|Grade of Evidence|
|Study design||Randomized- and description||Research procedure||Measures used & their reliability & validity||Statistics reported|
(include type of statistic reported & p value/confidence intervals as indicated)
|Study results & midwifery perspective|
|Lundquist, M. et al, 2000|
Fleming, V. et al,
Parallel group randomized- controlled
|80 term primiparas with minor perineal lacerations|
40 sutured -control group
Initially 1314 recruited with 74 randomized primiparas > 37 wks gestation, with single fetus being randomized.
nonsutured group n 41. Final # at 10 days = 73 (33 sutured and 40 not) and at 6 weeks = 70 (33 sutured and 37 not)
|Differences in healing and experience of pain were compared for minor, < 2cm, perineal lacerations which were sutured versus not sutured.|
Differences in healing and experience of pain were compared for suturing and nonsuturing first- or second-degree lacerations.
|A structured observational method was used by midwives to evaluate healing, edema, hematoma, bleeding and infection at 2-3 days, 8 weeks and 6 months. Self-reporting was used to qualitatively evaluate subjects with a questionnaire for perineal discomfort including effects on breastfeeding and resumption of intercourse at 3 & 6 months. Validity and reliability are dependent on objective observation of healing and subjective responses of pain|
A structured observational method was used by midwives, using REEDA scale for healing and a self-report method for pain were measured at 1 and 10 days and 6 weeks postpartum. Postpartum depression, considered a secondary outcome, evaluated day 10 and week 6.
|Mean standard deviation.|
Student's t test used for interval data. chi square used for category data. No significant differences in healing. Sutured group had increased discomfort from stitches.
16 % in sutured group but none in nonsutured group (p = 0.0385) reported a negative effect on breastfeeding.
Differences in outcome scores tested using 2-sided Mann Whitney U test. Logistic regression used to determine effects on dichotomous (REEDA) outcomes. SSPS Generalized Linear Model performed on continuous variables.
A higher proportion of women with a closed tear, at 6 weeks in the sutured group (P = 0.001). No significant difference regarding pain or depression.
|Minor lacerations can be left to heal unsutured. Benefits include choice, avoid discomfort of suturing, and positive effects on breastfeeding and pain. Midwives performed and participated in this study.|
Failure to achieve desired sample size. Pain level the same in both groups. Poorer wound approximation in nonsutured women. Midwives performed and participated in this study.
|Gordon, B. et al, 1998|
Grant, A. et al, 2001
|Stratified, randomized controlled study using a 2 x 2 factorial design|
Stratified, randomized controlled study using a 2 x 2 factorial design
|1780 women delivered vaginally and had an episiotomy or first- or second-degree tear requiring suturing.|
790 of the women participating in the initial research
|Designed to evaluate the procedure of a two stage perineal repair leaving the skin unsutured compared to the routine three stage repair already utilized.|
Designed to evaluate, at one year, the results of two-stage repair versus three-stage repair.
The second part of this trial-was designed to compare the two absorbable suture materials, polyglycolic acid and chromic catgut, and their potential for decreasing pain and the need for resuturing.
|A structured observational method was used by a midwife researcher blinded to the assignment of two or three stage repair. The midwife evaluated perineal pain and healing on 99% of the participants, utilizing self-report questionnaires from 24 to 48 hours and included suture removal at 10 days postpartum. A self-report questionnaire completed by 93% of the participants at 3 months postpartum, including evaluation of perineal pain, healing, removal of sutures, resuturing and dyspareunia.|
Self-report questionnaires were completed at approximately 400 days postpartum measuring feeling different from prepregnant status, time frame for resumption of or failure to resume pain free intercourse, and resuturing.
|Mean standard deviation and stratified analysis. Perineal pain at 24 to 48 hours or 10 days (P= 0.3 & 0.2, respectively). Perineal pain at 3 months with two stage suturing resulting in decreased pain and dyspareunia (P= 0.04). Two stage suturing- decrease in complaint of tight stitches at 10 days (P= 0.02) and decreased report of necessity to remove suture material (P= 0.01). Evaluation of perineal healing performed at 24 to 48 hours, 10 days and three months resulted in no significant difference|
Simple descriptive statistics used at 1 year follow up. Primary analyses - intention-to-treat. Statistical tests were two sided. The Yates correction was used for x2 statistics. RR with 95% CI calculated where appropriate. 2P<0.01
|Leaving the skin unsutured resulted in a decreased need for resuturing, a decreased wound breakdown, decreased pain and increased ability to resume pain-free intercourse. They also noted increased effectiveness of the two-stage repair and decrease in cost. Midwives performed and participated in this study.|
Two-stage repair reduced likelihood that perineum felt different from before delivery and less pain and dyspareunia initially. Polyglactin 910 maintains short term benefits and reduces long term dyspareunia over chromic catgut. Midwives performed and participated in this study.
|Albers, L. et al, 1999|
Clement, S. and Reed, B. 1999
|Large randomized clinical trial|
Longitudinal follow up study
|5404 women with SVD at term were examined by midwives.|
107 women who had unsutured tears who had been delivered by one or more of five midwives. A socially and ethnically diverse set of women is used.
|Designed to describe the range and extent of childbirth trauma and related postnatal pain. |
Designed to examine and describe women's views, experiences and long term perineal health who had nonsuturing of perineal tears after several (1-7) years.
|A structured observational method was used by midwives to evaluate episiotomy versus laceration, episiotomies with extensions, various sites of trauma and associated pain with each type of trauma at 2 days, 10 days, and 3 months postpartum. Self-report questionnaires were filled out by mothers describing pain in or around perineum at 2 and 10 days and 3 months.|
Self report using McGill Pain Questionnaires, questions used in other research studies and questions designed by the authors were sent. Questionnaire covered: decision making, women's views, perceived advantages and disadvantages, satisfaction, worries, perineal problems, pain, continence, subsequent births. Open and closed ended questions were utilized.
85% experienced trauma. Unsutured trauma - restricted to first or second degree lacerations, outer vaginal and labial sites. Pain declined with passage of time, pain gradient observed with site and complexity of trauma. 59% sustained trauma that required suturing.
Closed questions analyzed using SPSS v7.0. A thematic analysis was used for open ended questions.
70%-felt there was a choice.
68%-felt they had a big influence. A majority felt they made the right decision.
82% would choose not to have stitches if given the choice again.
33% never had and 42% very occasionally had incontinence.
Level of worry reported by participants: Not a worry by 76% regarding sex; 78% about partners experience;
88% pain in perineum; 50% leaking urine; 93% lack of bowel control; 85% how perineum is healed; 74% how perineum looks.
|Genital tract trauma is very common with SVD. Sutured trauma had increased reports of discomfort as opposed to nonsutured trauma. Effective measures to prevent or reduce trauma would be beneficial. Midwives performed and participated in this study.|
Women were generally very satisfied having an unsutured perineal tear. Women viewed it from a holistic perspective: weighing physical and psychosocial factors.
Randomized controlled trials are needed evaluate meaningful comparative data. Midwives performed and participated in this study.
|Kettle, C. et al, 2002|
Head, M. 1993
Retrospective pilot study.
|1543 eligible women randomly assigned to interrupted or continuous method of suturing, and to the standard or rapidly absorbed polyglactin suture material. All had SVD with episiotomy or a second-degree perineal laceration.|
75 multiparous women who had sutures at least once previously after a birth. Of 75 questionnaires 62 were returned. 7 had no sutures to perineum leaving 55 women representing a total of 155 births.
|Designed to evaluate level of pain and healing with continuous versus interrupted suturing for perineal repair, following spontaneous vaginal birth. Also evaluated the standard or rapidly absorbed polyglactin (vicryl) versus chromic catgut suture material.|
Designed to evaluate whether is it preferable to leave first and second degree tears to heal naturally unsutured or to suture them.
The aim is to compare trauma, pain and healing.
|Self report with questionnaire regarding pain at 2 and 10 days, dyspareunia at 3 and 12 months and the necessity of suture removal with each type of suture method and material.|
Self report with questionnaire regarding pain, infection, tear versus episiotomy, resumption of intercourse.
|Mean standard deviation and stratified analysis.Use of continuous suturing and pain P<0.0001 Types of suture material P=0.10 Removal of sutures with continuous stitch and standard chromic P< 0.0001.|
92% did not suffer infection of perineum. Those more likely to have infection had previous episiotomy and suturing.
34.5% made comments regarding pain
|Use of continuous suturing was noted with increased pain and need to remove sutures. Types of suture material were found to be comparable in level of pain. Suture removal was required more frequently with the interrupted method of suturing and with the utilization of the standard suture material. Wound approximation at 10 days was noted more frequently in the continuous method of suturing and women documented more satisfaction in regards to 'feeling back to normal' and decreased dyspareunia at 3 months. No significant difference was noted at 3 and 12 months regarding dyspareunia and the use of either suture material type. The women required suture removal significantly less often with the use of rapidly absorbed suture material. Midwives performed and participated in this study. |
Small study with satisfactory outcomes regarding leaving tears unsutured. No problem with healing. Pain levels are decreased. Earlier resumption of intercourse. Further studies recommended by author.
The author, a midwife performed and participated in this study.