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Secondary suturing compared to non-suturing for broken down perineal wounds following childbirth

  1. Lynn M Dudley1,*,
  2. Christine Kettle2,
  3. Khaled MK Ismail3

Editorial Group: Cochrane Pregnancy and Childbirth Group

Published Online: 25 SEP 2013

Assessed as up-to-date: 4 SEP 2013

DOI: 10.1002/14651858.CD008977.pub2


How to Cite

Dudley LM, Kettle C, Ismail KMK. Secondary suturing compared to non-suturing for broken down perineal wounds following childbirth. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD008977. DOI: 10.1002/14651858.CD008977.pub2.

Author Information

  1. 1

    University Hospital of North Staffordshire, Maternity Centre, Stoke-on-Trent, Staffordshire, UK

  2. 2

    Staffordshire University, Beaconside, Staffordshire, UK

  3. 3

    University of Birmingham, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, Birmingham, UK

*Lynn M Dudley, Maternity Centre, University Hospital of North Staffordshire, Newcastle Road, Stoke-on-Trent, Staffordshire, ST4 6QG, UK. lynn.dudley@uhns.nhs.uk.

Publication History

  1. Publication Status: New
  2. Published Online: 25 SEP 2013

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Characteristics of included studies [ordered by study ID]
Christensen 1994

MethodsParticipants were allocated into 2 treatment groups.

No methods of randomisation were provided.

No details were provided regarding how the randomisation sequence was generated.

Outcome assessment - no details provided.

20 women following vaginal delivery with an episiotomy wound were asked to participate and 17 women were randomised.


Participants17 women were included in the study - no inclusion criteria specified.

11 women had wound infection and wound breakdown.

6 women had a wound infection but no wound breakdown.

Exclusion criteria - Chron's disease, ulcerative colitis, immunosuppressive treatment.


InterventionsIntervention group (n = 8) Incision, drainage, curettage and suture under antibiotic cover. No specific suture technique or material used detailed (referred to as 'primary suture').

7 of the 11 women with wound infection and wound breakdown were allocated the intervention group.

1 of the 6 women with wound infection but no wound breakdown was allocated the intervention group.

Control group (n = 9) Incision and drainage (conventional treatment, also described as 'open healing') compared with intervention.

4 of the 11 women with wound infection and wound breakdown were allocated the control group.

5 of the 6 women with wound infection but no wound breakdown were allocated the control group.


OutcomesIncluded in the analysis:

Healing time.

Time spent in hospital (inpatient).

Recidivism (relapse/reoccurrence) of abscess.

Vaginal reconstructive surgery.


NotesSetting - Odense University Hospital.

3 women who were approached for inclusion did not want to participate.

1 woman in the control group could not be contacted for assessment of wound healing.

Tables provided indicate an intention-to-treat analysis although not revealed in the paper.

There was no recidivism of abscess.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo details provided.

Allocation concealment (selection bias)Unclear riskNo details provided.

Incomplete outcome data (attrition bias)
All outcomes
Low risk20 women were asked to participate in the study; 17 women were randomised, 3 withdrew before being allocated to a treatment group.

1 woman from the incision and drainage group was unable to attend the 4 week follow-up assessment.

Selective reporting (reporting bias)Unclear riskWe were not clear whether all pre-specified outcomes were reported in the published papers.

Other biasUnclear riskNot stated.

Blinding of participants and personnel (performance bias)
All outcomes
High riskParticipant: no details provided.

Clinician: no details provided.

Blinding of outcome assessment (detection bias)
All outcomes
High riskDue to the obvious differences in treatments, the women and outcome assessors could not be blinded to the allocated intervention.

Monberg 1987

MethodsParticipants were randomised into 2 groups.

No methods of randomisation were provided.

No details regarding how the randomisation sequence was generated were provided.

35 participants with an infected and/or ruptured episiotomy were included.


Participants35 participants (33 primipara) were randomised into 2 groups.

No exclusion criteria were provided.


InterventionsIntervention group A (n = 20) women had their episiotomy repaired (referred to as 'primary resuturing) and received Clindamycin 600 mg 2 hours prior to suturing and continuously for 5 days (300 mg 3 times a day).

Group B (n = 15) women were treated in accordance with the routine management of the department: cleaning the wound with chloramine and saline, resulting in spontaneous healing.


OutcomesIncluded in the analysis:

Healing time.

Time spent in hospital (inpatient).

Recidivism (relapse/reoccurrence) of abscess.

Vaginal reconstructive surgery.


NotesSetting - Hvidore Hospital, Copenhagan, Denmark.

Tables indicate intention-to-treat analysis although not stated in the paper.

All episiotomies examined for bacteria, unfortunately the authors reported that the results had been lost.

Method of repair described.

Lactation continued in both groups but length of times not provided.

No losses to follow-up reported.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo details provided.

Allocation concealment (selection bias)Unclear riskNo details provided.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskDetails unclear in paper.

Selective reporting (reporting bias)Unclear riskWe were not clear whether all pre-specified outcomes were reported in the published papers.

Other biasUnclear riskNot stated.

Blinding of participants and personnel (performance bias)
All outcomes
High riskParticipant: no details provided.

Personnel: no details provided.

Blinding of outcome assessment (detection bias)
All outcomes
High riskDue to the obvious differences in treatments, the women and outcome assessors could not be blinded to the allocated intervention

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Arona 1995Not a randomised trial. Case note review of 23 women who underwent early secondary repair of third- and fourth-degree perineal tears. 21 women had wound dehiscence following primary repair of a fourth-degree tear and 2 had wound dehiscence following primary repair of a third-degree tear. All repairs were successful with no subsequent wound dehiscence occurring.

Hankins 1990Not a randomised trial. Early repair of episiotomy dehiscence was performed in 22 women with a fourth degree tear and 4 with a third-degree tear and 5 with a mediolateral episiotomy. Most of the women (n = 27) 1 year post secondary repair demonstrated excellent anatomical results and the women reported complete continence and normal coital activity.

Ramin 1992Not a randomised trial. Case note review of 34 women who underwent early repair of episiotomy dehiscence. Clinical follow-up was reported in 29 cases, 5 women were lost to follow-up. Most of wounds were healed completely in 2-3 weeks; 2 women had subsequent wound dehiscence.

Uygur 2004Not a randomised trial. A retrospective case note review including 37 women with episiotomy dehiscence. 12 women with episiotomy dehiscence were allowed to heal by secondary intention and 25 women underwent early secondary repair. 3 women from the re-suturing group had superficial separation of the skin edges, whilst healing was complete in the remaining 22 women.

 
Characteristics of ongoing studies [ordered by study ID]
Dudley 2012

Trial name or titlePerineal resuturing versus expectant management following vaginal delivery complicated by a dehisced wound (PREVIEW).

MethodsPilot and feasibility randomised controlled trial designed to provide preliminary evidence of the effectiveness of re-suturing versus expectant management for dehisced perineal wounds following childbirth, and to feed into the design and feasibility of a larger definitive trial. 

ParticipantsPostnatal women referred to the perineal care clinics at the recruiting sites with dehisced perineal wound (spontaneous second-degree tear or episiotomy) that occurs within 2 weeks following childbirth.

InterventionsResuturing versus expectant management.

OutcomesPrimary outcome

The proportion of women with a healed perineal wound at 6-8 weeks from the trial entry.

Secondary outcomes

Pain at  2 and 6 weeks, 3 and 6 months following trial entry.

Dyspareunia  at 6 weeks, 3 and 6 months following trial entry.

Rates of breastfeeding at 6 weeks, 3 and 6 months following trial entry.

Woman’s satisfaction with aesthetic results of perineal wound at 6 weeks, 3 and 6 months following trial entry.

Starting dateJuly 25th 2011.

Contact informationLynn.dudley@uhns.nhs.uk

Notes12 women who have participated in the randomised controlled trial will also be interviewed to explore their physical and psychological experiences following perineal wound dehiscence; assess the acceptability of the research plan and ensure that all outcomes relevant to women are included in the definitive trial.

 
Comparison 1. Suturing versus non-suturing for perineal wound infection/breakdown

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Wound healing within 4 weeks117Risk Ratio (M-H, Fixed, 95% CI)1.69 [0.73, 3.88]

 2 Resumed intercourse within 2 months135Risk Ratio (M-H, Fixed, 95% CI)1.78 [1.10, 2.89]

 3 Resumed intercourse by 6 months135Risk Ratio (M-H, Fixed, 95% CI)1.08 [0.91, 1.28]

 4 Dyspareunia at 2 months126Risk Ratio (M-H, Fixed, 95% CI)0.44 [0.18, 1.11]

 5 Dyspareunia at 6 months132Risk Ratio (M-H, Fixed, 95% CI)0.39 [0.04, 3.87]