Continuous and individual interrupted sutures for repair of episiotomy or second-degree tears

Continuous stitching causes less pain than interrupted absorbable 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 for them to have an episiotomy (surgical cut) to increase the size of the vaginal outlet to facilitate the birth. Episiotomies and tears that involve the muscle layer (second degree) need to be stitched. Millions of women worldwide undergo perineal suturing after childbirth and the type of repair may have an impact on pain and discomfort, and healing. In the UK alone, approximately 1000 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 16 randomised controlled trials involving 8184 women from eight different countries. Results from the trials showed that stitching just underneath the skin (subcutaneous) was associated with less pain with reduced need for analgesics after the birth, or for the sutures to be removed; however, when the 'continuous stitching method' was used for repair of all three layers, this may be associated with even less pain. The level of operator skill and training varied in the different trials. 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.

There is also some evidence that the continuous techniques use less suture material when compared with the interrupted methods (one packet compared to two or three packets, respectively).

Authors' conclusions: 

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

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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 strategy: 

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

Selection criteria: 

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

Data collection and analysis: 

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

Main results: 

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

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