuals of whom more than 80% were followed up. There was no minimum length of follow-up. We excluded all studies described as 'open', 'open label', or not blinded unless blinding was impossible. We included RCTs and systematic reviews of RCTs where harms of an included intervention were studied applying the same study design criteria for inclusion as we did for benefits. In addition, we use a regular surveillance protocol to capture harms alerts from organisations such as the FDA and the MHRA, which are added to the reviews as required. To aid readability of the numerical data in our reviews, we round many percentages to the nearest whole number. Readers should be aware of this when relating percentages to summary statistics such as relative risks (RRs) and odds ratios (ORs). We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table). The categorisation of the quality of the evidence (high, moderate, low, or very low) reflects the quality of evidence available for our chosen outcomes in our defined populations of interest. These categorisations are not necessarily a reflection of the overall methodological quality of any individual study, because the Clinical Evidence population and outcome of choice may represent only a small subset of the total outcomes reported, and population included, in any individual trial. For further details of how we perform the GRADE evaluation and the scoring system we use, please see our website (www.clinicalevidence.com).

Table.

GRADE Evaluation of interventions for Perineal care.

Important outcomes Adverse effects, Perineal trauma
Studies (Participants) Outcome Comparison Type of evidence Quality Consistency Directness Effect size GRADE Comment
What are the effects of different methods and materials for primary repair of first- and second-degree tears and episiotomies?
2 (2857) Perineal trauma Vagina and perineal muscle sutured but perineal skin left unsutured in first- and second-degree tears and episiotomies versus conventional suturing 4 –1 –1 0 0 Low Quality point deducted for no intention-to-treat analysis; consistency point deducted for statistical heterogeneity between RCTs
2 (2594) Adverse effects Vagina and perineal muscle sutured but perineal skin left unsutured in first- and second-degree tears and episiotomies versus conventional suturing 4 –1 –1 0 0 Low Quality point deducted for no intention-to-treat analysis in one study; consistency point deducted for statistical heterogeneity between RCTs
2 (152) Perineal trauma Non-suturing of all layers in first- and second-degree tears versus conventional suturing 4 –3 0 0 0 Very low Quality points deducted for sparse data, incomplete reporting of results, and unclear outcome measurement
2 (152) Adverse effects Non-suturing of all layers in first- and second-degree tears versus conventional suturing 4 –3 0 0 0 Very low Quality points deducted for sparse data, incomplete reporting of results, and unclear outcome measurement
12 (5472) Perineal trauma Absorbable synthetic sutures versus catgut sutures 4 –3 –1 0 0 Very low Quality points deducted for incomplete reporting of results, no blinding in some RCTs, and incomplete recruiting in one RCT; consistency point deducted for statistical heterogeneity between RCTs
5 (2711) Adverse effects Absorbable synthetic sutures versus catgut sutures 4 –1 –1 0 0 Low Quality point deducted for incomplete reporting of results of one RCT; consistency point deducted for statistical heterogeneity between RCTs
5 (2182) Perineal trauma Different types of absorbable synthetic suture versus each other 4 0 0 –1 0 Moderate Directness point deducted for clinical heterogeneity
3 (1967) Adverse effects Different types of absorbable synthetic suture versus each other 4 0 0 –1 0 Moderate Directness point deducted for clinical heterogeneity between RCTs
11 (at least 4231) Perineal trauma Continuous versus interrupted sutures for repair of all layers or only perineal skin (analysed as a group) 4 0 –1 0 0 Moderate Consistency point deducted for statistical heterogeneity
At least 7 (at least 3457) Adverse effects Continuous versus interrupted sutures for repair of all layers or only perineal skin (analysed as a group) 4 0 –1 0 0 Moderate Consistency point deducted for significant heterogeneity
at least 7 (at least 3289) Perineal trauma Continuous versus interrupted sutures for repair of all layers 4 –1 –1 0 0 Low Quality point deducted for weak methodology; consistency point deducted for statistical heterogeneity between RCTs
What are the effects of different methods and materials for primary repair of obstetric anal sphincter injuries (third- and fourth-degree tears)?
3 (279) Perineal trauma Different methods for primary repair versus each other 4 –1 –1 0 0 Low Quality point deducted for weak methods; consistency point deducted for different results for different outcomes
1 (112) Perineal trauma Different materials for primary repair versus each other 4 –2 0 –1 0 Very low Quality points deducted for sparse data and methodological weakness; directness point deducted for composite outcome
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We initially allocate 4 points to evidence from RCTs, and 2 points to evidence from observational studies. To attain the final GRADE score for a given comparison, points are deducted or added from this initial score based on preset criteria relating to the categories of quality, directness, consistency, and effect size. Quality: based on issues affecting methodological rigour (e.g., incomplete reporting of results, quasi-randomisation, sparse data [<200 people in the analysis]). Consistency: based on similarity of results across studies. Directness: based on generalisability of population or outcomes. Effect size: based on magnitude of effect as measured by statistics such as relative risk, odds ratio, or hazard ratio.

Glossary

End-to-end technique

for primary repair of third-degree obstetric anal sphincter tears involves the torn ends of the external anal sphincter being juxtaposed with interrupted sutures.

Low-quality evidence

Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Moderate-quality evidence

Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Overlap technique

for primary repair of third-degree obstetric anal sphincter tears involves the torn ends of the external anal sphincter being overlapped and sutured with interrupted stitches.

Very low-quality evidence

Any estimate of effect is very uncertain.

Disclaimer

The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients. To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.

Contributor Information

Dr Julie Frohlich, St Thomas' Hospital, London, UK.

Christine Kettle, Faculty of Health Sciences, Staffordshire University, Stoke-on-Trent, UK.

References

  • 1.Fernando RJ, Williams AA, Adams EJ; Royal College of Obstetricians and Gynaecologists . The management of third and fourth degree perineal tears. RCOG Green top Guidelines No 29. 2007. Available at https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg29/ (last accessed 16 September 2014). [Google Scholar]
  • 2.McCandlish R, Bowler U, van Asten H, et al. A randomised controlled trial of care of the perineum during second stage of normal labour. Br J Obstet Gynaecol 1998;105:1262–1272. [DOI] [PubMed] [Google Scholar]
  • 3.Sleep J, Grant A, Garcia J, et al. West Berkshire perineal management trial. BMJ 1984;289:587–590. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Health and Social Care Information Centre. Hospital Episode Statistics–NHS maternity statistics, England: 2012–2013. December 2013. Available at http://www.hscic.gov.uk/catalogue/PUB12744 (last accessed 16 September 2014). [Google Scholar]
  • 5.Graves EJ, Kozak LJ. National hospital discharge survey: annual summary, 1996. Vital Health Stat 1999;140:i–iv,1–46. [PubMed] [Google Scholar]
  • 6.Audit Commission. First class delivery: improving maternity services in England and Wales. London: Audit Commission Publications, 1997. [Google Scholar]
  • 7.National Institute for Health and Welfare. Parturients, delivers and newborns. December 2012. Available at http://www.thl.fi/en/web/thlfi-en/statistics/information-on-statistics/quality-descriptions/parturients-delivers-and-newborns (last accessed 16 September 2014). [Google Scholar]
  • 8.EURO PERISTAT. European perinatal health report: health and care of pregnant women and babies in Europe in 2010. 2010. Available at http://www.europeristat.com/reports.html (last accessed 16 September 2014). [Google Scholar]
  • 9.Fenner DE, Genberg B, Brahma P, et al. Fecal and urinary incontinence after vaginal delivery with anal sphincter disruption in an obstetrics unit in the United States. Am J Obstet Gynecol 2003;189:1543–1549. [DOI] [PubMed] [Google Scholar]
  • 10.Gurol-Urganci I, Cromwell DA, Edozien LC, et al. Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. BJOG 2013;120:1516–1525. [DOI] [PubMed] [Google Scholar]
  • 11.Sultan AH, Kamm MA, Bartram CI, et al. Perineal damage at delivery. Contemp Rev Obstet Gynaecol 1994;6:18–24. [Google Scholar]
  • 12.Dahlen HG, Priddis H, Thornton C. Severe perineal trauma is rising, but let us not overreact. Midwifery 2015;31:1–8. [DOI] [PubMed] [Google Scholar]
  • 13.Renfrew MJ, Hannah W, Albers L, et al. Practices that minimize trauma to the genital tract in childbirth: a systematic review of the literature. Birth 1998;25:143–160. Search date 1997. [DOI] [PubMed] [Google Scholar]
  • 14.Glazener CMA, Abdalla M, Stroud P, et al. Postnatal maternal morbidity: extent, causes, prevention and treatment. Br J Obstet Gynaecol 1995;102:286–287. [DOI] [PubMed] [Google Scholar]
  • 15.Sleep J, Grant A. Pelvic floor exercises in postnatal care. Midwifery 1987;3:158–164. [DOI] [PubMed] [Google Scholar]
  • 16.Sultan AH, Kamm MA, Hudson CN. Anal sphincter disruption during vaginal delivery. N Engl J Med 1993;329:1905–1911. [DOI] [PubMed] [Google Scholar]
  • 17.Kettle C, Hills RK, Ismail KMK. Continuous versus interrupted sutures for repair of episiotomy or second degree tears. In: The Cochrane Library, Issue 10, 2013. Chichester, UK: John Wiley & Sons, Ltd. Search date 2012. [DOI] [PubMed] [Google Scholar]
  • 18.Gordon B, Mackrodt C, Fern E, et al. The Ipswich Childbirth study: 1. A randomised evaluation of two stage after birth perineal repair leaving the skin unsutured. Br J Obstet Gynaecol 1998;105:435–440. [DOI] [PubMed] [Google Scholar]
  • 19.Oboro VO, Tabowei TO, Loto OM, et al. A multicentre evaluation of the two-layer repair of after birth perineal trauma. J Obstet Gynaecol 2003;1:5–8. [DOI] [PubMed] [Google Scholar]
  • 20.Lundquist M, Olsson A, Nissen E, et al. Is it necessary to suture all lacerations after a vaginal delivery? Birth 2000;27:79–85. [DOI] [PubMed] [Google Scholar]
  • 21.Fleming EM, Hagen S, Niven C. Does perineal suturing make a difference? The SUNS trial. BJOG 2003;110: 684–689. [PubMed] [Google Scholar]
  • 22.Kettle C, Dowswell T, Ismail KMK. Absorbable suture materials for primary repair of episiotomy and second degree tears. In: The Cochrane Library, Issue 10, 2013. Chichester, UK: John Wiley & Sons, Ltd. Search date 2010. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Kettle C, Johanson RB. Absorbable synthetic versus catgut suture material for perineal repair. In: The Cochrane Library, Issue 10, 2013. Chichester, UK: John Wiley & Sons, Ltd. Search date 1999. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Upton A, Roberts CL, Ryan M, et al. A randomised trial, conducted by midwives, of perineal repairs comparing a polyglycolic suture material and chromic catgut. Midwifery 2002;18:223–229. [DOI] [PubMed] [Google Scholar]
  • 25.Mackrodt C, Gordon B, Fern E, et al. The Ipswich Childbirth study: 2. A randomised comparison of polyglactin 910 with chromic catgut for after birth perineal repair. Br J Obstet Gynaecol 1998;105:441–445. [DOI] [PubMed] [Google Scholar]
  • 26.Grant A, Gordon B, Mackrodt C, et al. The Ipswich Childbirth study: one year follow up of alternative methods used in perineal repair. BJOG 2001;108:34–40. [DOI] [PubMed] [Google Scholar]
  • 27.Bharathi A, Reddy DB, Kote GS. A prospective randomized comparative study of vicryl rapide versus chromic catgut for episiotomy repair. J Clin Diagnostic Res 2013;7:326–330. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Leroux N, Bujold E. Impact of chromic catgut versus polyglactin 910 versus fast-absorbing polyglactin 910 sutures for perineal repair: a randomized, controlled trial. Am J Obstet Gynecol 2006;194:1585–1590. [DOI] [PubMed] [Google Scholar]
  • 29.Iqbal R, Intsar A, Khursheed S, et al. Outcome of continuous versus interrupted method of episiotomy stitching. Pakistan J Med Health Sci 2012;6:759-762. [Google Scholar]
  • 30.Kindberg S, Stehouwer M, Hvidman L, et al. Postpartum perineal repair performed by midwives: a randomised trial comparing two suture techniques leaving the skin unsutured. BJOG 2008;115:472–479. [DOI] [PubMed] [Google Scholar]
  • 31.Valenzuela P, Saiz Puente MS, Valero JL, et al. Continuous versus interrupted sutures for repair of episiotomy or second-degree perineal tears: a randomised controlled trial. BJOG 2009;116:436–441. [DOI] [PubMed] [Google Scholar]
  • 32.Fernando R, Sultan AH, Kettle C, et al. Methods of repair for obstetric anal sphincter injury. In: The Cochrane Library, Issue 10, 2013. Chichester, UK: John Wiley & Sons, Ltd. Search date 2006. 24318732 [Google Scholar]
  • 33.Farrell SA, Flowerdew G, Gilmour D, et al. Overlapping compared with end-to-end repair of complete third-degree or fourth-degree obstetric tears: three-year follow-up of a randomized controlled trial. Obstet Gynecol 2012;120:803–808. [DOI] [PubMed] [Google Scholar]
  • 34.Fitzpatrick M, Fynes M, Behan M, et al. A randomized clinical trial comparing primary overlap with approximation repair of third-degree obstetric tears. Am J Obstet Gynecol 2000;183:1220–1224. [DOI] [PubMed] [Google Scholar]
  • 35.Williams A, Adams EJ, Tincello DG, et al. How to repair an anal sphincter injury after vaginal delivery: results of a randomised controlled trial. BJOG 2006;113:201–207. [DOI] [PubMed] [Google Scholar]
BMJ Clin Evid. 2015 Mar 10;2015:1401.

Vagina and perineal muscle sutured but perineal skin left unsutured in first- and second-degree tears and episiotomies versus conventional suturing

Summary

Leaving the perineal skin alone unsutured (vagina and perineal muscles sutured) reduces dyspareunia and may reduce pain at 14 days to 6 weeks.

Benefits and harms

Vagina and perineal muscle sutured but perineal skin left unsutured in first- and second-degree tears and episiotomies versus conventional suturing:

We found one systematic review (search date 2012), which identified two RCTs (2857 women) that compared leaving the perineal skin unsutured but apposed (the vagina and perineal muscle were sutured [two-stage repair]) with a conventional repair in which all three layers were sutured (three-stage repair).

Perineal trauma

Vagina and perineal muscle sutured but perineal skin left unsutured in first- and second-degree tears and episiotomies compared with conventional suturing Leaving the perineal skin unsutured but apposed (with the vagina and perineal muscles sutured [two-stage repair]) may be more effective than conventional repair (in which all three layers are sutured [three-stage repair]), in women with first- and second-degree tears or episiotomies, at decreasing the proportion of women with dyspareunia at 3 months. Leaving the perineal skin unsutured but apposed may be more effective than conventional suturing, in women with first- and second-degree tears or episiotomies, at reducing perineal pain from 14 days to 6 weeks postpartum but not at 3 months; however we don’t know how they compare in the longer term. We don’t know how effective leaving the perineal skin unsutured but apposed and conventional suturing are compared to each other, in women with first- and second-degree tears or episiotomies, in reducing analgesic use postpartum (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Perineal pain

Systematic review		 2597 women; see Further information on studies
2 RCTs in this analysis		 Pain up to day 2 postpartum
782/1302 (60%) with 2-stage repair
834/1295 (64%) with 3-stage repair
RR 0.92
95% CI 0.84 to 1.02
P = 0.11
I2 = 55%; P = 0.14
See Further information on studies for heterogeneity 		Not significant

Systematic review		 2594 women; see Further information on studies
2 RCTs in this analysis		 Pain up to day 14 postpartum
314/1303 (24%) with 2-stage repair
361/1291 (28%) with 3-stage repair
RR 0.86
95% CI 0.76 to 0.98
P = 0.025 		Small effect size two-stage repair

Systematic review		 823 women who sustained a second-degree tear or episiotomy; see Further information on studies
2 RCTs in this analysis		 Analgesia use up to day 10 postpartum
543/1302 (42%) with 2-stage repair
589/1295 (46%) with 3-stage repair
RR 0.86
95% CI 0.59 to 1.23
P = 0.40
I2 = 93%; P = 0.0002
See Further information on studies for heterogeneity 		Not significant

Systematic review		 2487 women; see Further information on studies
2 RCTs in this analysis		 Pain up to 3 months after delivery
68/1245 (6%) with 2-stage repair
108/1242 (9%) with 3-stage repair
RR 0.41
95% CI 0.10 to 1.59
P = 0.20
I2 = 84%; P = 0.01
See Further information on studies for heterogeneity 		Not significant

RCT		 823 women who sustained a second-degree tear or episiotomy; see Further information on studies
In review 		Proportion of women with perineal pain 6 weeks
41/417 (10%) with perineal skin unsutured
62/406 (15%) with perineal skin sutured
RR 0.64
95% CI 0.44 to 0.93 		Small effect size perineal skin unsutured
Dyspareunia

Systematic review		 2487 women; see Further information on studies
2 RCTs in this analysis		 Dyspareunia up to 3 months after delivery
171/1245 (14%) with 2-stage delivery
231/1242 (19%) with 3-stage delivery
RR 0.72
95% CI 0.56 to 0.94
P = 0.014 		Small effect size 2-stage repair

Systematic review		 2487 women; see Further information on studies
2 RCTs in this analysis		 Failure to resume pain-free intercourse up to 3 months
562/1245 (45%) with 2-stage repair
650/1242 (52%) with 3-stage repair
RR 0.86
95% CI 0.80 to 0.92
P = 0.00002 		Small effect size 2-stage repair
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Adverse effects

Vagina and perineal muscle sutured but perineal skin left unsutured in first- and second-degree tears and episiotomies compared with conventional suturing Leaving the perineal skin unsutured but apposed (with the vagina and perineal muscles sutured [two-stage repair]) may be more effective than conventional suturing (in which all three layers are sutured [three-stage repair]) at decreasing the proportion of women requiring removal of suture material, but not the rates of wound gaping or proportion of women requiring re-suturing of their wound at up to 3 months (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Wound gaping/wound breakdown

Systematic review		 2594 women; see Further information on studies
2 RCTs in this analysis		 Wound 'gaping' ( >0.5 cm) up to 3 months after delivery
334/1303 (26%) with 2-stage repair
166/1291 (13%) with 3-stage repair
RR 2.74
95% CI 0.87 to 8.63
P = 0.086
I2 = 96%; P <0.00001
See Further information on studies for heterogeneity 		Not significant

Systematic review		 2487 women; see Further information on studies
2 RCTs in this analysis		 Re-suturing of wound up to 3 months after delivery
17/1245 (1%) with 2-stage repair
30/1242 (2%) with 3-stage repair
RR 0.56
95% CI 0.31 to 1.00
P = 0.051 		Not significant

Systematic review		 2603 women; see Further information on studies
2 RCTs in this analysis		 Removal of suture material up to 3 months after delivery
84/1307 (6%) with 2-stage repair
140/1296 (11%) with 3-stage repair
RR 0.60
95% CI 0.46 to 0.77
P = 0.000088 		Small effect size 2-stage repair
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Further information on studies

The systematic review reported that there was a significant degree of heterogeneity between trials for several outcomes that may be a result of clinical heterogeneity in terms of input in perineal repair training, different suturing techniques and materials used. One of the RCTs investigated primiparous and multiparous women with first- and second-degree tears or episiotomies after spontaneous or assisted vaginal delivery in a single UK centre. The other RCT was a multicentre trial conducted in Nigeria and investigated women who had sustained a second-degree tear or episiotomy. Initially, 1077 women were recruited into the trial, but only 823 of these responded up to 3 months after birth and were included in the analysis.

Comment

Clinical guide:

There is some evidence of benefit associated with leaving the perineal skin unsutured compared with skin sutured in terms of reducing pain and dyspareunia. However, there are no long-term follow-up studies and practitioners must be aware that, with non-suturing, there is an increased risk of wound gaping that may be unacceptable to women themselves in the months and years to come.

Substantive changes

Vagina and perineal muscle sutured but perineal skin left unsutured in first- and second-degree tears and episiotomies versus conventional suturing One systematic review added. Categorisation unchanged (likely to be beneficial).

BMJ Clin Evid. 2015 Mar 10;2015:1401.

Non-suturing of all layers in first- and second-degree tears

Summary

Non-suturing of all layers in first- and second-degree tears may be associated with reduced wound healing at 6 weeks after birth.

Benefits and harms

Non-suturing of all layers in first- and second-degree tears versus conventional suturing:

We found no systematic review. We found two small RCTs comparing non-suturing of all layers versus conventional suturing of first- and second-degree tears.

Perineal trauma

Non-suturing of all layers compared with suturing of first- and second-degree tears We don't know whether non-suturing of all layers in first- and second-degree perineal tears is more effective than suturing at reducing the proportion of women with 'burning sensation' (not further defined) or with soreness at 2 to 3 days after birth, or at reducing pain scores at 10 days or 6 weeks (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Perineal pain

RCT		 78 women in Sweden Proportion of women with burning sensation at 2–3 days after birth
9/40 (23%) with non-suturing of first- and second-degree tears
4/38 (11%) with suturing of first- and second-degree tears
RR 0.47
95% CI 0.16 to 1.39
Results should be interpreted with caution because of study limitations; see Further information on studies 		Not significant

RCT		 78 women in Sweden Proportion of women with soreness at 2–3 days after birth
3/40 (8%) with non-suturing of first- and second-degree tears
1/38 (3%) with suturing of first- and second-degree tears
RR 0.35
95% CI 0.04 to 3.23
Results should be interpreted with caution because of study limitations; see Further information on studies 		Not significant

RCT		 74 primiparous women in Scotland McGill pain scores at 10 days
with non-suturing of first- and second-degree tears
with suturing of first- and second-degree tears
Absolute results not reported
P = 0.8 		Not significant

RCT		 74 primiparous women in Scotland McGill pain scores at 6 weeks
with non-suturing of first- and second-degree tears
with suturing of first- and second-degree tears
Absolute results not reported
P = 0.8 		Not significant
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Adverse effects

Non-suturing of all layers compared with suturing of first- and second-degree tears Non-suturing of all layers in first- and second-degree perineal tears may be less effective at reducing the proportion of women with an open tear at 6 weeks after birth, but not at reducing 'healing' (not further defined; not clear how assessed) at 2 to 3 days and at 8 weeks after birth (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Wound gaping/non-healing

RCT		 74 primiparous women in Scotland Proportion of women with a closed tear 6 weeks after delivery
16/36 (44%) with non-suturing of first- and second-degree tears
26/31 (84%) with suturing of first- and second-degree tears
RR 0.53
95% CI 0.36 to 0.79 		Small effect size sutured

RCT		 78 women in Sweden Healing at 2–3 days after birth
with non-suturing of first- and second-degree tears
with suturing of first- and second-degree tears
Absolute results not reported
Results should be interpreted with caution because of study limitations; see Further information on studies 		Not significant

RCT		 78 women in Sweden Healing at 8 weeks after birth
with non-suturing of first- and second-degree tears
with suturing of first- and second-degree tears
Absolute results not reported
Results should be interpreted with caution because of study limitations; see Further information on studies 		Not significant
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Further information on studies

Results from the first small RCT should be interpreted with caution, because the study limitations compromise the validity of the results. It is unclear how healing was defined and assessed, and the study had an insufficient sample size to detect clinically important differences. This is suggested by the broad confidence intervals in the presence of a large difference in rates between the study groups.

The RCT was of reasonable methodological quality and used sealed opaque envelopes to allocate treatment. It was acknowledged that it was impossible to blind assessors to the allocated treatment, and that this might have biased results.

Comment

Clinical guide:

There is limited evidence regarding the benefits and harms of leaving all layers of perineal trauma unsutured (first- and second-degree tears). Practitioners should be extremely cautious about leaving this type of trauma unsutured unless it is the explicit wish of the woman, not least because of the decrease in closed tears at 6 weeks. While there was an apparent trend towards an increase in ‘burning sensation’ and soreness (reported 2 to 3 days after birth) when all layers are left unsutured, the long-term outcomes are likely to be of far greater importance for women. It is possible that leaving a second-degree tear unsutured (by definition, also including muscle), may adversely affect the integrity and function of the woman’s pelvic floor in the years to come. Leaving first-degree tears unsutured may have less long-term effect as far as the function of pelvic floor muscles are concerned; however, there is no evidence to support this practice.

Substantive changes

No new evidence

BMJ Clin Evid. 2015 Mar 10;2015:1401.

Absorbable sutures in first- and second-degree tears

Summary

Absorbable synthetic sutures for repair of first- and second-degree tears and episiotomies are less likely to result in short-term perineal pain and dyspareunia at 12 months than catgut sutures.

Benefits and harms

Absorbable synthetic sutures versus catgut sutures:

We found one systematic review (search date 2010), which identified 11 RCTs (5072 primiparous and multiparous women) that compared standard absorbable synthetic sutures and fast-absorbing synthetic sutures with catgut. Data from three RCTs in the systematic review were not reported in the review, and so are reported here directly from the RCT. RCTs varied in quality and in operator skills and training, and were conducted in Europe, the US, Australia, and Canada. We also found one subsequent RCT (400 women, carried out in India), which compared absorbable synthetic sutures versus chromic catgut.

Perineal trauma

Absorbable synthetic sutures compared with catgut sutures Standard absorbable synthetic sutures may be more effective than catgut sutures at reducing the proportion of women with perineal pain at up to 10 days but not at 3 to 6 months. Fast-absorbing synthetic sutures may be more effective than catgut sutures at reducing the proportion of women with perineal pain at 3 to 5 days and at 6 weeks. Standard absorbable synthetic sutures may be more effective than catgut sutures at reducing analgesic use at up to 10 days. Standard absorbable synthetic sutures may be more effective than catgut sutures at reducing dyspareunia at 12 months but not at 3 or 6 months. We don’t know if fast-absorbing synthetic sutures are more effective than catgut sutures at reducing the proportion of women with dyspareunia postpartum (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Perineal pain/analgesic use

RCT		 391 women who sustained a first- or second-degree tear or episiotomy after a spontaneous vaginal delivery
In review 		Proportion of women with perineal pain 6 months
9/158 (6%) with absorbable synthetic (standard polyglactin-910 or polyglycolic acid)
5/159 (3%) with catgut suture material
RR 1.81
95% CI 0.62 to 5.28 		Not significant

Systematic review		 4017 women
9 RCTs in this analysis		 Pain at or before 3 days after delivery
1108/2020 (55%) with standard absorbable synthetic sutures
1308/1997 (66%) with catgut sutures
RR 0.83
95% CI 0.76 to 0.90
P = 0.000014
I2 = 57%; P = 0.02
See Further information on studies for heterogeneity 		Large effect size standard absorbable synthetic sutures

Systematic review		 2044 women
3 RCTs in this analysis		 Pain at 4–10 days following delivery
232/1024 (23%) with standard absorbable synthetic sutures
298/1020 (29%) with catgut sutures
RR 0.78
95% CI 0.67 to 0.90
P = 0.00085 		Small effect size standard absorbable synthetic sutures

Systematic review		 2820 women
5 RCTs in this analysis		 Analgesia use up to 10 days
262/1422 (18%) with standard absorbable synthetic sutures
338/1398 (24%) with catgut sutures
RR 0.71
95% CI 0.59 to 0.87
P = 0.00081
I2 = 48%; P = 0.10
See Further information on studies for heterogeneity 		Small effect size standard absorbable synthetic sutures

Systematic review		 2525 women
4 RCTs in this analysis		 Pain at 3 months postpartum
112/1261 (9%) with standard absorbable synthetic sutures
130/1264 (10%) with catgut sutures
RR 0.86
95% CI 0.68 to 1.09
P = 0.22 		Not significant

RCT		 400 women No pain 24–48 hours
17/200 (9%) with polyglactin-910
10/200 (5%) with chromic catgut
Significance not assessed 		Not significant

RCT		 400 women No pain 3–5 days
114/200 (57%) with polyglactin-910
65/200 (33%) with chromic catgut
P <0.05 		Effect size not calculated polyglactin-910

RCT		 400 women No pain at 6 weeks
171/200 (86%) with polyglactin-910
158/200 (79%) with chromic catgut
P <0.05 		Effect size not calculated polyglactin-910

Systematic review		 908 women
Data from 1 RCT		 Pain at or before 3 days after delivery
424/459 (92%) with fast-absorbing synthetic sutures
407/449 (91%) with catgut sutures
RR 1.02
95% CI 0.98 to 1.06
P = 0.35 		Not significant

Systematic review		 846 women
Data from 1 RCT		 Pain at 4–10 days following delivery
256/430 (60%) with fast-absorbing synthetic sutures
235/416 (56%) with catgut sutures
RR 1.05
95% CI 0.94 to 1.18
P = 0.37 		Not significant

Systematic review		 908 women
Data from 1 RCT		 Analgesia use up to 10 days
375/459 (82%) with fast-absorbing synthetic sutures
383/449 (85%) with catgut sutures
RR 0.96
95% CI 0.90 to 1.01
P = 0.14 		Not significant

Systematic review		 370 women
2 RCTs in this analysis		 Pain at 3 months postpartum
43/215 (20%) with fast-absorbing synthetic sutures
40/155 (26%) with catgut sutures
RR 0.8
95% CI 0.55 to 1.17
P = 0.25 		Not significant
Dyspareunia

RCT		 793 women Proportion of women with dyspareunia 12 months after birth
30/395 (8%) with absorbable synthetic sutures
51/398 (13%) with catgut sutures
RR 0.59
95% CI 0.39 to 0.91
NNT 20
95% CI 11 to 106 		Small effect size absorbable synthetic sutures

RCT		 391 women who sustained a first- or second-degree tear or episiotomy after a spontaneous vaginal delivery
In review 		Proportion of women with dyspareunia 6 months
24/148 (16%) with absorbable synthetic (standard polyglactin-910 or polyglycolic acid)
19/147 (13%) with catgut suture material
RR 1.25
95% CI 0.72 to 2.19 		Not significant

Systematic review		 2506 women
5 RCTs in this analysis		 Dyspareunia 3 months after delivery
217/1251 (17%) with standard absorbable synthetic sutures
221/1255 (18%) with catgut sutures
RR 0.93
95% CI 0.70 to 1.24
P = 0.63 		Not significant

RCT
3-armed trial 		192 women (repair of second-degree perineal lacerations or uncomplicated episiotomy [median or mediolateral]) Dyspareunia 6 weeks postpartum
with fast-absorbing polyglactin-910
with chromic catgut suture material
Absolute results not reported
P <0.05
See Further information on studies 		Effect size not calculated fast-absorbing polyglactin-910
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Adverse effects

Absorbable synthetic sutures compared with catgut sutures Absorbable synthetic sutures may be more effective than catgut sutures at reducing wound dehiscence at up to 10 days and at reducing wound infection. Absorbable synthetic sutures may be more effective than catgut sutures at reducing the proportion of women requiring re-suturing at up to 3 months. Absorbable synthetic sutures may be less effective than catgut sutures at reducing the proportion of women requiring removal of unabsorbed suture material at up to 3 months (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Adverse effects

Systematic review		 2219 women
4 RCTs in this analysis		 Superficial wound dehiscence up to day 10
174/1111 (16%) with standard absorbable synthetic sutures
283/1108 (26%) with catgut sutures
RR 0.58
95% CI 0.36 to 0.94
P = 0.027
I2 = 65%; P = 0.04
See Further information on studies for heterogeneity 		Moderate effect size standard absorbable synthetic sutures

Systematic review		 2402 women
4 RCTs in this analysis		 Required perineal re-suturing up to 3 months
3/1201 (0%) with standard absorbable synthetic sutures
15/1201 (1%) with catgut sutures
RR 0.25
95% CI 0.08 to 0.74
P = 0.012 		Moderate effect size standard absorbable synthetic sutures

Systematic review		 2520 women
3 RCTs in this analysis		 Required the removal of unabsorbed suture material up to 3 months
198/1255 (16%) with standard absorbable synthetic sutures
110/1265 (9%) with catgut sutures
RR 1.81
95% CI 1.46 to 2.24
P <0.00001 		Small effect size catgut sutures

Systematic review		 309 women
Data from 1 RCT		 Required the removal of unabsorbed suture material up to 3 months
2/175 (1%) with standard absorbable synthetic sutures
2/134 (1%) with catgut sutures
RR 0.77
95% CI 0.11 to 5.37
P = 0.79 		Not significant

RCT		 400 women Wound dehiscence
7/200 (4%) with polyglactin-910
27/200 (14%) with chromic catgut
P <0.05 		Effect size not calculated polyglactin-910

RCT		 400 women Wound infection
0/200 (0%) with polyglactin-910
8/200 (4%) with chromic catgut
P <0.05 		Effect size not calculated polyglactin-910

RCT		 400 women Required perineal re-suturing
0/200 (0%) with polyglactin-910
4/200 (2%) with chromic catgut
Significance not assessed 		Not significant
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Different types of absorbable synthetic suture versus each other:

We found one systematic review (search date 2010), which identified five RCTs (2349 people) that compared rapidly absorbed polyglactin-910 with standard polyglactin-910.

Perineal trauma

Different types of absorbable synthetic suture compared with each other Rapidly absorbed polyglactin-910 may be more effective than standard polyglactin-910 at reducing analgesic use at 10 days postpartum. Rapidly absorbed polyglactin-910 seems no more effective than standard polyglactin-910 at reducing the proportion of women with perineal pain at up to 3 months, or dyspareunia at up to 12 months (moderate-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Perineal pain

Systematic review		 1968 women
3 RCTs in this analysis		 Perineal pain up to 3 days after delivery
446/985 (45%) with rapidly absorbed polyglactin-910
440/983 (45%) with standard polyglactin-910
RR 1.01
95% CI 0.92 to 1.10
P = 0.83 		Not significant

Systematic review		 1847 women
2 RCTs in this analysis		 Perineal pain 10–14 days
325/924 (35%) with rapidly absorbed polyglactin-910
354/923 (38%) with standard polyglactin-910
RR 0.92
95% CI 0.81 to 1.03
P = 0.15 		Not significant

Systematic review		 1539 women
Data from 1 RCT		 Use of analgesia for perineal pain at 10 days post delivery
62/769 (8%) with rapidly absorbed polyglactin-910
108/770 (14%) with standard polyglactin-910
RR 0.57
95% CI 0.43 to 0.77
P = 0.00024 		Small effect size rapidly absorbed polyglactin-910

Systematic review		 369 women
2 RCTs in this analysis		 Pain at 3 months after delivery
12/195 (6%) with rapidly absorbed polyglactin-910
13/174 (8%) with standard polyglactin-910
RR 0.79
95% CI 0.37 to 1.67
P = 0.53 		Not significant
Dyspareunia

Systematic review		 1708 women
4 RCTs in this analysis		 Dyspareunia at 3 months
180/856 (21%) with rapidly absorbed polyglactin-910
180/852 (21%) with standard polyglactin-910
RR 0.93
95% CI 0.67 to 1.29
P = 0.66
I2 = 58%; P = 0.07 		Not significant

Systematic review		 1325 women
Data from 1 RCT		 Dyspareunia at 6–12 months
88/671 (13%) with rapidly absorbed polyglactin-910
97/654 (15%) with standard polyglactin-910
RR 0.88
95% CI 0.68 to 1.16
P = 0.37 		Not significant
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Adverse effects

Different types of absorbable synthetic suture compared with each other Rapidly absorbed polyglactin-910 may be less effective than standard polyglactin-910 at reducing wound gaping at up to 10 days. Rapidly absorbed polyglactin-910 may be more effective than standard polyglactin-910 at reducing the proportion of women requiring removal of suture material at up to 3 months. Rapidly absorbed polyglactin-910 seems no more effective than standard polyglactin-910 in reducing the proportion of women requiring wound re-suturing at 3 months (moderate-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Suture removal

Systematic review		 1659 women
2 RCTs in this analysis		 Wound gaping up to 10 days
50/829 (6%) with rapidly absorbed polyglactin-910
30/830 (4%) with standard polyglactin-910
RR 1.67
95% CI 1.07 to 2.60
P = 0.023 		Moderate effect size standard polyglactin-910

Systematic review		 1174 women
Data from 1 RCT		 Wound re-suturing at 3 months
3/586 (1%) with rapidly absorbed polyglactin-910
1/588 (0%) with standard polyglactin-910
RR 3.01
95% CI 0.31 to 28.86
P = 0.34 		Not significant

Systematic review		 1847 women
2 RCTs in this analysis		 Required the removal of suture material up to 3 months
24/924 (3%) with rapidly absorbed polyglactin-910
102/923 (11%) with standard polyglactin-910
RR 0.24
95% CI 0.15 to 0.36
P <0.00001 		Moderate effect size rapidly absorbed polyglactin-910
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Further information on studies

The systematic review reported that there was clinical heterogeneity among the included trials and that this should be taken into account when interpreting the results. The trials varied in suturing techniques used, the calibre of material, size of needle, skill of operators, duration of follow-up, and outcomes assessed. The review reported that the findings must be viewed in context of the variation between trials. One of the RCTs used sealed opaque envelopes for treatment allocation, and analysis was by intention to treat. It was not possible to blind operators to allocated treatments because of obvious differences in suture materials. Follow-up was by face-to-face interview until participants were discharged from hospital, and then by telephone interview. The RCT was powered to detect a reduction in short-term pain from 60% to 45%. A second RCT used sealed opaque envelopes for treatment allocation, and analysis was by intention to treat. It would not have been possible to blind participants, operators, or assessors to treatment allocation because of the obvious differences in appearance and handling of suture materials. The RCT also reported results from 6 to 8 weeks of follow-up, but we have not included these, as the follow-up rate was low (175/459 [35%] with fast absorbing v 134/449 [30%] with chromic catgut). The RCT was powered to show an 8% difference in vaginal or uterine pain between groups at 24 to 48 hours; the study did not assess perineal pain or carry out a power calculation based on analgesia use. A third RCT used sealed opaque envelopes for treatment allocation, and analysis was by intention to treat. The women were not informed of the suture material used by the operator. The research nurse who evaluated pain scores at 36 to 48 hours following the suturing was also blinded to the suture type. The short form of the McGill Pain Questionnaire was used to measure perineal pain. The RCT originally planned to recruit 1200 women, but after 6 months the study was stopped when 192 women had been randomised because chromic catgut suture material was withdrawn from the hospital for reasons not related to the trial. This RCT reported 20% attrition for women with dyspareunia at 6 weeks. For women with dyspareunia at 3 months the RCT reported 40% attrition. The systematic review advised caution in the interpretation of results from this RCT due to the high attrition, as those women available to follow up may not be representative of the sample randomised.

Comment

Clinical guide:

There is good evidence of benefit associated with absorbable synthetic suture material compared with catgut. Overall, the benefit seems to be even greater if fast-absorbing polyglactin-910 suture material is used; although, the proportion of women experiencing wound gaping at up to 10 days may be greater.

Substantive changes

Absorbable sutures in first- and second-degree tears One systematic review added, as well as one RCT. Categorisation unchanged (beneficial).

BMJ Clin Evid. 2015 Mar 10;2015:1401.

Continuous sutures in second-degree tears and episiotomies

Summary

Continuous sutures reduce short-term pain and analgesic use.

Benefits and harms

Continuous versus interrupted sutures for repair of all layers or only perineal skin (analysed as a group):

We found one systematic review (search date 2012), which identified 12 RCTs (4777 primiparous and multiparous women) and one subsequent RCT from Pakistan (200 women) comparing continuous versus interrupted sutures for repair of episiotomy or second-degree tears.

Perineal trauma

Continuous sutures for perineal repair of all layers or only perineal skin (analysed together as a group) compared with interrupted sutures Continuous sutures may be more effective than interrupted sutures at reducing the proportion of women with perineal pain at 48 hours and up to 10 days, but not at 3 months. Continuous sutures seem no more effective than interrupted sutures at reducing the proportion of women with dyspareunia or at reducing the proportion of women who fail to resume pain-free intercourse at 3 months after delivery (moderate-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Perineal pain

Systematic review		 4231 women
9 RCTs in this analysis		 Pain up to 10 days postpartum
703/2111 (33%) with continuous sutures
959/2120 (45%) with interrupted sutures
RR 0.76
95% CI 0.66 to 0.88
I2 = 67%; P = 0.002
See Further information on studies for heterogeneity 		Small effect size continuous sutures

Systematic review		 2971 women
6 RCTs in this analysis		 Analgesia use up to day 10 postpartum
171/1481 (12%) with continuous sutures
244/1490 (16%) with interrupted sutures
RR 0.70
95% CI 0.59 to 0.84 		Small effect size continuous sutures

Systematic review		 2891 women
4 RCTs in this analysis		 Pain up to 3 months after delivery
138/1462 (9%) with continuous sutures
157/1429 (11%) with interrupted sutures
RR 0.88
95% CI 0.64 to 1.20
P = 0.22 		Not significant

RCT		 200 women delivering singleton fetus and having episiotomy Pain at 48 hours
37/100 (37%) with continuous stitching
83/100 (83%) with interrupted stitching
P = 0.0005 		Effect size not calculated continuous stitching

RCT		 200 women delivering singleton fetus and having episiotomy Pain at 10 days
28/100 (28%) with continuous stitching
57/100 (57%) with interrupted stitching
P = 0.0005 		Effect size not calculated continuous stitching
Dyspareunia

Systematic review		 3619 women
9 RCTs in this analysis		 Dyspareunia up to 3 months after delivery
374/1829 (20%) with continuous sutures
399/1790 (22%) with interrupted stitching
RR 0.86
95% CI 0.70 to 1.06 		Not significant

Systematic review		 2305 women
2 RCTs in this analysis		 Failure to resume pain-free intercourse up to 3 months after delivery
293/1165 (25%) with continuous sutures
267/1140 (23%) with interrupted stitching
RR 1.07
95% CI 0.93 to 1.24 		Not significant
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Adverse effects

Continuous sutures for perineal repair of all layers or only perineal skin (analysed together as a group) compared with interrupted sutures Continuous sutures may be more effective than interrupted sutures at reducing the proportion of women requiring the removal of suture material up to 3 months after delivery. Continuous sutures seem no more effective than interrupted sutures at reducing the proportion of women requiring re-suturing of the wound up to 3 months after delivery (moderate-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Adverse effects

Systematic review		 3255 women
5 RCTs in this analysis		 Re-suturing of wound up to 3 months after delivery
6/1636 (0%) with continuous sutures
6/1619 (0%) with interrupted stitching
RR 0.99
95% CI 0.33 to 2.91 		Not significant

Systematic review		 3453 women
6 RCTs in this analysis		 Removal of suture material up to 3 months after delivery
177/1736 (10%) with continuous sutures
302/1717 (18%) with interrupted stitching
RR 0.56
95% CI 0.32 to 0.98
I2 = 82%; P = 0.00021
See Further information on studies for heterogeneity 		Small effect size continuous sutures
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Continuous versus interrupted sutures for repair of all layers:

We found one systematic review (search date 2012), which identified seven RCTs (3136 primiparous and multiparous women) comparing continuous versus interrupted sutures for repair of episiotomy or second-degree tears. The review presented subgroup analyses based on whether the continuous group used continuous suture techniques for all layers (including vagina, perineal muscles, and skin) or perineal skin only.

Perineal trauma

Continuous sutures for perineal repair of all layers compared with interrupted sutures Continuous sutures for repair of all layers seem to be more effective than interrupted sutures at reducing pain and analgesic use at up to 10 days. We don't know whether continuous sutures are more effective than interrupted sutures at reducing dyspareunia in the longer term (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Perineal pain

Systematic review		 3163 women
7 RCTs in this analysis		 Pain up to day 10
567/1584 (36%) with continuous sutures (for repair of all layers)
801/1579 (51%) with interrupted sutures
RR 0.74
95% CI 0.62 to 0.87
P = 0.00035
I2 = 71%; P = 0.002 		Small effect size continuous sutures (for repair of all layers)

Systematic review		 1903 women
4 RCTs in this analysis		 Analgesia up to day 10
115/954 (12%) with continuous sutures (for repair of all layers)
179/949 (19%) with interrupted sutures
RR 0.64
95% CI 0.52 to 0.79
P = 0.000022 		Small effect size continuous sutures (for repair of all layers)
Dyspareunia

RCT		 400 primiparous women with a second-degree tear or episiotomy
In review 		Proportion of women with dyspareunia 6 months
47/198 (24%) with continuous suture technique for all layers (vagina, perineal muscles, and skin)
58/197 (29%) with interrupted inverted stitches to close perineal muscles and skin (the inverted interrupted skin sutures were placed in the subcutaneous layer and not transcutaneously through the skin)
RR 0.81
95% CI 0.58 to 1.12
ITT analysis 		Not significant

Systematic review		 2372 women
7 RCTs in this analysis		 Dyspareunia up to 3 months postpartum
206/1190 (17%) with continuous sutures (for repair of all layers)
245/1182 (21%) with interrupted sutures
RR 0.79
95% CI 0.61 to 1.03
P = 0.083 		Not significant
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Adverse effects

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Suture removal

Systematic review		 At least 2372 women Risk of complications
with continuous suture technique for all layers
with interrupted inverted stitches to close perineal muscles and skin
Absolute results not reported
Suture removal up to 3 months was reported as not significant
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Further information on studies

In the comparison ‘continuous versus interrupted sutures’, the systematic review reported that for the primary outcome of short-term pain (up to day 10 postpartum), the results from individual studies varied considerably and there was high heterogeneity. The systematic review also reported that subgroup analysis suggested that there may have been a reduction in pain associated with continuous suturing for all layers versus continuous subcutaneous for closure of perineal skin only. However, there was high heterogeneity in the 'all layers' subgroup, there was considerable overlap in the confidence intervals for the two subgroups, and the test for subgroup differences was not statistically significant. Loss to follow-up and missing data were reported as problems in many of these studies in the review. This means that results for some outcomes may be at high risk of bias; this particularly applies to long-term outcomes.

The RCT changed from rapidly absorbing polyglactin-910 (Vicryl rapide) to standard polyglactin-910 (Vicryl) part way through the study. It was reported that the continuous technique was quicker to perform. The RCT placed the inverted interrupted skin sutures in the subcutaneous layer (not transcutaneously through the skin) in the comparison group, which may have contributed to the non-significant difference in pain at 24 to 48 hours and 10 days following birth.

The RCT was conducted in Pakistan and included women of reproductive age with any parity in labour having no gross anomaly on anomaly scan and having singleton pregnancy with cephalic presentation at, or more than, 37 weeks. The study excluded women with third- or fourth-degree perineal tear, instrumental vaginal delivery, maternal illness such as anaemia and diabetes, and with previous history of gaped episiotomy. The study reported that in the two groups of women compared (women, in whom interrupted method of episiotomy stitching was employed [n = 100] versus women in whom continuous method of episiotomy stitching was employed [n = 100]) the only difference was the suture technique used. However, the skills of the doctors suturing the episiotomy and the type of material used were the same. The suture material used was not reported.

Comment

Clinical guide:

There is good evidence of benefit when using a continuous subcuticular suture for perineal skin closure, and the benefit seems to be increased if the continuous technique is used to repair all layers (vagina, perineal muscles, and skin) compared with methods using interrupted stitches to close perineal muscles with trancutaneous interrupted stitches inserted for skin closure.

Substantive changes

Continuous sutures in second-degree tears and episiotomies One new systematic review added, and one subsequent RCT. Categorisation unchanged (beneficial).

BMJ Clin Evid. 2015 Mar 10;2015:1401.

Different methods and materials for primary repair of obstetric anal sphincter injuries (third- and fourth-degree tears)

Summary

We don't know how primary overlap repair approximation and end-to-end approximation compare as we found insufficient evidence.

Benefits and harms

Different methods for primary repair versus each other:

We found one systematic review (search date 2006, 3 RCTs, 279 primiparous and multiparous women) comparing overlap versus end-to-end approximation for primary repair of the external anal sphincter after childbirth (third-degree obstetric tears). The three included RCTs were of good methodological quality, but there was considerable heterogeneity in outcome measures, time points, and reported results. We also found one subsequent RCT (174 women) that compared overlapping repair with end to-end repair of complete third- and fourth-degree obstetric anal sphincter tears.

Perineal trauma

Different methods for primary repair compared with each other We don't know how effective the overlap technique for primary repair of the external anal sphincter (third-degree tears) and end-to-end approximation are, when compared with each other, at reducing perineal pain at 3 months, or faecal urgency or incontinence at 3 to 12 months (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Perineal pain

Systematic review		 172 women
2 RCTs in this analysis		 Proportion of women with perineal pain 3 months postpartum
22/84 (26%) with overlap approximation for primary repair of the external anal sphincter after childbirth (third-degree obstetric tears)
27/88 (31%) with end-to-end approximation for primary repair of the external anal sphincter after childbirth (third-degree obstetric tears)
RR 0.85
95% CI 0.54 to 1.34 		Not significant
Faecal urgency or incontinence

Systematic review		 172 women
2 RCTs in this analysis		 Proportion of women with faecal urgency 3 months postpartum
20/84 (24%) with overlap approximation for primary repair of the external anal sphincter after childbirth (third-degree obstetric tears)
31/88 (35%) with end-to-end approximation for primary repair of the external anal sphincter after childbirth (third-degree obstetric tears)
RR 0.68
95% CI 0.42 to 1.09 		Not significant

Systematic review		 52 women
Data from 1 RCT		 Proportion of women with faecal urgency 12 months
1/27 (4%) with overlap approximation for primary repair of the external anal sphincter after childbirth (third-degree obstetric tears)
8/25 (32%) with end-to-end approximation for primary repair of the external anal sphincter after childbirth (third-degree obstetric tears)
RR 0.12
95% CI 0.02 to 0.86 		Large effect size overlap approximation

Systematic review		 60 women
Data from 1 RCT		 Proportion of women with faecal incontinence 3 months postpartum
2/29 (7%) with overlap approximation for primary repair of the external anal sphincter after childbirth (third-degree obstetric tears)
9/31 (29%) with end-to-end approximation for primary repair of the external anal sphincter after childbirth (third-degree obstetric tears)
RR 0.24
95% CI 0.06 to 1.01 		Not significant

Systematic review		 52 women
Data from 1 RCT		 Anal incontinence scores 12 months
0.74 with overlap approximation for primary repair of the external anal sphincter after childbirth (third-degree obstetric tears)
2.44 with end-to-end approximation for primary repair of the external anal sphincter after childbirth (third-degree obstetric tears)
Weighted mean difference –1.70
95% CI –3.03 to –0.37 		Effect size not calculated overlap approximation

RCT		 174 women Faecal incontinence 6 months
5/62 (8%) with end-to-end repair
9/61 (15%) with overlapping repair
Risk difference 0.166
95% CI 0.102 to 0.434
P >0.2 		Not significant
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Adverse effects

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Adverse effects

RCT		 112 women
In review 		Proportion of women with residual full-thickness defect in the external anal sphincter ultrasound 3 months postpartum
34/55 (62%) with overlap approximation for primary repair of the external anal sphincter after childbirth (third-degree obstetric tears)
40/57 (70%) with end-to-end approximation for primary repair of the external anal sphincter after childbirth (third-degree obstetric tears)
RR 0.88
95% CI 0.67 to 1.15 		Not significant
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Different materials for primary repair versus each other:

We found one RCT (112 women), which had a factorial 2×2 design, comparing PDS 3/0 versus coated vicryl 2/0 and also overlap versus end-to-end approximation for primary repair of the external anal sphincter.

Perineal trauma

Different materials for primary repair compared with each other We don't know how effective PDS 3/0 and coated vicryl 2/0 are, compared with each other, at reducing suture-material related morbidity (including suture migration and/or dyspareunia) at 6 weeks after childbirth (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Perineal trauma

RCT		 112 women Proportion of women with suture material-related morbidity (including suture migration and/or dyspareunia) 6 weeks after childbirth
10/50 (20%) with PDS 3/0 for primary repair of the external anal sphincter
9/53 (17%) with coated vicryl 2/0 for primary repair of the external anal sphincter
RR 0.8
95% CI 0.4 to 1.9
P = 0.18 		Not significant
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Adverse effects

No data from the following reference on this outcome.

Further information on studies

This RCT, also identified by the systematic review, was small and had a low event rate; therefore the results must be interpreted with caution.

In the RCT, 174 women were randomised, of whom 11 were not eligible and 25 were excluded from analysis (multiparous) leaving 138 primiparous women. In the follow-up reported in the RCT, 123 women completed the 6-month questionnaire (62 on the end-to-end group and 61 in the overlapping group). Of this study group, 104 women completed the 1-year follow-up questionnaire (54 in the end-to-end group and 50 in the overlapping group, 85%). The return rate at 2 and 3 years was 77% (48 end-to-end and 47 overlapping) and 55% (31 end-to-end group and 37 overlapping group).

Comment

Clinical guide:

It is unclear if there is a benefit associated with the overlap technique for primary repair of the external anal sphincter compared with the end-to-end method, as the evidence is weak.

Substantive changes

Different methods and materials for primary repair of obstetric anal sphincter injuries (third- and fourth-degree tears) One new RCT added. Categorisation unchanged (unknown effectiveness).

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