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ORIGINAL ARTICLE
Year : 2020  |  Volume : 33  |  Issue : 2  |  Page : 392-399

Continuous versus interrupted sutures for repair of episiotomy using monofilament versus synthetic absorbable multifilament suture materials: a randomized controlled trial


Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission17-Oct-2015
Date of Decision15-Nov-2015
Date of Acceptance22-Nov-2015
Date of Web Publication27-Jun-2020

Correspondence Address:
Mohamed Abd El-Monem Mobarak
Miami, Alexandria
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_394_15

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  Abstract 

Objective
To compare different repair techniques and different suture materials for episiotomy.
Background
Care of the perineum during and after childbirth has been a topic of considerable interest to all involved for many years. A considerable amount of research has been carried out in the area of perineal care, particularly in relation to the practice of performing episiotomy and to the methods of suturing.
Patients and methods
A total of 90 primigravidae were admitted for labor and underwent a mediolateral episiotomy after vaginal delivery. They were randomly allocated into four groups in which continuous and interrupted episiotomy repair techniques were performed under two different types of suture materials, that is, monofilament type in the form of poliglecaprone 25 and multifilament type in the form of polyglactin 910. Perineal pain during different activities on the first and seventh day postpartum was questioned by visual analog scale, and the presence of perineal pain after 3 months of delivery, repair time, amount of suture material, and episiotomy complications were investigated in each group.
Results
The results of the present study showed that the assessments of pain in the first day and after 1 week in movement, repose, sitting, urination, and defecation were insignificant regarding suture techniques and suture materials. The repair time and the length of suture material were statistically less in the continuous technique groups. The type of suture material did not show significant effect on either the length of suture material used or the episiotomy repair time.
Conclusion
The use of continuous technique of episiotomy repair is better than interrupted technique, because the former is quicker and cheaper as less suture material is used with no differences on either short-term or long-term morbidity.

Keywords: continuous technique, episiotomy, interrupted technique, monofilament suture, multifilament suture


How to cite this article:
Shabana AA, Sayyed TM, El-Mallah EM, Mobarak MA. Continuous versus interrupted sutures for repair of episiotomy using monofilament versus synthetic absorbable multifilament suture materials: a randomized controlled trial. Menoufia Med J 2020;33:392-9

How to cite this URL:
Shabana AA, Sayyed TM, El-Mallah EM, Mobarak MA. Continuous versus interrupted sutures for repair of episiotomy using monofilament versus synthetic absorbable multifilament suture materials: a randomized controlled trial. Menoufia Med J [serial online] 2020 [cited 2020 Oct 24];33:392-9. Available from: http://www.mmj.eg.net/text.asp?2020/33/2/392/287798




  Introduction Top


Care of the perineum during and after childbirth has been a topic of considerable interest to all involved for many years. A considerable amount of research has been carried out in the area of perineal care, particularly in relation to the practice of performing episiotomy and to the methods of suturing[1].

Perineal pain is strongly associated with perineal trauma following normal or instrumental vaginal birth. Pain is reported to be most severe in the immediate postnatal period; however, discomfort continues for up to 2 weeks postpartum in 20–25% of women, and in 10% of women, pain continues for at least 3 months. The extent of perineal trauma is often underestimated, so too is the effect of perineal trauma on experiences of motherhood. Negative consequences include reduced mobility, urinary and fecal incontinence, and sexual dysfunction. These may lead to mental exhaustion. Negative effects can influence the mother's relationship with her baby and her family, which may cause relationship disharmony and in extreme cases complete marital breakdown[2].

Many women sustain perineal trauma during childbirth that requires surgical repair. For most, the associated pain and discomfort is temporary, but in a minority, it persists as chronic pain and discomfort. Two factors that may be linked with morbidity are the suturing technique and the choice of suturing material[3].


  Patients and Methods Top


This randomized controlled trial was conducted at the Department of Obstetrics and Gynecology, Menoufia University Hospitals, and at Dar Ismael Hospital in Alexandria, in the period from August 2013 to June 2014, after obtaining an approval by Faculty Ethical Committee for Human Research and Institutional Board revision. This study was generally in agreement with the Declaration of Helsinki. Unfortunately, registration of the study was not undertaken in an international clinical trial website.

This study included 90 pregnant women admitted for labor. They were primigravidae and underwent a mediolateral episiotomy after vaginal delivery.

The patients were chosen to participate in the study after obtaining a verbal consent. Randomization was done via random number table in a statistical textbook where allocation sequence of the trial was hidden in sequentially numbered opaque envelopes. Each envelope included single assignment to one participant. They were randomly allocated into four groups: A, B, C, and D.

The exclusion criteria

Women with assisted delivery, injury of external anal sphincter or anal canal (third degree or fourth degree tears), anemia (hemoglobin <8 g/dl), prolonged rupture of membranes more than 24 h, offensive vaginal discharge or fever, varicose veins of the perineum, multiple gestations, and presentations other than cephalic were excluded.

All the enrolled randomized women were assigned into the following episiotomy repair groups:

  1. Group A: it included 22 patients who had episiotomy repair using poliglecaprone 25 (Monocryl) as a monofilament suture in a continuous suturing manner
  2. Group B: it included 28 patients who had episiotomy repair using polyglactin 910 (Vicryl) as a multifilament suture in a continuous suturing manner
  3. Group C: it included 25 patients who had episiotomy repair using poliglecaprone 25 (Monocryl) as a monofilament suture in an interrupted suturing manner
  4. Group D: it included 15 patients who had episiotomy repair using polyglactin 910 (Vicryl) as a multifilament suture in an interrupted suturing manner.


All the patients involved in the study underwent the following:

  1. History taking, including personal history, obstetric history, menstrual history, and family history
  2. Examination included the following:


    1. General examination: vital data, height, weight, and BMI
    2. Abdominal examination: assessment of gestational age, expected fetal weight, amount of liquor, fetal lie and presentation, fetal heart rate, uterine contractions, and scar of previous operations
    3. Vaginal examination (PV): it was done to exclude factors that lead to exclusion of the patient from the study.


  3. Newborn outcome parameters: birth weight and head circumference was estimated.


At the second stage of labor, women were placed in lithotomy position, and mediolateral episiotomy was done after crowning of the fetal head and local infiltration anesthesia using up to 20 ml of 1% lidocaine.

Episiotomy repair was done using monofilament or multifilament suture material

The monofilament suture material used in the trial was poliglecaprone 25 (Monocryl), gauge 1, 1/2 circle, 40 mm round body needle for either continuous or interrupted suturing technique. On the contrary, polyglactin 910 (Vicryl), gauge 1, 1/2 circle, 45-mm round body needle was used as multifilament suture material for episiotomy repair for both techniques continuous or interrupted (Vicryl and Monocryl both ETHICON Company, Cincinnati, OHIO, USA).

Continuous suture technique

Continuous suturing technique was not tightly taken. Continuous nonlocking suture was used to close the vaginal mucosa, commencing above the apex of the wound by half cm and finishing with a knot in front of the hymenal ring. The same suture was then continued in the perineal muscles, which are sutured continuously reaching the end of the incision. The perineal skin was approximated with the same continuous suture a few millimeters under the perineal skin edges finishing with a terminal knot in the vaginal mucosa in front of the hymenal ring.

Interrupted suture technique

The interrupted technique used for episiotomy was the three-layer technique, in which the vaginal mucosa was sutured with a continuous locking stitch, commencing above the apex of the wound by half centimeters and finishing at the level of the fourchette; three or four interrupted sutures to re-approximate the deep and superficial muscles; and interrupted transcutaneous technique to close the skin.

For each patient, the time needed for suturing was estimated in minutes. The amount of suture material in centimeters used was measured by subtraction of the remains from the full length of suture strand.

At 6 h and 7 days after delivery, each patient was followed up for perineal pain in movement, repose, while sitting, while urinating, and while defecating using the visual analog scale (VAS). The patient was asked to indicate on the line where the pain is in relation to the two extremes. Using a ruler, the score is determined by measuring the distance in mm on the 10-cm line between the no pain anchor and the patient's mark, providing a range of score from 0 to 100. A higher score indicates greater pain intensity. The following cutoff points on the pain VAS have been recommended: no pain (0–4 mm), mild pain (5–44 mm), moderate pain (45–74 mm), and severe pain (75–100 mm). The VAS was taken at 6 h by direct questioning of the parturient and on day 7 by telephone conversation.

Any complications such as dehiscence of the perineal wound, need to removal of suture material, incomplete healing, and wound infection were also noted during the first 6 weeks after delivery through contact with a telephone call.

Three months after delivery, the parturient was asked for perineal pain in the last 24 h before the telephone call, if sexual intercourse had been resumed and how long after delivery, if pain was experienced at the first intercourse after delivery, and the necessity of resuturing the episiotomy at any time during the first 3 months postpartum.

Data collection was completed 3 months after parturition of the last patient included in the study.

Statistical analysis

Data were fed to the computer using IBM SPSS software package, version 20.0 (IBM, North Castle, New York, USA). Qualitative data were described using number and percent. Comparison between different groups regarding categorical variables was tested using χ2 test. Quantitative data were described using mean and SD, minimum, and maximum. For normally distributed data, comparison between more than two populations was analyzed using F-test (analysis of variance) and post-hoc test (Scheffe). Correlations between two quantitative variables were assessed using Pearson coefficient. Significance test results are quoted as two-tailed probabilities. Significance of the obtained results was judged at the 5% level.

Power analysis was also carried out assuming that the absolute VAS score difference in pain perception between groups is 0.7 at alpha = 0.05 and 80% power. Accordingly, a total sample size of 90 participants is needed.


  Results Top


A total of 90 women were enrolled in this trial, where 22, 28, 25, and 15 women were included in groups A, B, C, and D, respectively.

However, statistical analysis was carried on 85 participants because of lost to follow-up of five women.

Infected episiotomies constituted 10.6% (nine cases) of all participants.

Incomplete healing and dehiscence of the wound constituted 9.4% (eight cases) of all participants.

Nine (10.6%) cases in this study required removal of suture material.

Resuturing of the episiotomy was done in two cases.

[Table 1] shows the comparison between the studied groups according to demographic data. There was no statistical significant difference between the studied groups (A, B, C, and D) according to age, BMI, birth weight, newborn head circumference, and gestational age (P > 0.05).
Table 1: Comparison between the studied groups according to demographic data

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[Table 2] shows the comparison between the studied groups according to length of used suture and repair time. The mean length of used suture was 69.86 ± 13.82 cm in group A; in group B, it was 65.77 ± 10.64 cm; in group C, it was 91.96 ± 14.28 cm, and in group D, it was 90.86 ± 10.73 cm. On comparing the four groups, it was found that there was a statistically significant difference between group A and both groups C and D, whereas there was no significant difference between groups A and B. Moreover, there was a significant difference between group B and both groups C and D. On the contrary, group C showed no significant difference from group D.
Table 2: Comparison between the studied groups according to length of suture (cm) and repair time (min)

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Regarding repair time (min), the repair time in group A was 13.43 ± 2.11, in group B was 12.15 ± 1.70, in group C was 18.34 ± 2.50, and in group D was 18.05 ± 2.02. On comparing the four groups, it was found that there was a statistically significant difference between group A and both groups C and D, whereas there was no significant difference between groups A and B. Moreover, there was a significant difference between group B and both groups C and D. On the contrary, group C showed no significant difference from group D.

[Table 3] shows the comparison between the studied groups according to pain score within the first 24 h. Pain score during movement, repose, sitting, and urination was matched in all groups. There was no statistical significance between the studied groups according to pain within the first 24 h (P > 0.05).
Table 3: Comparison between the studied groups according to pain within the first 24 h

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[Table 4] depicts the comparison between the studied groups according to pain score after 7 days. Mild degree of pain during movement, repose, sitting, urination, and defecation was the most common pain degree finding in groups A, B, C, and D. However, most of the participants did not complain of pain after 7 days of episiotomy. There was no statistical significance between the studied groups according to pain after 7 days (P > 0.05).
Table 4: Comparison between the studied groups according to pain after 7 days

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[Table 5] shows the comparison between the studied groups according to episiotomy complications after 6 weeks. Dehiscence of the wound was seen only in groups A and D (4.8 and 7.1%, respectively). Need to removal of suture material was two (9.5%), two (7.7%), three (12.5%), and two (14.3%) in groups A, B, C, and D, respectively. Rate of incomplete healing was one (4.8%), two (7.7%), one (4.2%), and two (14.3%) in groups A, B, C, and D, respectively. Finally, wound infection rate was two (9.5%), three (11.5%), two (8.3%), and two (14.3%) in groups A, B, C, and D, respectively. There was no statistical significant difference between the studied groups according to types of complications after 6 weeks (P > 0.05).
Table 5: Comparison between the studied groups according to episiotomy complications after 6 weeks

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[Table 6] demonstrates a comparison between the studied groups according to episiotomy complications after 3 months. Pain experienced at the first intercourse after delivery was 11 (52.4%), 13 (50%), 10 (41.7%), and six (42.9%) in groups A, B, C, and D, respectively. Necessity of resuturing the episiotomy was one (4.8%), 0 (0.0%), 0 (0.0%), and one (7.1%) in groups A, B, C, and D, respectively. There was no statistically significant difference between the studied groups according to complications after 3 months (P > 0.05).
Table 6: Comparison between the studied groups according to episiotomy complications after 3 months

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[Table 7] shows the correlation between length of used suture (cm) and repair time (min) with different demographic data. There was no statistically significant correlation between age, height, weight, BMI, birth weight, newborn head circumference, and gestational age and either the length of used suture or repair time.
Table 7: Correlation between length of used suture (cm) and repair time (min) and different demographic data

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  Discussion' Top


This trial has revealed that both short-term and long-term complaints of perineal pain during movement, repose, sitting, urination, and defecation in the parturient women did not differ significantly among the studied groups, considering the technique of repair either continuous or interrupted.

This result is matched with Valenzuelaet al.[4], Perveen and Shabbir[5], and Mahomedet al.[6].

However, Kokanaliet al.[7] found a difference in short-term pain after 1 day, which was less with continuous technique than interrupted technique. This difference between our finding and their results may be owing to the use of different suture materials, which were polyglycolide-co-caprolactone as a monofilament suture and polyglactin 910-Rapide (Vicryl-Rapide) as a multifilament suture in their trial[7].

Morano et al.[8] used only one type of suture material (Vicryl-Rapide) and found a difference in short-term pain, where the pain was less with continuous than interrupted technique for their studied groups[8].

A meta-analysis of the data collected by Kettleet al.[9] on 8184 women from eight countries showed that continuous suture techniques compared with interrupted sutures for perineal closure were associated with less pain for up to 10 days postpartum. However, no significant difference in long-term pain was recorded. The trials were heterogeneous in respect of operator skill and training[9].

Regarding dyspareunia, the results showed no significant difference between continuous suture technique and interrupted suture technique among the studied groups.

This result agreed with previous studies of Valenzuelaet al.[4], Perveen and Shabbir[5], and Kettleet al.[9].

In the present study, the type of suture material used, poliglecaprone 25 (Monocryl) as a monofilament suture or polyglactin 910 (Vicryl) as a multifilament one, did not affect the pain score both at short or long term and during sexual intercourse.

The foregoing results were in agreement with those obtained under using some other types of sutures, that is, polyglactin 910 and chromic catgut[5], chromic catgut and dexon[6], polyglactin 910, and polyglactin 910-Rapide[10].

Concerning the time needed for wound suturing, the present study showed that there was a significant difference between continuous and interrupted techniques, under which continuous groups had less time for wound suturing in minutes (13.43 ± 2.11 with Monocryl and 12.15 ± 1.70 with Vicryl), whereas interrupted groups consumed more time (18.34 ± 2.50 with Monocryl and 18.05 ± 2.02 with Vicryl).

The results agreed with previous studies, including Valenzuelaet al.[4] who published their research on 445 women who had undergone vaginal deliveries episiotomies, where one group was repaired with continuous nonlocking sutures and the other group with interrupted sutures. The threads used for stitching were identical in both groups. When comparing the group with continuous sutures to the group with interrupted sutures, there was a statistically significant higher operative time in the interrupted group than the continuous group.

The results of the present study also agreed with Kokanaliet al.[7], Perveen and Shabbir[5], and Kettleet al.[9], who reported that continuous technique needed less repair time than the interrupted one.

Concerning length of suture material, the obtained results showed that there was significant difference between continuous and interrupted techniques. With continuous technique, less suture material was used. In continuous technique, the mean length was 69.86 ± 13.82 cm with Monocryl and 65.77 ± 10.64 cm with Vicryl, whereas in interrupted technique, the mean length was 91.96 ± 14.28 cm with Monocryl and 90.86 ± 10.73 cm with Vicryl.

The results agreed with previous studies, including Valenzuelaet al.[4], Kokanaliet al.[7], Perveen and Shabbir[5], and Kettleet al.[9], who reported that continuous technique needed less suture material than interrupted technique.

Concerning the type of suture material used in this study, it had no influence on either repair time or their used materials.

In the present study, the length of suture material and the repair time were evaluated with respect to birth weight and the newborn head circumference; this was not highlighted in other studies. The results indicated that both the length of suture material and the repair time were positively correlated with birth weight and the newborn head circumference, though not significant.

This trial has revealed that morbidity in the parturient women, that is, dehiscence of the wound, need to removal of suture material, incomplete healing, wound infection, and wound resuturing, did not differ significantly considering either the type of suture material or the technique of repair.

Regarding wound resuturing, our results are in harmony with Kettleet al.[9] Mahomedet al.[6], Moranoet al.[8], and Valenzuelaet al.[4], who also found no significant difference in this criteria in their trials.

Kokanaliet al.[7] and Valenzuelaet al.[4] also found no significant differences in their studies regarding the rate of suture removal, whereas Mahomedet al.[6] and Kettleet al.[9] reported the removal of suture material to be less frequent in the continuous perineal closure groups. However, Moranoet al.[8] recorded no events of suture removal in their trial.

With respect to wound infection, the results of the present study coincide with those of Kettleet al.[10] and Moranoet al.[8], who reported no significant differences in their study groups regarding wound infection. However, Kokanaliet al.[7] did not observe any episiotomy infections.

Our results are also matched with Kokanaliet al.[7], who found no significant differences between the studied groups regarding incomplete healing.

Conclusion and recommendations

The use of continuous technique of episiotomy repair is better than interrupted technique, because the former is quicker and cheaper, as less suture material is used with no differences on either short-term or long-term morbidity.

Both poliglecaprone 25 (Monocryl) and polyglactin 910 (Vicryl) have no implications on postpartum women perineal morbidity.

Therefore, all of the obstetricians and midwives should be educated well in performing continuous repair technique of episiotomy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fleming VE, Hagen S, Niven C. Does perineal suturing make a difference? The SUNS trial. BJOG 2003; 110 :684–689.  Back to cited text no. 1
    
2.
Hedayati H, Parsons J, Crowther CA. Topically applied anaesthetics for treating perineal pain after childbirth. Cochrance Database Syst Rev 2005; 2 :CD004223.  Back to cited text no. 2
    
3.
Grant A, Gordon B, Mackrodat C, Fern E, Truesdale A, Ayers S. The Ipswich childbirth study: one year follow up of alternative methods used in perineal repair. BJOG 2001; 108 :34–40.  Back to cited text no. 3
    
4.
Valenzuela P, Saiz Puente MS, Valero JL, Azorin R, Ortega R, Guijarro R. Continuous versus interrupted sutures for repair of episiotomy or second-degree perineal tears: a randomised controlled trial. BJOG 2009; 116 :436–441.  Back to cited text no. 4
    
5.
Perveen F, Shabbir T. Perineal repair: comparison of suture materials and suturing techniques. J Surg Pak 2009; 14 :23–28.  Back to cited text no. 5
    
6.
Mahomed K, Grant A, Ashurst H, James D. The Southmead perineal suture study. A randomized comparison of suture materials and suturing techniques for repair of perineal trauma. BJOG 1989; 96 :1272–1280.  Back to cited text no. 6
    
7.
Kokanali D, Ugur M, Kuntay Kokanali M, Karayalcin R, Tonguc E. Continuous versus interrupted episiotomy repair with monofilament or multifilament absorbed suture materials: a randomised controlled trial. Arch Gynecol Obstet 2011; 284 :275–280.  Back to cited text no. 7
    
8.
Morano S, Mistrangelo E, Pastorino D, Lijoi D, Costantini S, Ragni N. A randomized comparison of suturing techniques for episiotomy and laceration repair after spontaneous vaginal birth. J Minim Invasive Gynecol 2006; 13 :457–462.  Back to cited text no. 8
    
9.
Kettle C, Dowswell T, Ismail KM. Continuous versus interrupted suturing techniques for repair of episiotomy or second-degree tears. Cochrance Database Syst Rev 2012; 11 :CD000947.  Back to cited text no. 9
    
10.
Kettle C, Hills RK, Jones P, Darby L, Gray R, Johanson R. Continuous versus interrupted perineal repair with standard or rapidly absorbed sutures after spontaneous vaginal birth: a randomized controlled trial. Lancet 2002; 359 :2217–2223.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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