British Journal of Obstetrics and Gynaecology May 1986, Vol. 93, pp. 417-419

COMMENTARY

Repair of episiotomies and perineal tears

It is surprising that a surgical procedure which is performed as commonly as perineal repair fol- lowing childbirth has been the subject of so little scientifically sound research. The underlying reason for this apparent lack of interest is pri- marily the clinical perspective on the morbidity which can result. The symptoms caused by per- ineal trauma usually remain unrecognized by the operator who performed the repair, they are believed to resolve with time in nearly all cases, and as a result are not rated as particularly serious. Also, the lack of interest amongst both those who sponsor and those who conduct research in obstetrics almost certainly reflects an attitude that the study of such problems is not only unglamorous, but also not really 'true science'.

This can only be regarded as regrettable when one considers that every day in England and Wales about 1000 women are likely to require repair of perineal trauma following childbirth (Sleep et al. 1984). As might be expected, the majority of those women experience some per- ineal pain or discomfort in the immediate post- partum period, but even 3 months later, as many as 20% still have problems (such as dyspareunia)' likely to be related to perineal trauma and its repair (Sleep et al. 1984). Furthermore, the few studies which have been conducted suggest that, to an important extent, this morbidity is poten- tially reducible or preventable for tens of thou- sands of women each year.

What can the controlled studies tell us about three factors which have a bearing on the extent of the morbidity associated with perineal trauma: the choice of suture material, the tech- nique of repair, and the competence of the operator?

Ten satisfactorily controlled trials, including two in this issue of the Journal (Spencer el al. p.426 and Isager-Sally et al. p.420) have been reported which compare commonly used materials for the repair of episiotomy or other trauma following vaginal delivery. Four of these

(Hansen et al. 1975; Gaasemyr et al. 1977; Buchan & Nicholls 1980; Isager-Sally et al. p.420) compared absorbable skin sutures left to dissolve with non-absorbable sutures removed in the early puerperium. The short-term results are clearcut. In all four trials, the group repaired with absorbable material had less perineal pain in the immediate post-partum period. In con- trast, the implications in the longer term are not clear. In two of the three trials which included longer-term follow-up (Buchan & Nicholls 1980; Hansen et al. 1975), use of polyglycolic acid absorbable sutures (Dexon, Davis and Geck Ltd., Gosport) was associated with an increase in perineal pain and dyspareunia, and a delay in resuming intercourse; this difference was par- ticularly marked in the study of Buchan & Nicholls (1980). The third trial with follow-up (Isager-Sally et al. p.420) provides some reas- surance: in terms of morbidity 3 months post- partum, the group repaired with nylon skin sutures removed on the 5th day was intermedi- ate between the groups repaired with continuous and interrupted polyglycolic acid skin stitches. However, the fact that the material used for the deeper tissues was not the same in all three groups is a limitation of this trial.

Five of the ten trials (Livingstone et al. 1974; Rogers 1974; Beard et al. 1974; Banninger et al. 1978; Roberts & McKay Hart 1983) compared polyglycolic acid (Dexon) sutures with chromic catgut when used for both the skin and the deeper layers. A consistent and clearcut finding was that polyglycolic acid was associated with fewer problems in the immediate post-partum period.

Unfortunately, none of these studies included adequate follow-up after discharge from hos- pital (reflecting the perspective discussed earlier) and so it is impossible to assess the rela- tive merits of these two materials in the longer term. The only trial of two absorbable materials used for all layers which did include longer-term follow-up compared chromic catgut with

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glycerol-impregnated catgut (Softgut-braun, Davis and Geck Ltd., Gosport) (Spencer et al. p.426). It showed that the type of absorbable material chosen may have dramatic effects on both short- and longer-term maternal morbidity. In the group repaired with glycerol-impregnated catgut, pain on the tenth day was 37% more common (95% confidence limits: 6% and 77%) and dyspareunia in the first 3 months after delivery was 26% more common (95% con- fidence limits: 8% and 46%) than in the group repaired with chromic catgut. Extrapolation of the results of this trial to England and Wales would suggest that the choice of suture material could make a difference of as many as 30 000 cases of dyspareunia each year. Despite chromic catgut clearly performing the better, the findings of this study also question the use of chromic catgut as a skin suture which does not require removal: as many as one in six women had to have chromic catgut stitches removed during the puerperium .

Considering now the choice of material for the deeper tissues, the usefulness of these trials is limited by the fact that they all involved a com- parison of different materials used for all layers. But no trial has compared different materials for the repair of deeper tissues in two groups of women, both of which had the same material and technique for the skin repair, and so these five studies currently represent the best evidence available in this respect.

Nevertheless, important effects of different suture materials in the immediate post-partum period are clear. Firstly, for skin closure, com- monly-used absorbable materials, like catgut and polyglycolic acid, are more comfortable than the commonly-used non-absorbable materials, like silk. Secondly, polyglycolic acid is preferable to chromic catgut when used for all layers. Worries remain, however, about the long-term morbidity associated with these absorbable materials and with polyglycolic acid in particular. Further well-controlled trials are therefore required.

Turning now to the technique of skin closure, all three trials, which included a randomized comparison of interrupted transcutaneous sutures with a continuous subcuticular stitch using the same material for both techniques, showed that there was less pain immediately post-partum in the groups repaired with a con- tinuous subcuticular suture (Banninger et al. 1978; Detlefson et al. 1980; Isager-Sally et al.

p.420). Only Isager-Sally and his colleagues included a 3 month follow-up. Somewhat sur- prisingly, there was still a marked difference between the two groups; women repaired with interrupted sutures had significantly more com- plaips than those repaired with a continuous subcuticular stitch. On the limited evidence currently available a continuous subcuticular suture therefore appears preferable to inter- rupted transcutaneous stitches.

To what extent is current clinical practice con- sistent with this evidence about ways in which morbidity can be minimized by choice of suture material or suturing technique? A telephone survey of a random sample of 50 English mater- nity units conducted for this commentary revealed a wide variation in the ‘most popular’ materials for perineal repair. Thirteen different combinations of materials for the deeper tissue and the skin were mentioned. As many as a quarter of the units used two or more combina- tions equally frequently, the most extreme example of this being a hospital in which the four obstetricians all had individual and markedly different policies. Nevertheless, chromic catgut used for all layers was clearly most popular being the choice in 50% of units with a consistent policy. Polyglycolic acid sutures (either the homopolymer, Dexon, or the copolymer with lactide, Vicryl, Ethicon Ltd., Edinburgh), used for both deeper tissues and the skin was the choice in 17% of units. Other popular combina- tions were glycerol-impregnated catgut (Soft- gut) throughout (8%) and chromic catgut for the deep tissues with silk to the skin (6%). The survey also revealed that, when absorbable materials were chosen for skin closure, 50% of units predominantly used interrupted sutures, and only 7% predominantly used continuous subcuticular suturing; 34% used the two tech- niques equally. Clearly, current practice is inconsistent with the available evidence.

A proposal to introduce the more difficult technique of subcuticular suturing as a routine raises questions about the ways in which the operators are chosen and trained. Although there is really no research evidence on the effects of skill on symptoms associated with perineal repair, the skills of the operator are likely to be as important as, if not more important than, the materials and techniques used. Yet, because perineal repairs are performed in such large numbers they are usually delegated to a junior obstetrician or a medical student. There are

Commentary 419

ing the comfort of literally hundreds of thou- sands of women worldwide.

Adrian Grant Epidemiologist

National Perinatal Epidemiology Unit Radcliffe Infirmary Oxford OX2 6HE

References Banninger, V., Biihrig, H. & Schreiner, W. E. (1978)

A comparison between chromic catgut and poly- glycolic acid sutures in episiotomy repair. Geburtshilfe Frauenheilk 30, 30-33.

Beard R., Boyd, I. & Sims, C. (1974). A trial of polyglycolic acid and chromic catgut sutures in epi- siotomy repair. Br J Clin Pract 28,409-410.

Buchan, P. C. & Nicholls, J . A. J. (1980) Pain after episiotomy - a comparison of two methods of repair. J R CON Gen Pract 30, 297-300.

Detlefson, A., Vinther, S . , Larsen, P. & Schroeder, E. (1980) Intradermal suturing of episiotomy wounds compared with interrupted sutures. Ugeskr Laeger

Gaasemyr, M., Hovland, E. & Bergsjo, P. (1977) Suturmaterialets betydning for tilheling etter epi- siotomi - sammenlikning mellom cromcatgut og supramid. Fra Medisinske Publikasjoner 2, 1-5.

Garcia, J. , Garforth S. & Ayers S. (1986) Midwives confined? Labour ward policies and routine. Pro- ceedings of the 1985 Research and the Midwife Conference, Manchester, in press.

Hansen, M. K., Selnes A, , Simonsen, E., Sorensen, K. M. & Pedersen, G. T. (1975) Polyglycolic acid (Dexon) used as suture material for the repair of episiotomies. Ugeskr Laeger 137, 617-620.

Isager-Sally, L., Legarth, J . , Jacobson, B. & Bustofte, E. (1986) Episiotomy repair - immediate and long-term sequelae. A prospective randomized study of three different methods of repair. Br J Obstet Gynaecol93,420-425.

Livingstone, E., Simpson, D. & Naismith, W. C. M. K. (1974) A comparison between catgut and poly- glycolic acid sutures in episiotomy repair. J Obstet Gynaecol Br Commonw 81,245-247.

Roberts, A. D. G. & McKay Hart, D. (1983) Poly- glycolic acid and catgut sutures with and without oral proteolytic enzymes, in the healing of epi- siotomies. Br J Obstet Gynaecol90,650-653.

Rogers, R. W. (1974) Evaluation of post-episiorrha- phy pain: polyglycolic acid vs catgut sutures. Milit Med 139, 102-104.

Sleep, J. & Grant, A , , Garcia, J . , Elbourne, D. , Spencer, .I. & Chalmers, I. (1984) West Berkshirc perineal management trial. Br MedJ 289,587-590.

Spencer, J . A. D., Grant, A., Elbourne D. , Garcia J . & Sleep, J. (1986) A randomized comparison of glycerol-impregnated chromic catgut with untre- ated chromic catgut for the repair of perineal trauma. Br J Obster Gynaecol93, 426-430.

142, 3117-3120.

signs that this situation is changing. A resolution passed at the Royal College of Midwives Branch Representative meeting in 1985 ‘deplored the fact that repair of episiotomy is still undertaken by medical students’. Perineal repair is now an integral part of midwifery training and a survey conducted in England in 1984 revealed that mid- wives were suturing the perineum in over 60% of consultant units and it was planned that they would do so in a further 10% of units in the near future (Garcia et al. 1986). It seems quite poss- ible, but by no means certain, that this develop- ment will improve the quality of repair. But resource implications for midwifery are unclear. There is understandable resistance from many midwifery managers who are unhappy for mid- wives to take on this extra responsibility. On the other hand, midwifery time may be wasted wait- ing for, and then waiting on, an obstetrician operator.

As far as training is concerned, the usual approach is still ‘see three, do three, and now you are on your own!’ Video recordings have been introduced in some places to supplement this and teaching apparatuses are becoming available. Ideally, the usefulness of these developments should also be carefully assessed before they are introduced widely.

Where does this leave us? On the basis of currently available research results, the use of polyglycolic acid sutures (Dexon or Vicryl) for both the deep layers and skin, with the skin closed by a continuous subcuticular suture, is the best policy for perineal repair following child- birth. Worries remain that the clearcut short- term advantages of this approach may be balanced or even outweighed by longer-term problems and further research is urgently needed to clarify this. (Given this concern, a rational development would seem to be a con- tinuous synthetic suture removed in the early puerperium. Unfortunately, the methods used for fixing the ends in other sites, such as beads and clips or multiple-throw knots, are not suit- able for the perineum). Other areas needing research are the training of the operators and the implications for both mothers and midwives of the extension of the midwifery role to include perineal suturing. Research into the repair of episiotomies and perineal tears may be con- sidered unglamorous in some circles. But there can be no doubt about its relevance for improv-