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Meta-Analysis
. 2010 Jun 16;2010(6):CD000006.
doi: 10.1002/14651858.CD000006.pub2.

Absorbable suture materials for primary repair of episiotomy and second degree tears

Christine Kettle  1 , Therese Dowswell, Khaled Mk Ismail
Affiliations
Meta-Analysis

Absorbable suture materials for primary repair of episiotomy and second degree tears

Christine Kettle et al. Cochrane Database Syst Rev. .

Abstract

Background: 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.

Objectives: To assess the effects of different suture materials on short- and long-term morbidity following perineal repair.

Search strategy: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (February 2010).

Selection criteria: Randomised trials comparing different suture materials for perineal repair after vaginal delivery.

Data collection and analysis: Two review authors independently assessed trial quality and extracted data.

Main results: 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.

Authors' conclusions: 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.

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Conflict of interest statement

Christine Kettle (CK) was the recipient of a fellowship from the Iolanthe Midwifery Research Trust 1996, which provided funding to enable her to carry out a randomised controlled trial of perineal repair following childbirth (Kettle 2002). The Iolanthe Midwifery Research Trust and Ethicon Ltd, UK (manufacturers of suture material) provided funding for employment of a part‐time data management clerk for that trial.

CK and Khaled MK Ismail run perineal repair workshops both nationally and internationally and have developed an episiotomy and second‐degree tear training model with Limbs & Things, UK.

C Kettle was the lead investigator for one of the included studies (Kettle 2002) and was not involved in the assessment of the trial or the data extraction.

Figures

1.1
1.1. Analysis
Comparison 1 Synthetic sutures versus catgut, Outcome 1 Short‐term pain: pain at day 3 or less (women experiencing any pain).
1.2
1.2. Analysis
Comparison 1 Synthetic sutures versus catgut, Outcome 2 Short‐term pain: pain at day 4 ‐ 10.
1.3
1.3. Analysis
Comparison 1 Synthetic sutures versus catgut, Outcome 3 Analgesia use ‐ up to day 10.
1.4
1.4. Analysis
Comparison 1 Synthetic sutures versus catgut, Outcome 4 Suture dehiscence (wound breakdown).
1.5
1.5. Analysis
Comparison 1 Synthetic sutures versus catgut, Outcome 5 Superficial wound dehiscence, wound gaping up to day 10.
1.6
1.6. Analysis
Comparison 1 Synthetic sutures versus catgut, Outcome 6 Resuturing of wound ‐ up to 3 months.
1.7
1.7. Analysis
Comparison 1 Synthetic sutures versus catgut, Outcome 7 Removal of suture material ‐ up to 3 months.
1.8
1.8. Analysis
Comparison 1 Synthetic sutures versus catgut, Outcome 8 Long‐term pain ‐ at 3 months postpartum.
1.9
1.9. Analysis
Comparison 1 Synthetic sutures versus catgut, Outcome 9 Dyspareunia ‐ at 3 months postpartum.
2.1
2.1. Analysis
Comparison 2 Fast‐absorbing synthetic versus standard absorbable synthetic material, Outcome 1 Short‐term pain: at 3 days or less.
2.2
2.2. Analysis
Comparison 2 Fast‐absorbing synthetic versus standard absorbable synthetic material, Outcome 2 Short‐term pain: at 10 ‐ 14 days.
2.3
2.3. Analysis
Comparison 2 Fast‐absorbing synthetic versus standard absorbable synthetic material, Outcome 3 Use of analgesics at 10 days.
2.4
2.4. Analysis
Comparison 2 Fast‐absorbing synthetic versus standard absorbable synthetic material, Outcome 4 Wound gaping ‐ up to 10 days.
2.5
2.5. Analysis
Comparison 2 Fast‐absorbing synthetic versus standard absorbable synthetic material, Outcome 5 Resuturing at 3 months postpartum.
2.6
2.6. Analysis
Comparison 2 Fast‐absorbing synthetic versus standard absorbable synthetic material, Outcome 6 Suture material removed ‐ up to 3 months.
2.7
2.7. Analysis
Comparison 2 Fast‐absorbing synthetic versus standard absorbable synthetic material, Outcome 7 Long‐term pain: pain at 3 months.
2.8
2.8. Analysis
Comparison 2 Fast‐absorbing synthetic versus standard absorbable synthetic material, Outcome 8 Dyspareunia at 3 months.
2.9
2.9. Analysis
Comparison 2 Fast‐absorbing synthetic versus standard absorbable synthetic material, Outcome 9 Dyspareunia at 6 ‐ 12 months.
2.10
2.10. Analysis
Comparison 2 Fast‐absorbing synthetic versus standard absorbable synthetic material, Outcome 10 Maternal satisfaction: satisfied with repair at 3 months.
2.11
2.11. Analysis
Comparison 2 Fast‐absorbing synthetic versus standard absorbable synthetic material, Outcome 11 Maternal satisfaction: satisfied with repair at 12 months.
3.1
3.1. Analysis
Comparison 3 Glycerol impregnated catgut (softgut) versus chromic catgut, Outcome 1 Short‐term pain: pain at 3 days or less.
3.2
3.2. Analysis
Comparison 3 Glycerol impregnated catgut (softgut) versus chromic catgut, Outcome 2 Short‐term pain: pain at 10 ‐ 14 days.
3.3
3.3. Analysis
Comparison 3 Glycerol impregnated catgut (softgut) versus chromic catgut, Outcome 3 Analgesia at day 10.
3.4
3.4. Analysis
Comparison 3 Glycerol impregnated catgut (softgut) versus chromic catgut, Outcome 4 Wound dehiscence at 10 days.
3.5
3.5. Analysis
Comparison 3 Glycerol impregnated catgut (softgut) versus chromic catgut, Outcome 5 Suture removal by 3 months.
3.6
3.6. Analysis
Comparison 3 Glycerol impregnated catgut (softgut) versus chromic catgut, Outcome 6 Long‐term pain: pain at 3 months.
3.7
3.7. Analysis
Comparison 3 Glycerol impregnated catgut (softgut) versus chromic catgut, Outcome 7 Dyspareunia at 3 months.
3.8
3.8. Analysis
Comparison 3 Glycerol impregnated catgut (softgut) versus chromic catgut, Outcome 8 Dyspareunia at 6 ‐ 12 months.
4.1
4.1. Analysis
Comparison 4 Monofilament versus standard polyglycolic sutures, Outcome 1 Short‐term pain: mean pain scores at 3 days.
4.2
4.2. Analysis
Comparison 4 Monofilament versus standard polyglycolic sutures, Outcome 2 Long‐term pain: pain score greater than 2 at 8 ‐ 12 weeks.
4.3
4.3. Analysis
Comparison 4 Monofilament versus standard polyglycolic sutures, Outcome 3 Long‐term pain: mean pain scores at 8 ‐ 12 weeks.
4.4
4.4. Analysis
Comparison 4 Monofilament versus standard polyglycolic sutures, Outcome 4 Wound problems at 8 ‐ 12 weeks: women seeking professional help for problem with perineal repair.
See this image and copyright information in PMC

Update of

Comment in

References

References to studies included in this review

Banninger 1978 {published data only}
    1. Banninger U, Buhrig H, Schreiner WE. A comparison between chromic catgut and polyglycolic acid sutures in episiotomy repair. Geburtshilfe und Frauenheilkunde 1978;38:30‐3. - PubMed
Beard 1974 {published data only}
    1. Beard RJ, Boyd I, Sims CD. A trial of polyglycolic acid and chromic catgut sutures in episiotomy repair. British Journal of Clinical Practice 1974;28:409‐10. - PubMed
Dencker 2006 {published data only}
    1. Dencker A, Lundgren I, Sporrong T. Suturing after childbirth ‐ a randomised controlled study testing a new monofilament material. BJOG: an international journal of obstetrics and gynaecology 2006;113(1):114‐6. - PubMed
Gemynthe 1996 {published data only}
    1. Gemynthe A, Langhoff‐Roos J, Sahl S, Knudsen J. New VICRYL* formulation: an improved method of perineal repair?. British Journal of Midwifery 1996;4:230‐4.
Greenberg 2004 {published data only}
    1. Greenberg JA, Lieberman E, Cohen AP, Ecker JL. Randomized comparison of chromic versus fast‐absorbing polyglactin 910 for postpartum perineal repair. Obstetrics & Gynecology 2004;103(6):1308‐13. - PubMed
Kettle 2002 {published data only}
    1. Kettle C, Hills RK, Jones P, Darby L, Gray R, Johanson R. Continuous versus interrupted perineal repair with standard or rapidly absorbed sutures after spontaneous vaginal birth: a randomised controlled trial. Lancet 2002;359:2217‐23. - PubMed
Leroux 2006 {published data only}
    1. Leroux N, Bujold E. Impact of chromic catgut versus polyglactin 910 versus fast‐absorbing polyglactin 910 sutures for perineal repair: a randomized, controlled trial. American Journal of Obstetrics and Gynecology 2006;194(6):1585‐90. - PubMed
Livingstone 1974 {published data only}
    1. Livingstone E, Simpson D, Naismith WCMK. A comparison between catgut and polyglycolic acid sutures in episiotomy repair. Journal of Obstetrics and Gynaecology of the British Commonwealth 1974;81:245‐7. - PubMed
Mackrodt 1998 {published data only}
    1. Gordon B, Mackrodt C, Fern E, Truesdale A, Ayers S, Grant A. The Ipswich childbirth study: 1 A randomised evaluation of two stage postpartum perineal repair leaving the skin unsutured. British Journal of Obstetrics and Gynaecology 1998;105(4):435‐40. - PubMed
    1. Grant A, Gordon B, Mackrodt C, Fern E, Truesdale A, Ayers S. The Ipswich childbirth study: one year follow up of alternative methods used in perineal repair. BJOG: an international journal of obstetrics and gynaecology 2001;108(1):34‐40. - PubMed
    1. Mackrodt C, Fern E, Gordon B. Ipswich childbirth study ‐ perineal suturing study. Proceedings of Research in Midwifery Conference; 1993 Sept 14; Birmingham, UK. 1993.
    1. Mackrodt C, Gordon B, Fern E, Ayers S, Truesdale A, Grant A. The Ipswich Childbirth Study: 2. A randomised comparison of polyglactin 910 with chromic catgut for postpartum perineal repair. British Journal of Obstetrics and Gynaecology 1998;105:441‐5. - PubMed
Mahomed 1989 {published data only}
    1. Mahomed K, Grant AM, Ashurst H, James D. The Southmead perineal suture study. A randomised comparison of suture materials and suturing techniques for repair of perineal trauma. British Journal of Obstetrics and Gynaecology 1989;96:1272‐80. - PubMed
McElhinney 2000 {published data only}
    1. McElhinney BR, Glenn DR, Dornan G, Harper MA. Episiotomy repair: Vicryl versus Vicryl Rapide. Ulster Medical Journal 2000;69(1):27‐9. - PMC - PubMed
Nikolov 2006 {published data only}
    1. Nikolov A, Dimitrov A, Iliev D, Krsteva K. [Repair of episiotomies with synthetic suture material]. [Bulgarian]. Akusherstvo i Ginekologiia 2006;45(7):12‐5. - PubMed
Olah 1990 {published data only}
    1. Olah KS. Episiotomy repair ‐ suture material and short term morbidity. Journal of Obstetrics and Gynaecology 1990;10:503‐5.
Roberts 1983 {published data only}
    1. Roberts ADG, McKay Hart D. Polyglycolic acid and catgut sutures, with and without oral proteolytic enzymes, in the healing of episiotomies. British Journal of Obstetrics and Gynaecology 1983;90:650‐3. - PubMed
Rogers 1974 {published data only}
    1. Rogers RE. Evaluation of post‐episiorrhaphy pain: polyglycolic acid vs catgut sutures. Military Medicine 1974;139:102‐4. - PubMed
Saint 1993 {published data only}
    1. Saint H, Bamford D. Obstetric perineal repair: a comparison between the use of untreated chromic catgut and glycerol‐impregnated catgut. Obstetrics and Gynaecology Today 1993;4(3):56‐7.
Spencer 1986 {published data only}
    1. Grant AM, Sleep J, Ashurst H, Spencer JAD. Dyspareunia associated with the use of glycerol‐impregnated catgut to repair perineal trauma. Report of a 3‐year follow‐up study. British Journal of Obstetrics and Gynaecology 1989;96:741‐3. - PubMed
    1. Spencer JAD, Grant AM, Elbourne DR, Garcia J, Sleep J. A randomized comparison of glycerol‐impregnated chromic catgut with untreated chromic catgut for the repair of perineal trauma. British Journal of Obstetrics and Gynaecology 1986;93:426‐30. - PubMed
Upton 2002 {published data only}
    1. Upton A, Roberts CL, Ryan M, Faulkner M, Reynolds M, Raynes‐Greenow C. A randomised trial, conducted by midwives, of perineal repairs comparing a polyglycolic suture material and chromic catgut. Midwifery 2002;18(3):223‐9. - PubMed

References to studies excluded from this review

Gaasemyr 1977 {published data only}
    1. Gaasemyr M, Hovland E, Bergsjo P. The importance of suturing material for healing after episiotomy. Comparison between cromcatgut and supramid. Fra Medisinske Publikasjoner 1977;2:1‐5.
Hemsley 1997 {unpublished data only}
    1. Hemsley L. Perineal suturing: vicryl rapide versus plain catgut. Personal communication December 2 1997.
Ketcham 1994 {published data only}
    1. Ketcham KR, Pastorek JG, Letellier RL. Episiotomy repair: chromic versus polyglycolic acid suture. Southern Medical Journal 1994;87(4):514‐7. - PubMed
Marques 2001 {published data only}
    1. Marques R, Almeida E. Episiorrhaphy comparative study of chromic/vicryl rapide. Journal of Perinatal Medicine 2001;29 Suppl 1(Pt 2):724.
Tompkins 1972 {published data only}
    1. Tompkins MG, Lea RH. The use of polyglycolic acid sutures in obstetrics and gynaecology. Canadian Medical Association Journal 1972;106:675‐7. - PMC - PubMed
Uslu 1992 {published data only}
    1. Uslu MA, Ozekici U, Simsek M, Berkman S. A prospective randomized study of three different methods of episiotomy repair. Istanbul Tip Fakultesi Mecumasi 1992;55:237‐42.
Wikoff 1992 {published data only}
    1. Wikoff MD, Kuehl TJ, Cooney AT, Knight AB. Comparison of postpartum pain and healing with repair of perineal disruptions using chromic catgut or polyglycolic acid suture. American Journal of Obstetrics and Gynecology 1992;166:409.

Additional references

Chalmers 1989
    1. Chalmers I, Hetherington J, Elbourne D, Keirse MJNC, Enkin M. Materials and methods used in synthesizing evidence to evaluate the effects of care during pregnancy and childbirth. In: Chalmers I, Enkin M, Keirse MJNC editor(s). Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989:39‐65.
Clinical Evidence 2008
    1. Kettle C, Tohill S. Perineal care. BMJ, Clinical Evidence. Vol. 09, London: BMJ Publishing Group Ltd, 2008:1401. - PMC - PubMed
Craig 1975
    1. Craig PH, Williams JA, Davis KW, Magoun AD. A biologic comparison of polyglactin 910 and polyglycolic acid synthetic absorbable sutures. Surgery, Gynecology & Obstetrics 1975;141(1):1‐10. - PubMed
Cuschieri 2000
    1. Cuschieri A, Steele RJC, Moossa AR. Essential surgical practice. 4th Edition. Oxford: Butterworth‐Heinemann, 2000.
Ethicon 1992
    1. Ethicon. Coated Vicryl Polyglactin 910: the gentle approach. Edinburgh, UK: Ethicon Limited, 1992.
Flanagan 1997
    1. Flanagan M. Wound management. Edinburgh: Churchill Livingstone, 1997.
Fleming 1990
    1. Fleming N. Can the suturing material make a difference in postpartum, perineal pain?. Journal of Nurse‐Midwifery 1990;35(1):19‐25. - PubMed
Glazener 1995
    1. Glazener CMA, Abdalla MI, Stroud P, Naji SA, Templeton AA, Russell IT. Postnatal maternal morbidity: extent, causes, prevention and treatment. British Journal of Obstetrics and Gynaecology 1995;102:282‐7. - PubMed
Gordon 1998
    1. Gordon B, Mackrodt C, Fern E, Truesdale A, Ayers S, Grant A. The Ipswich childbirth study: 1 A randomised evaluation of two stage postpartum perineal repair leaving the skin unsutured. British Journal of Obstetrics and Gynaecology 1998;105(4):435‐40. - PubMed
Graham 1997
    1. Graham ID. Episiotomy: challenging obstetric interventions. Oxford: Blackwell Science Ltd, 1997.
Grant 1989
    1. Grant A. Repair of perineal trauma after childbirth. In: Chalmers I, Enkin MW, Keirse MJNC editor(s). Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989:1173‐5.
Higgins 2008
    1. Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.1 [updated September 2008]. The Cochrane Collaboration, 2008. Available from www.cochrane‐handbook.org.
Howard 1995
    1. Howard S, McKell D, Mugford M, Grant A. Cost‐effectiveness of different approaches to perineal suturing. British Journal of Midwifery 1995;3(11):587‐605.
Irvin 1981
    1. Irvin TT. Wound healing ‐ principles and practices. London: Chapman and Hall, 1981.
Isager‐Sally 1986
    1. Isager‐Sally L, Legarth J, Jacobson B, Bustofte E. Episiotomy repair ‐ immediate and long‐term sequelae. A prospective randomised study of three different methods of repair. British Journal of Obstetrics and Gynaecology 1986;93:420‐5. - PubMed
Kettle 2007
    1. Kettle C, Hills RK, Ismail KMK. Continuous versus interrupted sutures for repair of episiotomy or second degree tears. Cochrane Database of Systematic Reviews 2007, Issue 4. [DOI: 10.1002/14651858.CD000947.pub2] - DOI - PubMed
McCaul 2000
    1. McCaul LK, Bagg J, Jenkins WMM. Rate of loss of irradiated polyglactin 910 (Vicryl Rapide) from the mouth: a prospective study. British Journal of Oral Maxillofacial Surgery 2000;38:328‐30. - PubMed
Mulrow 1997
    1. Mulrow CD, Oxman A, editors. Cochrane Collaboration Handbook [updated September 1997]. In: The Cochrane Library [database on disk and CDROM]. The Cochrane Collaboration. Oxford: Update Software; 1997, Issue 4.
NICE 2007
    1. National Institute for Health and Clinical Excellence (NICE). Intrapartum Guideline No 55 ‐ Care of healthy women and their babies during childbirth. London: NICE, 2007.
Oboro 2003
    1. Oboro VO, Tabowei TO, Loto Om, Bosah JO. A multicenter evaluation of the two‐layer repair of perineal trauma after birth. British Journal of Obstetrics and Gynaecology 2003;1:5‐8. - PubMed
ONS 2001
    1. Office of National Statistics. Population and Vital Statistics (2000). London: HMSO, 2001.
RCOG 2007
    1. Royal College of Obstetricians and Gynaecologists. The management of third‐ and fourth degree perineal tears (Green Top Guideline No. 29). London: RCOG, 2007.
RevMan 2008 [Computer program]
    1. The Cochrane Collaboration. Review Manager (RevMan). Version 5.0. Copenhagen, The Nordic Cochrane Centre: The Cochrane Collaboration, 2008.
Sleep 1984
    1. Sleep J, Grant A, Garcia J, Elbourne D, Spencer J, Chalmers I. West Berkshire perineal management trial. BMJ 1984;289:587‐90. - PMC - PubMed
Sultan 1996
    1. Sultan AH, Monga AK, Stanton SL. The pelvic floor sequelae of childbirth. British Journal of Hospital Medicine 1996;55(9):575‐579. - PubMed
Sultan 1999
    1. Sultan AH. Obstetric perineal injury and anal incontinence. Clinical Risk 1999;5:193‐6.
Taylor 1996
    1. Taylor I, Karran SJ. Surgical principles. 1st Edition. London: Oxford University Press, 1996.
Thacker 1983
    1. Thacker SB, Banta HD. Benefits and risks of episiotomy: an interpretative review of the English Language literature, 1860‐1980. Obstetrical and Gynecological Survey 1983;38:322‐38. - PubMed
Walsh 2001
    1. Walsh D. Perineal care should be a feminist issue. British Journal of Midwifery 2001;8(12):731‐7.
Woolley 1995a
    1. Woolley RJ. Benefits and risks of episiotomy: a review of the English‐language literature since 1980. Part I. Obstetrical and Gynecological Survey 1995;50(11):806‐20. - PubMed
Woolley 1995b
    1. Woolley RJ. Benefits and risks of episiotomy: a review of the English‐language literature since 1980. Part II. Obstetrical and Gynecological Survey 1995;50(11):821‐35. - PubMed

References to other published versions of this review

Johanson 1994
    1. Johanson RB. Polyglycolic acid vs catgut for perineal repair [revised 10 March 1994]. In: Keirse MJNC, Renfrew MJ, Neilson JP, Crowther C (eds). Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database [database on disk and CDROM]. The Cochrane Collaboration; Issue 2, Oxford: Update Software; 1995.
Kettle 1999
    1. Kettle C, Johanson R. Absorbable synthetic versus catgut suture material for perineal repair. Cochrane Database of Systematic Reviews 1999, Issue 4. [DOI: 10.1002/14651858.CD000006] - DOI - PMC - PubMed