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

 

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.

 

Plain language summary

Absorbable stitches for repair of episiotomy and tears at childbirth

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.

 

Resumen

Antecedentes

Materiales de sutura absorbible para la reparación primaria de la episiotomía y los desgarros de segundo grado

Aproximadamente el 70% de las mujeres presentará traumatismo perineal luego del parto vaginal y requerirá puntos. Este hecho puede dar lugar a dolor, retiro de los puntos de sutura y dispareunia superficial.

Objetivos

Evaluar los efectos de diferentes materiales de sutura sobre la morbilidad a corto y a largo plazo luego de la reparación perineal.

Estrategia de búsqueda

Se hicieron búsquedas en el Registro de Ensayos del Grupo Cochrane de Embarazo y Parto (Cochrane Pregnancy and Childbirth Group) (febrero 2010).

Criterios de selección

Ensayos aleatorios que comparaban diferentes materiales de sutura para la reparación perineal después del parto vaginal.

Obtención y análisis de los datos

Dos autores de la revisión evaluaron de forma independiente la calidad de los ensayos y extrajeron los datos.

Resultados principales

Se incluyeron 18 ensayos con 10 171 mujeres; las comparaciones incluyeron: suturas de catgut con suturas sintéticas estándar (nueve ensayos), suturas sintéticas de absorción rápida (dos ensayos) y suturas de catgut impregnado con glicerol (dos ensayos); y suturas sintéticas estándar con suturas sintéticas de absorción rápida (cinco ensayos) y suturas de monofilamento (un ensayo).

En comparación con las suturas de catgut, las suturas sintéticas estándar se asociaron con menos dolor hasta tres días después del parto (cociente de riesgos [CR] 0,83; intervalo de confianza [IC] del 95%: 0,76 a 0,90); y menos analgesia hasta diez días posparto (CR 0,71; IC del 95%: 0,59 a 0,87). Más mujeres con suturas de catgut requirieron una nueva sutura (15/1201) en comparación con las suturas sintéticas (3/1201) (RR 0,25; IC del 95%: 0,08 a 0,74); en tanto que más mujeres con suturas sintéticas estándar requirieron el retiro del material de sutura no absorbido (CR 1,81; IC del 95%: 1,46 a 2,24). En la comparación de las suturas sintéticas estándar con las suturas sintéticas de absorción rápida, el dolor a corto y a largo plazo fue similar; en un ensayo, menos mujeres con suturas de absorción rápida informaron el uso de analgésicos a los diez días (CR 0,57; IC del 95%: 0,43 a 0,77). Más mujeres del grupo de sutura sintética estándar requirieron el retiro de los puntos de sutura, en comparación con las del grupo de sutura de absorción rápida (CR 0,24; IC del 95%: 0,15 a 0,36). No se halló evidencia de diferencias significativas entre los grupos en cuanto al dolor a largo plazo (tres meses después del parto) o la dispareunia a tres, o a seis a 12 meses. Cuando se compararon el catgut y el catgut impregnado con glicerol, la mayoría de los resultados fueron similares, aunque el último se asoció con más dolor a corto plazo. Un ensayo que examinó suturas poliglicólicas estándar versus suturas de monofilamento no encontró diferencias en la mayoría de los resultados.

Conclusiones de los autores

El catgut puede aumentar el dolor a corto plazo comparado con las suturas sintéticas. Hubo pocas diferencias entre las suturas sintéticas estándar y las de absorción rápida, pero más mujeres de los grupos de suturas estándar requirieron el retiro de los puntos. En el caso de otros materiales, no se hallaron pruebas suficientes como para establecer conclusiones. Los resultados deben interpretarse en el contexto de la revisión Cochrane relacionada sobre las técnicas de sutura.

Traducción

Traducción realizada por el Centro Cochrane Iberoamericano