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Meta-Analysis
. 2012 Nov 14;11(11):CD000947.
doi: 10.1002/14651858.CD000947.pub3.

Continuous and interrupted suturing techniques for repair of episiotomy or second-degree tears

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

Continuous and interrupted suturing techniques for repair of episiotomy or second-degree tears

Christine Kettle et al. Cochrane Database Syst Rev. .

Abstract

Background: Millions of women worldwide undergo perineal suturing after childbirth and the type of repair may have an impact on pain and healing. For more than 70 years, researchers have been suggesting that continuous non-locking suture techniques for repair of the vagina, perineal muscles and skin are associated with less perineal pain than traditional interrupted methods.

Objectives: To assess the effects of continuous versus interrupted absorbable sutures for repair of episiotomy and second-degree perineal tears following childbirth.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (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.

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

Figures

1.1
1.1. Analysis
Comparison 1 Continuous versus interrupted sutures for repair of all layers or perineal skin only, Outcome 1 Short‐term pain ‐ up to day 10.
1.2
1.2. Analysis
Comparison 1 Continuous versus interrupted sutures for repair of all layers or perineal skin only, Outcome 2 Analgesia ‐ up to day 10.
1.3
1.3. Analysis
Comparison 1 Continuous versus interrupted sutures for repair of all layers or perineal skin only, Outcome 3 Dyspareunia ‐ up to 3 months' postpartum.
1.4
1.4. Analysis
Comparison 1 Continuous versus interrupted sutures for repair of all layers or perineal skin only, Outcome 4 Re‐suturing ‐ up to 3 months.
1.5
1.5. Analysis
Comparison 1 Continuous versus interrupted sutures for repair of all layers or perineal skin only, Outcome 5 Long‐term pain ‐ up to 3 months' postpartum.
1.6
1.6. Analysis
Comparison 1 Continuous versus interrupted sutures for repair of all layers or perineal skin only, Outcome 6 Failure to resume pain‐free intercourse ‐ 3 months' postpartum.
1.7
1.7. Analysis
Comparison 1 Continuous versus interrupted sutures for repair of all layers or perineal skin only, Outcome 7 Removal of suture material ‐ up to 3 months' postpartum.
1.8
1.8. Analysis
Comparison 1 Continuous versus interrupted sutures for repair of all layers or perineal skin only, Outcome 8 Suture material use (used 2 or more packets of suturing material).
1.9
1.9. Analysis
Comparison 1 Continuous versus interrupted sutures for repair of all layers or perineal skin only, Outcome 9 Time taken to carry out the repair (minutes).
2.1
2.1. Analysis
Comparison 2 Subgroup analysis: continuous versus interrupted (all layers or skin only)), Outcome 1 Short‐term pain ‐ up to day 10.
2.2
2.2. Analysis
Comparison 2 Subgroup analysis: continuous versus interrupted (all layers or skin only)), Outcome 2 Analgesia ‐ up to day 10.
2.3
2.3. Analysis
Comparison 2 Subgroup analysis: continuous versus interrupted (all layers or skin only)), Outcome 3 Dyspareunia ‐ up to 3 months' postpartum.
3.1
3.1. Analysis
Comparison 3 Three ‐stage versus two‐ stage (skin not sutured) approach, Outcome 1 Short‐term pain: number of women with perineal pain (up to 48 hours).
3.2
3.2. Analysis
Comparison 3 Three ‐stage versus two‐ stage (skin not sutured) approach, Outcome 2 Short‐term pain up to 14 days.
3.3
3.3. Analysis
Comparison 3 Three ‐stage versus two‐ stage (skin not sutured) approach, Outcome 3 Analgesia use up to 10 days.
3.4
3.4. Analysis
Comparison 3 Three ‐stage versus two‐ stage (skin not sutured) approach, Outcome 4 Dyspareunia up to 3 months.
3.5
3.5. Analysis
Comparison 3 Three ‐stage versus two‐ stage (skin not sutured) approach, Outcome 5 Long‐term pain (up to 3 months).
3.6
3.6. Analysis
Comparison 3 Three ‐stage versus two‐ stage (skin not sutured) approach, Outcome 6 Failure to resume pain‐free intercourse up to 3 months.
3.7
3.7. Analysis
Comparison 3 Three ‐stage versus two‐ stage (skin not sutured) approach, Outcome 7 Wound 'gaping' (< 0.5 cm) up to 10 days.
3.8
3.8. Analysis
Comparison 3 Three ‐stage versus two‐ stage (skin not sutured) approach, Outcome 8 Wound re‐sutured up to 3 months.
3.9
3.9. Analysis
Comparison 3 Three ‐stage versus two‐ stage (skin not sutured) approach, Outcome 9 Removal of suture material up to 3 months.
3.10
3.10. Analysis
Comparison 3 Three ‐stage versus two‐ stage (skin not sutured) approach, Outcome 10 Time (in minutes) taken to carry out the repair.
4.1
4.1. Analysis
Comparison 4 Other techniques using continuous versus interrupted sutures, Outcome 1 Short‐term pain (up to day 10).
4.2
4.2. Analysis
Comparison 4 Other techniques using continuous versus interrupted sutures, Outcome 2 Short‐term pain (at 12 hours after the repair).
4.3
4.3. Analysis
Comparison 4 Other techniques using continuous versus interrupted sutures, Outcome 3 Analgesia use up to 10 days.
4.4
4.4. Analysis
Comparison 4 Other techniques using continuous versus interrupted sutures, Outcome 4 Dyspareunia up to 3 months.
4.5
4.5. Analysis
Comparison 4 Other techniques using continuous versus interrupted sutures, Outcome 5 Re‐suturing up to 3 months.
4.6
4.6. Analysis
Comparison 4 Other techniques using continuous versus interrupted sutures, Outcome 6 Superficial skin gaping.
4.7
4.7. Analysis
Comparison 4 Other techniques using continuous versus interrupted sutures, Outcome 7 Removal of suture material ‐ up to 3 months' postpartum.
4.8
4.8. Analysis
Comparison 4 Other techniques using continuous versus interrupted sutures, Outcome 8 Time (minutes) taken to carry out the repair.
4.9
4.9. Analysis
Comparison 4 Other techniques using continuous versus interrupted sutures, Outcome 9 Satisfied with repair.
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References

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