Approximately 70% of women who have a vaginal birth will experience some degree of damage to the perineum, due to a tear or cut (episiotomy), and will need stitches. This damage may result in perineal pain during the two weeks after the birth, and some women experience long-term pain and discomfort during sexual intercourse. The impact of perineal trauma can be distressing for the new mother when she is trying to cope with hormonal changes and the demands of her baby, and it can have a long-term effect on her sexual relationship. Most modern materials that are used to stitch the perineum are gradually absorbed and do not need to be taken out. Sometimes, however, stitches have to be removed by the doctor or midwife. A small number of perineal wounds come open (break down) or have delayed healing, and some of these may need to be re-stitched.
This review includes 18 randomised controlled trials with 10,171 women and looks at catgut and synthetic materials used to stitch the perineum after childbirth. It also includes a more recently produced material which has been specially designed to be absorbed more quickly. The main findings were that women stitched with synthetic materials had less pain in the first three days after delivery and needed fewer drugs to relieve pain in the 10 days after giving birth, compared with women stitched with catgut. There was evidence that synthetic stitches were not always readily absorbed and some women with these stitches needed them to be removed. Women experienced similar short and long-term pain with standard absorbable synthetic materials and more rapidly absorbing stitches. However, in one trial, fewer women with rapidly absorbing stitches reported using pain-relieving drugs during the 10 days after delivery, and there was less need for these stitches to be removed. When catgut and glycerol-impregnated catgut were compared the results were similar, although the latter was associated with more short-term pain. One trial examined monofilament and standard synthetic stitches and there was little difference between the two materials in terms of pain and wound healing. As well as the type of material used, other factors such as the technique used to carry out the stitching (using a continuous thread or a series of separately tied stitches) and the skill of the person carrying out the procedure, may also affect the amount of pain and the way perineal wounds heal.
Catgut may increase short-term pain compared with synthetic sutures. There were few differences between standard and rapidly absorbing synthetic sutures but more women needed standard sutures removing. For other materials, there was insufficient evidence to draw conclusions. Findings should be interpreted in the context of the related Cochrane review on suturing techniques.
Approximately 70% of women will experience perineal trauma following vaginal delivery and will require stitches. This may result in pain, suture removal and superficial dyspareunia.
To assess the effects of different suture materials on short- and long-term morbidity following perineal repair.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (February 2010).
Randomised trials comparing different suture materials for perineal repair after vaginal delivery.
Two review authors independently assessed trial quality and extracted data.
We included 18 trials with 10,171 women; comparisons included: catgut with standard synthetic (nine trials), rapidly absorbing synthetic (two trials), and glycerol impregnated catgut sutures (two trials); and standard synthetic sutures with rapidly absorbing synthetic (five trials) and monofilament sutures (one trial).
Compared with catgut, standard synthetic sutures were associated with less pain up to three days after delivery (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.76 to 0.90); and less analgesia up to ten days postpartum (RR 0.71, 95% CI 0.59 to 0.87). More women with catgut sutures required resuturing (15/1201) compared with synthetic sutures (3/1201) (RR 0.25, 95% CI 0.08 to 0.74); while more women with standard synthetic sutures required the removal of unabsorbed suture material (RR 1.81, 95% CI 1.46 to 2.24). Comparing standard synthetic with rapidly absorbing sutures, short- and long-term pain were similar; in one trial fewer women with rapidly absorbing sutures reported using analgesics at 10 days (RR 0.57, 95% CI 0.43 to 0.77). More women in the standard synthetic suture group required suture removal compared with those in the rapidly absorbed group (RR 0.24, 95% CI 0.15 to 0.36). There was no evidence of significant differences between groups for long-term pain (three months after delivery) or for dyspareunia at three, or at six to 12 months. When catgut and glycerol impregnated catgut were compared, results were similar for most outcomes, although the latter was associated with more short-term pain. One trial examining monofilament versus standard polyglycolic sutures found no differences for most outcomes.