Student Projects
Evidence Based Clinical Practice Guideline

Perineal Lacerations: The Effects of Suturing versus Nonsuturing on Postpartum Healing and Pain

Mary DeWire

Student, Midwifery Institute of Philadelphia University
Posted Fall Term 2003

Abstract
During a spontaneous vaginal delivery, lacerations can occur anywhere in the woman's labia, vagina or perineum. They are labeled as first, second, third and fourth degree and involve differing levels of the perineal skin, vaginal mucosa, fourchette and perineal muscles, including the external anal sphincter and rectal mucosa. The pain associated with perineal tissue injury can impair physical functioning (bowel and urinary function, and mobility) and overshadow other important tasks (breastfeeding, infant care, and other household responsibilities) in the days and weeks following birth (Albers et al, 1996). Approximately 75 percent of all women who give birth vaginally will have lacerations of various levels of severity in the labia, vagina, and perineum (Lundquist et al, 2000). Reported advantages and disadvantages of leaving lacerations unsutured have been observed. Advantages include increased freedom of movement, better healing ability, and increased chances for the women to concentrate earlier on the first breastfeeding occasion (Lundquist et al, 2000). Disadvantages of spontaneous healing include increased burning sensations, a longer healing process, and incontinence (Lundquist et al, 2000). A review of the literature supports nonsuturing of perineal lacerations in regards to decreased pain, dyspareunia and suture removal, and supports suturing in relation to wound approximation and healing. The literature supports the use of rapidly absorbable suture material and the use of continuous over interrupted suturing technique when suturing is deemed necessary. Little research has been established regarding maternal choice or the possible utilization of a tissue adhesive in repairing
lacerations of mucous membranes. The conceptual framework guiding this inquiry includes both the midwifery model of care and the physiology of wound healing. As midwives, it is beneficial to the women we care for to provide effective strategies for perineal healing, in an effort to minimize the discomforts and maximize healing in the postpartum period. This inquiry will review and compare the known effects of suturing versus nonsuturing of perineal lacerations on selected maternal outcomes and provide an evidence-based clinical practice guideline based on those results.

Text
Chapter 1: Statement & Significance of the Problem

Introduction

During a spontaneous vaginal delivery, lacerations can occur anywhere in the woman's labia, vagina or perineum. They are labeled as first, second, third and fourth degree and involve differing levels of the perineal skin, vaginal mucosa, fourchette and perineal muscles, including the external anal sphincter and rectal mucosa. Varney (2002) describes perineal lacerations utilizing the following description. First degree lacerations include perineal skin, vaginal mucosa, and posterior fourchette. Second degree lacerations include the same tissues as first degree plus perineal muscles. Third degree lacerations include the same tissues as second degree plus the external anal sphincter. Finally, fourth degree lacerations include all of the tissue types listed above and extends into the rectal mucosa. Reported sequelae of lacerations include inadequate approximation due to gaping or jagged wound edges, increase in swelling, ecchymosis and potential for infection, uncontrolled bleeding and increased level of pain.

Reported advantages and disadvantages of leaving lacerations unsutured have been observed. Advantages include increased freedom of movement, better healing ability, and increased chances for the women to concentrate earlier on the first breastfeeding occasion (Lundquist et al, 2000). Disadvantages of spontaneous healing include a more burning sensation, a longer healing process, and incontinence (Lundquist et al, 2000). The drawbacks that Lundquist notes have also been associated with lacerations that have been sutured. The potential for infection is another focus of disagreement. The fact that there is further tissue damage with suturing is a concern related to potential infection. An additional issue is whether there is increased risk of infection with leaving the wound gaping and unclosed.

Scope of the problem

It is estimated that among women who did not routinely receive an episiotomy during a vaginal delivery, up to 57% will, nonetheless, sustain some form of perineal trauma. Spontaneous lacerations are reportedly very common. Some two-thirds of primigravidas have sufficient perineal trauma at birth to require suturing, and clinical populations of mixed parity show 30-40% of all gravidas sustain significant perineal injury (Albers et al, 1996). Suturing criteria are based on the degree of laceration and those lacerations that are identified as poorly approximated or having signs of severe swelling, bleeding or infection. Approximately 75 percent of all women who give birth vaginally will have lacerations of various levels of severity in the labia, vagina, and perineum (Lundquist et al, 2000). Considering there are around 4 million American women who give birth each year, with about 3 million vaginally, these research results demonstrate a substantial number of women effected by the problem of perineal trauma.

Significance to women’s health


The significance of perineal trauma can have an enormous impact on a woman in her postpartal period. The pain associated with perineal tissue injury can impair physical functioning (bowel and urinary function, and mobility) and overshadow other important tasks (breastfeeding, infant care, and other household responsibilities) in the days and weeks following birth (Albers et al, 1996). During the early minutes after a birth, suturing tends to interfere with the initial bonding process when mother and infant should be together. This initial time together would be better utilized in establishing effective breastfeeding patterns. The pain from the increased trauma of suturing can become a deterrent to that process. Perineal trauma is strongly associated with postpartum pain and morbidity, including bleeding and infection (McCandlish, 2001). The provision of numerous care measures are intended to facilitate perineal healing, such as ice packs, sitz baths and thorough perineal care. While these measures are sufficiently effective, it is realistic to assume that the prevention of unnecessary further trauma to lacerations would be increasingly beneficial.

For many new mothers, the postpartum period is noted as a stage of multiple transformations and adjustments. These include many changes in a woman's physical, emotional, psychological and cultural well-being. It is therefore vitally important, as advocates for women, that we appraise, research and modify current practices in order to positively influence this transitional period. Exploring techniques for the prevention of episiotomies, perineal lacerations and trauma has been the topic of multiple research studies. While prevention is preferable, there are many women who indeed sustain perineal lacerations and trauma. In fact, one article states that up to 57% of women birthing vaginally in a national context in which episiotomy was not routinely practiced were recorded as having some level of perineal injury (McCandlish, 2001). The significance to women's health would be in reducing postpartal discomfort, disability and the risk of infection, thereby providing the woman with increased functional capacity to accomplish her normal activities of daily living and to attend to the important transition to motherhood now upon her.

Significance to midwifery

Researching evidence based methods of practice are part of the quality management in midwifery care guidelines according to the ACNM (ACNM, 2002). Promotion and evaluation of high quality care are a priority for the midwifery profession, and ACNM strongly recommends that practicing midwives participate in all aspects of quality management: quality assurance, peer review and quality improvement (ACNM, 2002). The ACNM more specifically addresses the issue of perineal management in the intrapartum section (section B, number 6) of the core competencies: Section B- Applies knowledge of midwifery practice in the intrapartum period that includes, but is not limited to, the following: Number 6-Techniques for (i) administration of local anesthesia (ii), spontaneous vaginal delivery, (iii) third stage management, and (iv) performance and repair of episiotomy and repair of lacerations (ACNM 2003).

The Midwives Alliance of North America, under section IV-N, describes perineal trauma as a specific concern to midwifery care: Section IV- Care During Labor, Birth, and Immediately Thereafter:
The midwife provides health care, support, and information to women throughout labor, birth, and the hours immediately thereafter. She determines the need for consultation or referral as appropriate. The midwife uses a foundation of knowledge and/or skill which includes the following: N-Evaluation and care of the perineum and surrounding tissues (MANA, 2003). Generally, the evaluation and care of the perineum in midwifery care include decreased use of episiotomies, increased attempts to preserve perineal integrity and decreased use of suturing in the event of perineal trauma. Midwives are interested in providing each individual woman with choices regarding her care. In the event of certain perineal trauma, the education would be as such: "You have a laceration that is presently not bleeding and the edges are staying together. Would you prefer that I secure it with a few stitches or leave it unsutured to heal naturally?" This inquiry will review and compare the known effects of suturing versus nonsuturing of perineal lacerations on selected maternal outcomes.


Chapter Two: Review of Literature and Conceptual Framework

Literature Review

Literature searches were conducted using the following topics: perineal, perineum, perineal trauma, perineal lacerations, suturing and suture types, perineal pain, perineal healing, episiotomy and genital tract trauma. Searches involved various electronic resources, including the ACNM, Cochrane Database, Medline, CINAHL, Pubmed, MIDIRS and FirstSearch, as well as, personal journal resources, bibliography reviews, and midwifery texts. A wide range of interrelated topics were examined to provide opportunities for focused questions and conceptual framework development. The hospital learning resource center was used to obtain copies of the full text research articles as the various abstracts were deemed appropriate to the inquiry.

Trauma of the genital tract, especially of the perineum, is exceedingly common in women experiencing spontaneous vaginal births. Approximately 75 percent of all women who give birth vaginally will have lacerations of various levels of severity in the labia, vagina, and perineum (Lundquist et al, 2000). Childbirth trauma is associated with short- and long-term morbidity (Albers et al, 1999). Pain levels can be intense, and for some women pain persists over time (Albers et al, 1999). This pain can be very distressing, and can interfere with the new mother's daily activities such as walking, sitting, lying in bed, passing urine, and opening bowels, and could affect her ability to cope with the 24 hour demands of parenthood (Kettle et al, 2002). Two factors which may be linked with morbidity are the suturing technique and the choice of suturing material (Grant et al, 2001). These two factors are considered to be within the control of the care provider. This literature review is designed to examine and evaluate previously documented trials and relate the various findings to this present course of inquiry.

The study objective for the research by Lundquist, Olsson, Nissen, Norman (2000), was to determine the necessity of suturing vaginal lacerations after delivery. The study compared lacerations that were sutured and not sutured and focused on determining differences in the healing process and the woman's postpartum experience with each. The study was performed in a university hospital in Sweden and contained 80 term primiparas delivered by midwives. The perineal lacerations included were non-bleeding lacerations of the vagina, labia minora and perineum. They were graded I-II, and had to be less than 2 cm deep and 2 cm long. The nonsutured women, 40, were part of the experimental group and the sutured women, 38, part of the control group. Two women of the control group were removed due to repair with suture not approved for the purposes of the study. The objective means of evaluation included visualization of perineal healing at postpartum days 2 or 3, 8 weeks and 6 months. The subjective means of evaluation, during the same time frames, included a questionnaire to evaluate each participants experience of discomfort, ability to return to sexual intercourse and effect on breastfeeding.

The following results included no significant difference in healing process. On days 2-3, during visual examination of perineum, minor healing problems were noted in 11 of the 87 lacerations in the nonsutured women and in 4 of the 74 lacerations in the sutured group. Again, at 8 weeks, visualizations found minor healing problems in 8 of 87 of nonsutured women and in 8 of 74 sutured women. The results included no significant difference in level of discomfort between the two groups. The sutured group, did however, report utilization of analgesics for relief of discomfort and 5 of the women had their sutures removed. In regards to effects on breastfeeding, the nonsutured women found no effect and 16 % of the sutured women reported negative effects (P= < 0.04). The authors concluded that minor, nonbleeding laceration need not be sutured for effective healing. They concluded that there are positive benefits of nonsuturing for breastfeeding women, avoidance of unnecessary invasive procedures and opportunity for women to express a preference regarding suturing.

This article provides valuable insight and information regarding the need to suture perineal lacerations. The conclusions found by the authors correspond with my general theories regarding all of the observed and subjective outcomes of leaving lacerations to heal unsutured. Study strength includes the fact that the women were randomly assigned for sutured versus nonsutured lacerations using sealed envelopes. The results appeared unbiased, believable, accurately derived from the study findings. The results were found to be relevant to midwifery care and decision-making. The rights of the study participants were well protected, including the fact that 5 sutured patients were able to have their sutures removed upon request. The midwife authors of this article, described the possibility of women having a choice as a benefit. This would indicate that the authors were concerned with the welfare of women and accuracy in their research. The sample size was a bit limited in regards to a significant difference in visualized healing. This is where a larger sample size, perhaps several hundred to a thousand, would perhaps be more appropriate and demonstrative of significant results. On the other hand, it could demonstrate that there is no difference in the two treatments in this particular variable. Finally, this article is definitely a relevant asset to my research regarding sutured versus nonsutured perineal lacerations because it provides healing, pain and choice as variables necessary to consider.

Fleming, Hagen & Niven (2003) performed a trial in two hospitals in Great Britain, which was designed to determine differences between suturing and nonsuturing first- or second-degree vaginal lacerations in primiparous women of 37 weeks of gestation or greater, with a single fetus (Fleming, 2003). Perineal healing, using the REEDA scale (see appendices) and pain were measured at 1 and 10 days and 6 weeks postpartum. Postpartum depression was considered a secondary outcome that was also evaluated at the tenth day and the sixth week. Antenatally, 1314 women were recruited and given an initial sheet of information describing the parameters of the study and its requirements. Lacerations were evaluated by the midwife postnatally and she determined eligibility at that time. A nearby hospital held sealed, opaque envelopes containing instructions for the midwife on whether or not to suture the laceration. The study was a randomized, controlled study of a final number of 74 women who met with the study criteria at day one. The suture group included 33 and the nonsutured group 41. The final number of participating women at 10 days was 73 (33 sutured and 40 not) and at 6 weeks was 70 (33 sutured and 37 not). The sutured group of women uniformly received continuous suture to the posterior vaginal wall, intermittent sutures to the muscle layer and continuous subcutaneous sutures to the perineal skin.

Results of the study demonstrated no significant differences between suturing and nonsuturing in relation to pain at any point in time during the evaluations. The results of the healing process were demonstrated in the REEDA score with better approximation at days 1 and 10, and at week 6 for the sutured group. There was noted to be a significantly higher proportion of women with a closed tear, at 6 weeks in the sutured group (P = 0.001), indicating better healing in association with suturing. Finally, at 10 days and 6 weeks, the study showed no significant difference regarding depression for either group.

A strength of this study is the fact that the women were randomly assigned for sutured versus nonsutured lacerations using sealed envelopes. The results were found to be relevant to midwifery care and decision-making. The sample size was small. The authors noted that in spite of the small size of their study that there was positive findings regarding healing and pain in unsutured perineal lacerations. As opposed to the Lundquist et al article, participant choice was not discussed. The authors did note that qualitative research may elicit the reasons behind midwives' future decisions to suture or not (Fleming et al, 2003). For the purposes of this inquiry it is noted that, in addition to healing, it is necessary to include the topics of choice and the effects of pain to provide full scope decision making regarding perineal trauma.

Gordon, Mackrodt, Fern, Truesdale, Ayers & Grant (1998) performed a stratified, randomized controlled study using a 2 x 2 factorial design. The first trial was designed to evaluate the procedure of a two stage perineal repair leaving the skin unsutured compared to the routine three stage repair already utilized. Three stage repair includes suturing the skin either with continuous subcuticular or interrupted stitches. The study, performed at Ipswich Hospital NHS Trust, included 1780 women who delivered vaginally and had an episiotomy or first- or second-degree tear requiring suturing. Initially, in 1992, only women with spontaneous vaginal deliveries were included and starting in 1993, the trial was extended to women delivered by simple (nonrotational forceps or vacuum extraction) instrumental delivery. The trial utilized serially numbered, sealed opaque envelopes containing the assignment details, suture material, and a data sheet to be completed by the caregiver immediately after repair. Evaluation of the two groups were performed by a midwife researcher whom was blind to the assignment of two or three stage repair. The midwife evaluated perineal pain and healing on 99% of the participants, utilizing questionnaires from 24 to 48 hours and included suture removal at 10 days postpartum. A self-completed questionnaire was then completed by 93% of the participants at three months postpartum, including evaluation of perineal pain, healing, removal of sutures, resuturing and dyspareunia.

Results showed no significant difference in perineal pain at 24 to 48 hours or 10 days (P= 0.3 & 0.2, respectively). Evaluation of perineal pain at three months, however, showed a significant difference with two stage suturing resulting in decreased pain and dyspareunia (P= 0.04). Two stage suturing also provided a 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, with similar numbers of repairs noted to be breaking down (five compared to seven women). The researchers concluded that 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.

Strengths of this trial include the use of controlled randomization and the fact that the researcher's approach was scientifically based in an orderly manner. This study combined quantitative and qualitative findings to provide well rounded results based on healing and pain. The study did not describe differences in women such as ethnicity, culture or socioeconomic status, therefore, conclusions were not shared regarding these diverse issues. The women assigned to the study were all recruited from the same hospital between 1992 and 1994. This study is beneficial to midwifery care of women and provides various, valuable information regarding decision making for the care of perineal trauma.

Grant, Gordon, Mackrodat, Fern, Truesdale & Myers (2001) continued the first part of this research study which was designed to evaluate, at one year, the results of two-stage repair versus three-stage repair as stated previously. The second part of this trial, however, 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 sample of 790 of the women participating in the initial research were utilized for the second part of this study. The proportion of women, in this part of the study, who had simple instrumental delivery was higher (31% versus 17%) in order to maximize information regarding perineal repair with this type of delivery. Many of these women were repaired by a physician as a result of instrumental delivery and were, therefore, subject to an episiotomy. Questionnaires were completed by the women at approximately 400 days postpartum. Three of these women reported delivery of another infant since original trial entry.

At one year, fewer women receiving the two-stage repair reported perineal pain or a sense that the perineum felt different (P= 0.01). The specific words utilized by these women included: 'uneven', 'smaller', or 'more rigid' and the reasoning for this difference included the feeling of a 'ridge' or 'scar tissue'. No significant difference was noted in healing at one year. Polyglactin 910 provided a significant difference over chromic catgut in regards to dyspareunia (P= 0.02). Trial authors declared a decrease in long term dyspareunia, as well as, short term benefits of polyglactin 910. Polyglactin 910 use was noted to increase the need to remove suture materials postnatally in three women, however, there was a significantly decrease in need to resuture or in risk of breakdown. Trial authors noted that benefits of polyglactin and a two-stage repair outweigh the minimal risks.

These two trials provide valuable insight and information regarding the need to suture perineal skin lacerations and types of suture material utilized. The authors provided evidence that leaving the skin unsutured coincides with a decrease in pain and dyspareunia. A strength of this study is the fact that the women were again randomly assigned for sutured versus nonsutured skin lacerations using sealed envelopes. The questionnaire utilized by this study asked open-ended questions and provided valuable information in the areas of perineal wound healing, generalized pain and dyspareunia upon resumption of intercourse, long term. This article is definitely a relevant asset to my research regarding sutured versus nonsutured perineal lacerations, as well as types of suture material utilized.

Albers, Garcia, Renfrew, McCandlish, & Elbourne (1999) provided research geared toward describing the range and extent of childbirth trauma and related postnatal pain. This study focused on data collected for the HOOP trial completed in Oxford, England. The HOOP ("Hands On Or Poised") trial was originally designed to study the effects of two different methods of managing the perineum in the second stage of labor. The trial compared when to leave "hands on" or "hands poised" as the infant's head crowned and delivered. Data was obtained from a large randomized clinical trial of perineal management techniques. These techniques include episiotomy, lacerations, suturing and nonsuturing of first and second degree lacerations. Lacerations were found in the form of first-, second-, third- and fourth-degree, with third- and fourth-degree lacerations commonly occurring post-episiotomy. Nonsutured lacerations included first- or second-degree perineal lacerations, exterior vaginal, sulcus and labial tears. Data collected included 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.

Eight-five percent of the 5471 women eligible for the study were noted to experience some form of perineal trauma. Eligibility for this study consisted of the following parameters: singleton gestation, cephalic presentation, no episiotomy prescribed prior to labor and expected normal birth. Two-thirds of the women encountered first- or second-degree lacerations and one-half experienced external vaginal trauma. The use of episiotomy resulted more commonly in third- and fourth-degree lacerations. Responses by maternal participants included 98.3 % at 2 days, 97.2% at 10 days, when mothers reported pain "in or around the perineum in the last 24 hours, and 91.5% at 3 months, when they reported pain 'in or around the perineum in the last week' . While approximation and healing were not observed, women routinely reported decreased discomfort with reduced degree of trauma, episiotomy with extension being the most traumatic and intact perineum the least traumatic. Pain levels were elevated on day 2 and, expectedly, declined over time. Sutured trauma had increased reports of discomfort as opposed to nonsutured trauma. Notably, primiparous women reported increased discomfort more frequently than multiparous women.

A noted strength is that this trial provided effective information regarding episiotomies and the risk of extension that accompany them. It also supplied valuable information regarding the effects of laceration degree and repair on pain level. The conclusions found by the authors regarding pain were beneficial and should be combined with healing and choice for future research. While personal choice was not discussed in this trial, it is noted that the authors were concerned with the welfare of women and accuracy in their research. The authors noted a statistical significance indicated in the area of perineal pain. This trial would have found greater benefit if they would have observed for approximation and wound healing as part of its evaluation. This article is noted as an asset to my research regarding sutured versus nonsutured perineal lacerations, as well as the effects of episiotomy on wound extension and pain level.
Kettle, Hills, Jones, Darby, Gray, & Johanson (2002) provided a trial to evaluate level of pain and healing with continuous versus interrupted suturing for perineal repair, following spontaneous vaginal birth. A randomized controlled trial, at a UK district general hospital, compared standard versus rapidly absorbed suture material. Antenatally, 1543 eligible women were randomly assigned to the interrupted or continuous method of suturing, and to the standard or rapidly absorbed polyglactin suture material. These women all experienced spontaneous vaginal deliveries with an episiotomy or a second-degree perineal laceration. Midwives performed the study, randomly assigned methods and evaluated level of pain, with the mother, at 2 and 10 days and dyspareunia, via a mailed questionnaire, at 3 and 12 months. The questionnaire utilized was from the previous HOOP trial and was supplemented with open-ended questions and peer reviewed by other researchers for content validity.

A significant difference in pain at 2 and 10 days was observed with use of continuous suturing (P< 0.0001). Types of suture material, however, provided no significant difference in level of postpartum perineal pain at day 10 (P= 0.10). Suture removal was required more frequently with the interrupted method of suturing and with the utilization of the standard suture material (P< 0.0001). 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 (P< 0.0001).

A strength of this trial is that the authors provided effective information regarding suturing methods and suture material types, including advantages and disadvantages. They also supplied valuable information regarding the effects of repair with sutures on healing, pain and dyspareunia. While personal choice was not discussed in this trial, it is noted that the authors were concerned with the welfare of women. The authors demonstrated a statistical significance indicated in the area of perineal approximation, healing and dyspareunia. This trial was noted to be beneficial to my research regarding sutured lacerations due to the fact that it included comparisons of techniques and types of suture material utilized.

Upton, Roberts, Ryan, Faulkner, Reynolds & Raynes-Greenow (2002) provided research regarding the comparison of polyglycolic suture material versus chromic catgut in regards to perineal pain, dyspareunia and the necessity to remove suture material. This randomized controlled study was performed in Sydney, Australia on 391 women, post spontaneous vaginal delivery. Eligibility included single pregnancy greater than or equal to 34 weeks gestation with an episiotomy or first- or second-degree perineal laceration. Perineal pain was evaluated at day 3, while pain, dyspareunia and required suture removal were evaluated at 6 months. Authors found that the use of polyglycolic suture material yielded significantly decreased pain at 3 days postpartum, however, there was an incidence of increased pain, dyspareunia and suture removal at the 6 month evaluation. This trial did not evaluate wound approximation or healing at any interval. In contrast to other studies, the authors determined that chromic catgut, while inflammatory in the first several days, maintained decreased long-term disadvantages due to its rapid absorption rate.

The trial provided valuable information regarding suture material types and noted that the results were expected and similar to those in a Cochrane Systematic Review. It also supplied valuable information regarding the effects of suture type on pain, dyspareunia and the need to remove suture material. A strength of this study included random assignment and evaluation. This study was performed in an orderly manner with results that are relevant to midwifery care and decision-making. This trial was noted to be beneficial to my research regarding sutured lacerations due to the fact that it included comparisons of different types of suture material utilized.

Sleep, Grant, Garcia, Elbourne, Spencer & Chalmers (1984) performed the West Berkshire perineal management trial. This randomized controlled trial provided a comparison of restricting episiotomy use to those mothers whose infants demonstrated fetal distress versus liberally utilizing episiotomy to prevent perineal lacerations. Eligible women included pregnancies with a single vertex fetus of at least 37 weeks gestation and an anticipated spontaneous vaginal delivery nearing the end of second stage labor. Entry into the trial often occurred moments prior to delivery as a result of waiting for certainty of a spontaneous vaginal delivery. Evaluation of outcome measures included severe maternal trauma, maternal pain at 10 days postpartum, neonatal outcome- apgars greater than 7 at one minute, and perineal discomfort and resumption of intercourse at 3 months postpartum.

Results indicated a 10% rate of episiotomy in the restrictive group and a 51% rate in the liberal group, including various numbers of primiparas and multiparas. Moderate to severe maternal trauma was not statistically significant, a result less frequent than the authors anticipated. Women requiring suturing significantly fell into the liberal suturing group (P< 0.01). The utilization of more than 100 suture packets and 13 more hours of time was required for the liberal group (P< 0.01 for both). Evalutation of neonatal outcome and apgar scores provided no significant difference. Evaluation of perineal pain provided no significant difference between groups. Resumption of sexual intercourse was statistically significant with the restrictive group at a higher percent than the liberal group (<0.01). The authors note that 90% of the participants had resumed intercourse by 3 months postpartum, with an increased number of women in the liberal group experiencing dyspareunia. The authors conclude that restrictive use of episiotomy provided no indications of significant increase or decrease in problems experienced by mothers 3 months postpartally. They do note, however, that there is sufficient research to believe that spontaneous perineal lacerations pose a decrease in perineal healing and pain.

This trial's strength is that the authors provided helpful information regarding routine use of episiotomy as opposed to spontaneous lacerations, including advantages and disadvantages. They also supplied valuable information regarding the effects of episiotomy on healing, pain and dyspareunia. The results were found to be relevant to midwifery care and decision-making regarding perineal trauma. This trial was noted to be beneficial to my research regarding managing the perineum with restrictive versus liberal use of routine episiotomy and resultant perineal healing and pain experience. The trial is beneficial to this inquiry due to the fact that it demonstrates increased pain, third- and fourth-degree laceration extensions and morbidity related to routine use of episiotomy.

Head (1993) performed a retrospective pilot study designed to evaluate whether is it preferable to leave first and second degree tears to heal naturally unsutured or to suture them. The study included 75 multiparous women who had sutures at least once previously after a birth. Of the 75 questionnaires distributed, 62 were returned for and 83% response rate. Seven women had no tears to the perineum and so were excluded from the study, leaving 55 women, representing a total of 155 births (Head, 1993). The aim of this small study was to compare observable trauma and healing, and included a self report of pain with a questionnaire. The questionnaire was directed toward questions regarding pain, infection, tear versus episiotomy, resumption of intercourse.

Of the respondents, 92% denied suffering perineal infection. The author noted that those more likely to have infection had previous episiotomy with suturing. The topic of pain provided a result of 34.5% of the women who made comments regarding pain associated with an episiotomy. The strength of this study is in its attempt to use evidence-based research to draw conclusions. The major weakness is that the study was very small, had no randomization or control group. The authors did not define methods used to evaluate their outcomes other than in percentages. According to the author, this small study showed satisfactory outcomes regarding leaving tears unsutured, which include no problem with healing, decreased pain levels, and earlier resumption of intercourse. The author identified a need to expand upon this study and to research the long-term effects of not suturing perineal trauma. This study provided valuable information and ideas for future research in the area of perineal trauma, healing and pain.

Rogerson, Mason & Roberts (2000) provide preliminary research utilizing Indermil tissue adhesive for episiotomies and second-degree perineal lacerations. Twenty women, 19 primigravida and 1 multigravida, from the United Kingdom, were entered into this trial over a 5 month time frame. Each eligible woman delivered her infant via a spontaneous vaginal delivery and was entered into the trial at time of delivery. Dr. Rogerson was then notified and subsequently performed the perineal repair with the first two layers sutured using vicryl suture material. The vaginal mucosa was closed using a continuous suture, the deep muscle layer approximated with interrupted sutures and, finally, the Indermal adhesive application. The study evaluated ease of use relating to the tissue adhesive including the time frame used to perform the repair. Women were assessed upon discharge from the hospital and telephoned at least twice in regards to problems identified upon application of the adhesive and evaluated again in a minimum of 2 months postpartum.

Results included 10 spontaneous vertex deliveries, six ventouse (vacuum) deliveries, three mid-cavity forceps deliveries and one rotational forceps delivery (Rogerson et al, 2000). Application of the tissue adhesive was successful in all 20 participants with none requiring suturing of skin due to unsuccessful fusion of adhesive. A dry perineum was noted to enhance the adhesive's ability to adhere. The authors felt that perineal pain was minimal with the use of adhesive to approximate the layer of skin, unfortunately they had no control group with which to make their comparisons. A burning sensation was perceived by three of the trial participants, only at the time of application of the adhesive. Evaluation at discharge found 18 of the repairs intact and healing, one repair broken down with no resultant need for intervention and one repair lost the 'glue scab' in the tub on the second postpartum day and again did not require further intervention. Evaluation at 2 months demonstrated 11 women stating no problems with healing or pain, two women were unable to be located, two complained of sharp edges on the adhesive, two noted small areas were skin was not completely approximated and one required the use of silver nitrate at 6 weeks which resulted in no further problem. The authors made a point of stating that the two women who had problems prior to discharge resulted in complete perineal healing by 5 weeks postpartum. Dyspareunia was noted by one participant, 14 of the participants had demonstrated pain free intercourse and three women had not yet tried intercourse. The author concludes that the use of tissue adhesive promises to have the benefits of safety and effectiveness in potential future use for skin closure of episiotomies and perineal lacerations.

This trial provided interesting and new information regarding use of tissue adhesive as an alternate means of skin closure after perineal lacerations and episiotomy. It also supplied valuable information regarding the effects of tissue adhesive on healing, pain and dyspareunia. A strength of this study was the fact that the women were assigned and evaluated by the same researcher. A noted weakness was the lack of a control group for comparison. It would have been more advantageous if this trial would have been expanded to provide more participants and included more variables, such as comparing the use of adhesive to suturing or nonsuturing of perineal trauma. This trial, however, was noted to be beneficial to my research regarding managing the perineum with a potential alternative to suturing in the event that nonsuturing is deemed unfavorable. The trial is beneficial to this inquiry due to the fact that it demonstrates decreased pain and dyspareunia and increased wound approximation and healing.

This literature review was designed to examine and evaluate previously documented trials and relate the various findings to this present course of inquiry. A review of the literature supports nonsuturing of perineal lacerations in regards to decreased pain, dyspareunia and suture removal, and supports suturing in relation to wound approximation and healing. The literature supports the use of rapidly absorbable suture material and the use of continuous versus interrupted suturing technique when suturing is deemed necessary. Little research has been established regarding maternal choice or the possible utilization of a tissue adhesive in repairing lacerations of mucous membranes. The results of the few research articles obtained for this inquiry would indicate that further investigation in both of these areas would be beneficial for midwives, in the effort provide the best care possible to women.

Conceptual Framework

Theories and conceptual models are the primary mechanisms by which researchers organize findings into a broader conceptual context (Polit et al, 2001). Generally, a theory refers to an abstract idea that attempts to describe the relationship of various phenomena. A conceptual model deals with abstracts (concepts that are assembled because of their relevance to a common theme (Polit et al, 2001). Understanding the conceptual framework behind an inquiry is invaluable because it identifies basic assumptions about relationships among various concepts within the inquiry (Polit et al, 2001). Ultimately, a well designed conceptual framework is essential to guiding researchers in a direction of relevance to their intended inquiry.

The conceptual framework utilized to guide this inquiry is based on the Midwifery Model of Care. This model of care is based on the theory that pregnancy and birth are normal life processes and includes the following components (CFM, 2003 ): 1) monitoring of the physical, psychological, and social well-being of the mother throughout the childbearing cycle; 2) providing the mother with individualized education, counseling, and prenatal care; 3) continuous hands-on assistance during labor and delivery, and 4) postpartum support. It also supports minimizing the use of technological interventions, along with identifying and referring women who require obstetrical attention. This model, together with the physiology of wound healing, discussed later in this chapter, provides a relevant framework because it models the care practices consistent of midwives. In contrast to medicine, the midwife's education, training, knowledge, skills and role focus on protecting, supporting and enhancing normal childbearing and family formation (Rooks, 1997). Normal processes, in the case of perineal lacerations, would include the body's ability to heal itself spontaneously.

As midwives, we work toward the ultimate goal of providing support rather than intervention to encourage the natural healing processes of the human body. Individual beliefs can tend to bias the care providers' methods of practice. When a provider has always sutured the skin on an episiotomy or laceration, there is a tendency toward continuing in that direction. Many times the reasoning behind this method of practice is that it has 'always been done that way' and 'it is what I am used to' or 'it is what I was taught'. Evidence based practice allows midwives and their colleagues to find the best information upon which to answer questions, appraise findings, and apply or not apply available research findings to clinical practice (Paine, 2001). We should consider it our obligation to dispel potential incorrect practices by providing evidence based inquiries to test the effectiveness and reliability of proposed care methods, such as suturing versus nonsuturing of perineal trauma, the methods of suturing we utilize and the type of suture or possibly adhesive which provide the most effective management of wound healing and pain management. We can uphold our responsibility toward the application of the midwifery model of care, not only to our own clients, but also to women and professionals around the globe who share in our commitment to improve the health and welfare of all populations (Paine, 2001).

The concept of physiology is also utilized in this conceptual framework.The body provides multiple avenues in which it will support reapproximation and healing of tissue trauma. Tortora & Grabowski (2000) provide a description of the body's natural response to epidermal wound healing, which starts immediately post trauma.

Wound approximation occurs within the first 24 to 48 hours of injury and the entire healing process can take weeks. This description of wound healing and reapproximation on the cellular level gives valuable insight to the fact that the body will naturally heal itself and fill in gaps between epidermal edges. For this inquiry, the observation of healing of the perineum will be accomplished with the REEDA scale (see appendices) described by previous authors from the literature review. The REEDA scale is based on a four-point score (0-3) that measures five components associated with the healing process (Davidson, 1974). It is based on assessment of redness, oedema, ecchymosis, discharge and approximation of the wound (Davidson, 1974).

Pain is another physiologic process that accompanies healing. Pain that arises from the stimulation of receptors in the skin is call superficial somatic pain (Tortora et al, 2000). Tortora et al, (2000) contends that pain is indispensable for survival. From a medical standpoint, the subjective description and indication of the location of pain may help pinpoint the underlying cause (Tortora et al, 2000).

Cellular wound healing coupled with the REEDA scale for observation of wound healing and the evidence that healing involves pain provides the physiological conceptual framework for this particular inquiry.

Conceptual Map

Perineal trauma +/- Suturing +/- Nonsuturing +/- Maternal choice --> Perineal healing +/- Perineal pain

This inquiry is designed to identify the interventions of suturing versus nonsuturing of perineal trauma and maternal choices that will either increase or decrease the risk for perineal healing and subsequent perineal pain. The goal is to identify which methods of repair and midwifery choices provide women with the best chance of having increased perineal wound healing and decreased perineal pain. As interventions demonstrate a positive or negative outcome, they will be identified and utilized accordingly. The ultimate goal of this inquiry is to provide women with the best evidence based alternatives to meet their perineal care needs.

Perineal trauma includes invasive procedures such as episiotomies and infiltration of perineum with anesthetic, puncturing of the perineal tissue with a suture needle, as well as spontaneous perineal lacerations. An episiotomy is a surgical incision of the perineal body (Varney, 2002). This involves cutting of the epidermis, vaginal mucosa, fourchette and varying degrees of muscle depending on whether a midline or mediolateral incision is completed. This is considered an invasive procedure and historically yields an increase in perineal healing time and associated discomfort. Perineal lacerations are traumatic occurrences which interrupt the integrity of the epidermis and underlying tissues. Perineal lacerations are described in degrees (Varney, 2002). First degree lacerations include perineal skin, vaginal mucosa, and posterior fourchette. Second degree lacerations include the same tissues as first degree plus perineal muscles. Third degree lacerations include the same tissues as second degree plus the external anal sphincter. Finally, fourth degree lacerations include all of the tissue types listed above and extends into the rectal mucosa.

Many care providers suture lacerations in an effort to establish approximation and healing. Suturing of perineal trauma includes many different techniques and suture materials. The techniques include a continuous blanket stitch, most commonly used on the vaginal mucosa and subcutaneous layer. The interrupted stitch is a stitch that is cut after each bite of tissue is obtained and tied off and is utilized to approximate the muscle layers of the perineum. Lastly, a continuous subcuticular stitch is most often utilized to close the epidermal layer of tissue. Suturing is considered to add further invasive trauma to the already lacerated perineum. Perineal lacerations occur in many different degrees, lengths and shapes along the perineum. They may occur midline to the anus or be in a right or left mediolateral positions with edges may be jagged and irregular. Care providers need to be creative in managing these various alterations of perineal lacerations and providing the woman with the best options available to her individually. The goal is to avoid as much trauma as possible in order to accommodate healing and decrease the rate of discomfort.

Maternal choice is a factor that should be respected, even in judgements regarding perineal repairs (this is not often offered as a choice to women). Circumstances under which the provider could encourage choice as the primary deciding factor in management include adequate wound approximation, absence of swelling, bleeding or signs of infection. Women can be given an opportunity to choose suturing or not, when the laceration permits a choice (Lundquist et al, 2000). The goal of maternal choice is to provide the patient with enough educational information and instruction to be able to make an informed decision regarding her own care. Midwives tend to focus on the normal processes of the body and are able to provide teaching and support that will facilitate the maintenance of these processes.

Perineal discomfort or pain is another tool that will be utilized as an outcome measure for this inquiry. Pain in and around the perineum is a direct result of perineal trauma. The pain associated with perineal tissue injury can impair physical functioning (bowel and urinary function, and mobility) and overshadow other important tasks (breastfeeding, infant care, and other household responsibilities) in the days and weeks following birth (Albers et al, 1996). The fact that pain and discomfort can interfere with a new mother's activities of daily living, provides motivation to inquire regarding factors that will lead to their effective decrease in postpartum women. Pain is a phenomenon that coincides with the healing process due to nerve fibers that have been injured. Perineal lacerations are not exempt from this process. As structures are traumatized and begin their healing process, the body provides the sensation of pain to help identify location, and type of injury, as well as any potential infection that may be trying to establish itself. Pain is a beneficial identifier of the healing process but one that should be reduced as often as possible through techniques that decrease further injury. This inquiry will review and compare the known effects of suturing versus nonsuturing of perineal lacerations on selected maternal outcomes and provide an evidence-based clinical practice guideline based on those results.

Chapter 3: Evidence-based Clinical Practice Guideline

The problem addressed by the EB-CPG (the clinical issue addressed)
Perineal lacerations are a common occurrence during the second stage of a spontaneous vaginal delivery. Approximately 75 percent of all women who give birth vaginally will have lacerations of various levels of severity in the labia, vagina, and perineum (Lundquist et al, 2000). Management of perineal lacerations has drawn a tremendous amount of attention and controversy among health care providers. This inquiry was developed to review and compare the known effects of suturing versus nonsuturing of perineal lacerations on selected maternal outcomes and provide an evidence-based clinical practice guideline based on those results.

Method of development

Process used

Literature searches were conducted using the following topics: perineal, perineum, perineal trauma, perineal lacerations, suturing and suture types, perineal pain, perineal healing, episiotomy and genital tract trauma. Searches involved various electronic resources, including the ACNM, Cochrane Database, Medline, CINAHL, Pubmed, MIDIRS and FirstSearch, as well as, personal journal resources, bibliography reviews, and midwifery texts. The hospital learning resource center was then utilized to obtain copies of the full text research articles as the various abstracts were deemed appropriate to the inquiry. A wide range of interrelated topics were examined to provide opportunities for focused questions and development of an evidence-based clinical practice guideline regarding suturing versus nonsuturing of perineal lacerations.

Evidence considered

Evidence Table for Grading Research
Study
authors
Grade of Evidence
A=true
experiment
B= quasi-
experiment
C= correlation
D= description
Study design

Randomized- and descriptionResearch procedureMeasures used & their reliability & validityStatistics 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,
2003
A




























A
Randomized- controlled



























Parallel group randomized- controlled
80 term primiparas with minor perineal lacerations
40 sutured -control group
40 nonsutured
-experimental group




















Initially 1314 recruited with 74 randomized primiparas > 37 wks gestation, with single fetus being randomized.
sutured group
n 33
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
A












































A
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
2P=0.02
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
A


























B
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.
Descriptive analysis
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
A















































































B
Randomized- controlled














































































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.

Criteria established for effectiveness

In developing an EB-CPG to provide optimum decision making in the management of perineal trauma, specific criteria were extracted from the literature review and recent articles. The most important criteria is to allow the woman a choice to have her perineum sutured or left unsutured, depending on several common variables. These variables will include a first or second degree laceration that is well approximated, not bleeding or demonstrating signs of infection. Education and encouragement of thorough perineal self care will be provided to each woman. She in turn is required to state an understanding and willingness for compliance and is desiring her laceration to remain unsutured. Provision, education and encouragement of effective pain management is also a necessary criteria. Perineal lacerations are a common problem faced by a majority of women and it is imperative that, as midwives, we provide effective, thorough, evidence based management of perineal trauma. Albers (2001) describes the five steps for evidence based midwifery care:
1. Identify personal values and preferences of the woman and her family.
2. Use data from the clinical exam (history, physical examination, lab tests).
3. Obtain and evaluated evidence from research to inform decisions.
4. Full discussion with the woman and her family.
5. Reflection on physical and psychological outcomes and consequences.

Clinical perspectives represented

The literature review includes trials performed by certified nurse-midwives, nursing researchers and nurse-practitioners. Further articles included were also written and published by certified nurse-midwives and nurses. The evidence considered is interdisciplinary because the clinical perspectives included midwifery and nursing perspectives. While research by physicians was not utilized for this inquiry, this information would nonetheless be considered interdisciplinary in nature because this EB-CPG will provide direction that can be utilized by all obstetric care providers.

Population of interest/exceptions to the guideline

The population of interest would include any primiparous or multiparous, postpartum female sustaining a first or second degree laceration, periurethral or labial lacerations or a median episiotomy. This can include preterm or term gestation, spontaneous vaginal delivery, ventouse (vacuum) delivery or forceps delivery with no complications. Exceptions to the guidelines would include women who sustained third or fourth degree lacerations, a mediolateral episiotomy, continuous localized bleeding or signs of infection.

Decision support

Synthesis of evidence
Summary statement of findings

Approximately 75 percent of all women who give birth vaginally will have lacerations of various levels of severity in the labia, vagina, and perineum (Lundquist et al, 2000). Providing women with reasonable options regarding management of these lacerations is essential to providing an optimal postpartum recovery period. Suturing of perineal lacerations is an invasive procedure that must be considered judiciously prior to commencing perineal repair. When suturing is deemed necessary, methods of suturing and types of suture material must also be critically evaluated and utilized appropriately to decrease discomfort and increase healing of the perineum. A clear, concise, set of guidelines for clinical practice is necessary to ensure the healing and comfort of women sustaining perineal trauma.

Outline of EB-CPG/clinical algorithm
Evaluation/Measurement strategy and re-evaluation plan
The EB-CPG management of perineal trauma is based on the literature review and research analysis completed in this paper. There is a moderate amount of research pertaining to sutured versus nonsutured perineal lacerations, however, the research remains promising regarding providing a choice within certain criteria established for effectiveness. This is an area that would benefit from further investigation. New research regarding management of perineal trauma will be reviewed and analyzed annually and that evidence will be taken into consideration in the revision and updates for this particular EB-CPG.

References
ACNM (2003). Core competencies for basic midwifery practice. Retrieved on-line October 10, 2003 at http://www.midwife.org/prof/display.cfm?id=137.

ACNM (2002). Quality management in midwifery care. Retrieved on-line July 18, 2003 at http://www.midwife.org/prof/display.cfm?id=97.

Albers L, Garcia J, Renfrew M, McCandlish R, Elbourne D. (1999). Distribution of genital tract trauma in childbirth and related postnatal pain. Birth26(1):11–15.

Albers L, Anderson D, Cragin L, Daniels SM, Hunter C. (1996). Factors related to perineal trauma in childbirth. J Nurse Midwifery. 41(4):269-276.

Carr KC. (2000). Developing an evidence based practice protocol: Implications for midwifery practice. J Midwifery Womens Health. 45(6): 544-551.

Citizens for Midwifery (2003). Midwives model of care definition. Retrieved on-line July 29 at http://www.cfmidwifery.org/mmoc/define.asp.

Clement S, Reed B. (1999). To stitch or not to stitch? A long-term follow-up study with unsutured perineal tears. Practising Midwife. 2(4): 20-28.

Davidson N (1974). REEDA: evaluating postpartum healing. J Nurse Midwifery. 19(1): 6-9.

Fleming N. (1990). Can the suturing methods make a difference in postpartum perineal pain? J Nurse Midwifery.35: 19-25.

Fleming V, Hagen S, Niven C. (2003). Does perineal suturing make a difference? The SUNS trial. British J Obstetrics Gynecology. 110: 684-689.

Gordon B, Mackrodt C, Fern E, Truesdale A, Ayers S, Grant A. (1998). The Ipswich childbirth study: a randomized evaluation of two stage postpartum perineal repair leaving the skin unsutured. British J Obstetrics Gynaecology. 105:435-440.

Grant A, Gordon B, Mackrodat C, Fern E, Truesdale A, Myers S. (2001). The Ipswich childbirth study: one year follow up of alternative methods used in perineal repair. British J Obstetrics Gynaecology. 108:34-40.

Head M. (1993). Dropping stitches. Nursing Times. 89(33):64-65.

Kettle C, Hills R, Jones P, Darby L, Gray R, Johanson R. (2002). Continuous versus interrupted perineal repair with standard or rapidly absorbed sutures after spontaneous vaginal birth: a randomized controlled trial. The Lancet.359(9325) : 2217-23.

Lundquist M, Olsson A, Nissen E, Norman M. (2000). Is it necessary to suture all lacerations after vaginal delivery?. Birth.27:79-85.

MANA (2003). Mana core competencies for basic midwifery practice. Retrieved on-line October 10, 2003 at http://www.mana.org/manacore.html.

McCandlish R. (2001). Perineal trauma: prevention and treatment. J Midwifery Womens Health.46:396-401.

Paine L. (2001). Midwifing the science process...with confidence and humility. J Midwifery Womens Health. 46(3): 126.

Rogerson L, Mason G, Roberts A. (2000). Preliminary experience with twenty perineal repairs using indermal tissue adhesive. European JObstetrics Gynecology Reproductive Biology. 88(2): 139-142.

Sleep J, Grant A, Garcia J, Elbourne D, Spencer J, Chalmers I. (1984). The West Berkshire perineal management trial. British Medical Journal. 289: 587-590.

Upton A, Roberts C, Ryan M, Faulkner M, Reynolds M, Raynes-Greenow C. (2002). A randomized trial, conducted by midwives, of perineal repairs comparing a polyglycolic suture material and chromic catgut. Midwifery. 18(3): 223-9. Varney H. (1997). Varney’s Midwifery. 3rd ed. Sudbury.MA: Jones & Barlett.

Appendices

Appendix A: The REEDA scale (Davidson, 1974)
Points Redness Oedema Bruising Discharge Approximation
0 None None None None Closed
1 0-2.5mm bilateral <10 mm bilateral <2.5mm bilateral Serum <3mm
<5mm unilateral
2 2.5-5mm bilateral 10-20mm 2.5-10mm bilateral Sero- Skin and subq fat
5-20mm unilateral sanguinous seperate
3 > 5mm bilateral >20 mm >10mm bilateral Bloody- Skin, subq fat and
>20mm unilateral purulent fascia separate
. . . . . . .