Minimizing Genital Tract Trauma and Related Pain Following Spontaneous Vaginal Birth

Leah L. Albers, CNM, DrPH; Noelle Borders, CNM, MSN


J Midwifery Womens Health. 2007;52(3):246-253. 

In This Article

Suturing Method and Materials

The most important study about method of perineal suturing comes from Kettle[34] in the United Kingdom. This midwife researcher randomized 1542 women to one of two methods of perineal suturing for an episiotomy or second-degree laceration after a normal vaginal birth. One group received the traditional 3-layer repair, with interrupted sutures used to close the perineal skin. The other group was sutured according to the method of Fleming,[35] which involved continuous, nonlocked sutures in the vagina and perineal muscles, and a continuous subcuticular stitch under the perineal skin. Pain data were collected at 2 and 10 days after birth and at 3 and 12 months postdelivery. With 771 women in each group, women sutured by the "Fleming method" reported less perineal pain at all time points, and they used fewer analgesics in the 10 days after birth. Significantly less suture material was placed in the perineal tissues with this technique, and this may explain the decreased tissue reactivity.

The Ipswich Childbirth Study[36,37,38] compared a 3-layer perineal repair with a 2-layer approach that left the perineal skin unsutured, as long as the skin edges were not gaping (defined as a separation of ≤0.5 cm with the woman in lithotomy position). Midwife researchers in the United Kingdom randomly allocated 1780 women (890 to 3-layer repair and 890 to 2-layer repair), and they also compared polyglactin (Vicryl; Ethicon, Inc., Somerville, NJ) versus chromic catgut suture materials.[37] No pain differences were found at 2 or 10 days after birth, according to suturing method. However, at 3 months postpartum, slightly fewer women with the 2-layer repair reported any perineal pain (8% vs. 10%) and also less dyspareunia (15% vs. 19%). One-year follow-up with postal surveys[38] indicated equivalent ratings of pain and dyspareunia in the two groups, but women with a 2-layer repair were less likely to report that their perineums felt different than before the birth. No disadvantages in the 2-layer method were identified.

A Cochrane review[39] pooled data from 8 clinical trials that compared suture materials for perineal repairs. Although the quality of the included trials was variable, all compared use of chromic catgut with either polyglycolic acid (Dexon; U.S. Surgical; Norwalk, CT) or polyglactin (Vicryl), which are synthetic and are absorbed more quickly than chromic catgut. Use of the synthetic materials was associated with less short-term pain in the first 3 days after birth (RR = 0.62; 95% CI, 0.54-0.71). Also, women sutured with Dexon or Vicryl had less need for analgesia in the 10 days after birth (RR = 0.63; 95% CI, 0.52-0.77). No differences in longer-term pain or dyspareunia were associated with either type of suture material.

Greenberg et al.[40] compared chromic catgut with polyglactin 910 (Vicryl Rapide) in a randomized trial of 1361 women. Laboring women were assigned to one of two suture materials and two-thirds of all women ultimately required suturing after giving birth. Women were queried about pain at 24 to 48 hours after birth and by phone at 10 to 14 days postdelivery. The protocol also called for a pain assessment at 6 to 8 weeks, but the majority of women did not continue study participation to that time. Equal numbers of women reported perineal pain at 24 to 48 hours and at 10 to 14 days, regardless of the suture material used. However, women reported less uterine pain with the synthetic suture material at 24 to 48 hours, a curious finding unlikely to be related to the type of suture material used in the study.

These studies indicate that women who require suturing of perineal trauma will have less pain and less extended morbidity with the "Fleming method" of repair, which is easier for beginners to learn, and leaves less suture in the maternal tissues. Also, allowing the perineal skin to remain unsutured, as long as it is not gaping, is associated with less perineal pain. Synthetic suture materials are preferable to chromic catgut in terms of short-term perineal pain.


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