Postpartum Perineal Repair Research Articles

Early Postpartum Perineal Repair or C-Section Suture Removal Reduces Pain Without Wound Complications [7J

ACOG.org ACOG Clinical Green Journal For Patients Store ACOG.org ACOG Clinical Green Journal For Parents Store

Lignocaine Versus Ropivacaine Infiltration for Postpartum Perineal Pain.

Background:Millions of women worldwide undergo postpartum perineal repair under local infiltration. Inadequate postpartum pain management can negatively impact a mother's physical and psychological recovery.Aims:To study and compare the analgesic effect and maternal satisfaction with lignocaine versus ropivacaine infiltration for postpartum perineal pain relief.Materials and Methods:After clearance from the Institutional Ethics Committee, a double-blind prospective randomized study carried out on 100 parturients of aged 18–40 years who had spontaneous vaginal delivery, comparing 1% lignocaine and 0.75% ropivacaine infiltration for the repair of selective episiotomy or perineal injury. Time of the first analgesic (TFA) demand, maternal satisfaction at 24 h, and visual analog scale (VAS) pain score were studied.Statistical Analysis:Chi-square test and Student's t-test were used and P < 0.05 was considered as significant.Results:VAS pain score was significantly lower at 2 and 4 h in ropivacaine group versus lignocaine group (P < 0.0001). Significantly, longer TFA (10.2 ± 1.54 vs. 2.20 ± 0.44 h, P < 0.0001) and higher percentage of maternal satisfaction (86% vs. 44%) were observed in ropivacaine as compared to lignocaine group (P < 0.0001).Conclusions:Prolonged analgesia and higher rate of maternal satisfaction were found when ropivacaine infiltration was used for perineal repair as compared to lignocaine.

Effectiveness of nitrous oxide for postpartum perineal repair: a randomised controlled trial

ObjectiveTo compare the effectiveness of self-administered 50% nitrous oxide and conventional infiltrative anaesthesia with 1% prilocaine hydrochloride in postpartum perineal repair. Study designA total of 100 women were prospectively enrolled and randomised to receive either infiltrative anaesthesia or a self-administered nitrous oxide mixture (Livopan©) for pain relief during postpartum perineal suturing. Besides data concerning anaesthesia, characteristics of patients and labour were documented for statistical analysis. Pain experienced during perineal repair was assessed using the short form of the McGill Pain Questionnaire (SF-MPQ). ResultsForty-eight women received nitrous oxide and 52 underwent perineal suturing after infiltrative anaesthesia. There were no statistically significant differences regarding maternal age, body mass index (BMI), duration of pregnancy and suturing time between the groups. The most frequent birth injury was second-degree perineal laceration in the study group [22/48; 46%] and episiotomy in the control group [18/52; 35%]. Pain experienced during genital tract suturing and patients’ satisfaction showed no statistically significant differences between the groups. Thirty-seven women in the study group and 47 in the control group were satisfied with the anaesthesia during perineal repair and would recommend it to other parturients [37/48, 77% vs. 47/52, 90%; p=0.0699). ConclusionNitrous oxide self-administration during genital tract suturing after vaginal childbirth is a satisfactory and effective alternative to infiltrative anaesthesia.

Continuous versus Interrupted Techniques for Repair of Mediolateral Episiotomy: A Prospective 6 Months Follow-Up Study

Continuous versus Interrupted Techniques for Repair of Mediolateral Episiotomy: A Prospective 6 Months Follow-Up Study To compare the continuous suture technique of postpartum perineal repair of mediolateral episiotomies with the interrupted method after spontaneous vaginal birth in nulliparous women.

Postpartum Perineal Repair Performed by Midwives: A Randomized Trial Comparing Two Suture Techniques Leaving the Skin Unsutured

More than 4 in 5 primiparous women sustain injury to the labia, vagina, or perineum in the course of vaginal delivery. Apart from impairing sexual function, the pain caused by perineal trauma may impede daily activities such as sitting, walking, and lifting the infant. This randomized, double-blind study compared a continuous suture technique in which a loose, continuous nonlocking suture is used to close the vaginal mucosa, the muscular layer of the perineum, and the perineal skin, with interrupted stitches and “hidden” inverted knots tied in the depth of the injury, leaving no suture material visible at the skin surface. Participants were 395 healthy primiparous women who delivered vaginally at term. Midwives performed all the repairs and research midwives evaluated healing 24–48 hours, 10 days, and 6 months postpartum. Pain was estimated using a visual analogue scale and the McGill Pain Questionnaire. Wound healing was graded using the REEDA scale and by assessing gaping wounds larger than 0.5 cm. Intention-to-treat analyses were carried out. The 2 treatment groups were demographically similar at entry to the trial, had similar perineal injuries, and were managed in the same way. There were no differences in perineal pain 10 days after delivery or in wound healing, dyspareunia, or the need for resuturing. Patients in the 2 groups were similarly satisfied with the outcome 6 months after delivery. The continuous suture technique was significantly faster than using interrupted sutures (15 versus 17 minutes) and utilized less suture material (1 versus 2 packets). This study demonstrated that the use of interrupted and inverted stitches is an effective means of repairing second-degree perineal lacerations and episiotomies. The continuous suture technique is, however, more cost-effective.

Postpartum perineal repair performed by midwives: a randomised trial comparing two suture techniques leaving the skin unsutured*

To compare a continuous suture technique with interrupted stitches using inverted knots for postpartum perineal repair of second-degree lacerations and episiotomies. A double-blind randomised controlled trial. A Danish university hospital with more than 4800 deliveries annually. A total of 400 healthy primiparous women with a vaginal delivery at term. METHOD Randomisation was computer-controlled. Structured interviews and systematic assessment of perineal healing were performed by research midwives blinded to treatment allocation at 24-48 hours, 10 days and 6 months postpartum. Pain was evaluated using a visual analogue scale and the McGill Pain Questionnaire. Wound healing was evaluated using the REEDA scale and by assessment of gaping wounds >0.5 cm. Analysis complied with the intention-to-treat principle. The primary outcome was perineal pain 10 days after delivery. Secondary outcomes were wound healing, patient satisfaction, dyspareunia, need for resuturing, time elapsed during repair and amount of suture material used. A total of 400 women were randomised; 5 women withdrew their consent, leaving 395 for follow up. The follow-up rate was 98% for all assessments after delivery. No difference was seen in perineal pain 10 days after delivery. No difference was seen in wound healing, patient satisfaction, dyspareunia or need for resuturing. The continuous suture technique was significantly faster (15 versus 17 minutes, P = 0.03) and less suture material was used (one versus two packets, P < 0.01). Interrupted, inverted stitches for perineal repair leaving the skin unsutured appear to be equivalent to the continuous suture technique in relation to perineal pain, wound healing, patient satisfaction, dyspareunia and need for resuturing. The continuous technique, however, is faster and requires less suture material, thus leaving it the more cost-effective of the two techniques evaluated.

Postpartum perineal pain in primiparous women: a comparison of two local anaesthetic agents

Episiotomy is the commonest obstetric surgical operation performed to increase the introitus to enhance vaginal delivery. This study was to compare the effect of two local anaesthetic agents on postpartum perineal pain and time for demand for oral analgesics. A randomized double-blinded controlled clinical trial was conducted in primiparous women who had spontaneous vaginal delivery, comparing 1% plain lidocaine and 0.25% plain bupivacaine infiltration for the repair of selective episiotomy or perineal injury. The two groups were comparable in sociodemographic characteristics. At 2 and 4 hours, women who had perineorraphy under lidocaine had significantly higher pain scores on the Visual Analogue Scale (VAS) than those who had the repair under bupivacaine, (4.0 v. 2.0)and(6.0 v. 3.0)respectively. At the 6h hour, the mean pain score for the bupivacaine group was 4.0 on the VAS while the lidocaine group had already received a dose of oral analgesic (Ibuprofen 400 mg) following severe pain from the repair. There was however no statistically significant difference in the pain score on the VAS between the two groups at the time of request for oral analgesics. The mean time lapse before demand for oral analgesics for the lidocaine group was 2.25 +/- 0.46 hrs (Mean+Standard deviation) while that for the bupivacaine group was 7.13 1.56 hrs (Mean Standard deviation). The P value was P < 0.0000 (Student's t-test) and statistically significant. It is concluded that the patients in the bupivacaine group had a prolonged analgesia and needed fewer doses of oral analgesics in the immediate postpartum perineal repair period.

A multicentre evaluation of the two-layered repair of postpartum perineal trauma

We set out to compare a policy of two-layered postpartum perineal repair leaving the skin unsutured with a policy of three-layered repair, which involved skin closure. Parturients who sustained a second-degree tear or an episiotomy in four Nigerian centers were randomised to have either a two-layered repair (417 women) or a three-layered repair (406 women). Fewer women in the two-layered group reported perineal pain at 48 hours (57% vs. 65%, relative risk [RR] 0.87, 95% confidence interval [CI] 0.78-0.97) and 14 days postpartum (22% vs. 28%, RR 0.77, CI 0.61-0.98). The two-layered repair was also associated with reduced risk of suture removal (6% vs. 10%, RR 0.62, CI 0.39-0.99), and less superficial dyspareunia at 3 months (6% vs. 12%, RR 0.52, CI 0.33-0.81). The rates of wound healing were similar between the two groups. Leaving the skin unsutured during postpartum perineal repair reduces perineal pain and dyspareunia.

How cost-effective is it to leave perineal skin unsutured?

This paper describes a cost-effectiveness evaluation based on a randomized controlled trial comparing two policies for surgical repair of perineal trauma. Data were collected for 1780 women who were randomly allocated to either a two-stage postpartum perineal repair policy leaving the skin unsutured (n=890) or a three-stage postpartum perineal repair policy that required suturing of the skin (n=890). The two-stage postpartum perineal repair policy was found to reduce the risk of adverse outcomes at 10days and at 3months, without leading to a significant increase in health-care costs. A widespread adoption of a two-stage postpartum perineal repair policy leaving the skin unsutured following perineal trauma is likely to represent a cost-effective use of health-care resources.

The Ipswich childbirth study: one year follow up of alternative methods used in perineal repair

Objective To assess the long term implications of four alternative approaches to postpartum perineal repair. Design A stratified randomised controlled trial using a 2x2 factorial design. Setting Original recruitment at the Maternity Unit at Ipswich Hospital NHS Trust, a district general hospital, between 1992 and 1994. Sample Seven hundred and ninety three women who had participated in the Ipswich Childbirth Study – a trial among women who had required repair of episiotomy or first or second degree tears – at least one year previously. Methods Self-completed postal follow up at least one year after recruitment to trial comparing 1. two-stage repair leaving the skin unsutured with standard three-stage repair, and 2. polyglactin 910 with chromic catgut as suture material for the repair. Main outcome measures Failure to resume pain-free intercourse; persistent perineal pain; perineum feeling different; resuturing; time to resume pain-free intercourse; and dyspareunia. Results Fewer women allocated two-stage repair reported that the perineum felt different (30% versus 40%; RR 0.75; 95% CI 0.61 to 0.91; 2 P<0.01); otherwise there were no clear differences between the two methods. Women allocated polyglactin 910 were less likely to have dyspareunia (8% versus 13%; RR 0.59, 95% CI 0.39 to 0.91; 2 P= 0.02) and less likely to fail to resume pain-free intercourse (8% versus 14%; RR 0.57, 95% CI 0.38 to 0.87; 2 P<0.01). Conclusion Two-stage repair of perineal trauma leaving the skin unsutured appears to reduce the likelihood of the perineum feeling different from before delivery, in addition to less pain and dyspareunia initially; there were no apparent disadvantages. Polyglactin 910 reduces dyspareunia long term, indicating that the short term benefits of this material over chromic catgut persist.

The Ipswich Childbirth Study

Objective To evaluate a policy of two stage postpartum perineal repair leaving the skin unsutured. Design A stratified randomised controlled trial using a 2 × 2 factorial design. Setting The maternity unit at Ipswich Hospital NHS Trust, a district general hospital, between 1992 and 1994. Sample 1780 women requiring surgical repair of episiotomy or first or second degree tear following a spontaneous or simple instrumental delivery. Methods A policy of two-stage perineal repair leaving skin unsutured was compared with a policy of three stage repair including skin closure with interrupted or subcuticular sutures. Both groups were assessed by a research midwife, blind to the allocation, completing questionnaires at 24 to 48 hours and 10 days postpartum, and by self-completed questionnaires at three months after birth. Main outcome measures 1. 24 to 48 hours postpartum: perineal pain; healing; 2. 10 days postpartum: perineal pain, healing and removal of sutures; 3. three months postpartum: perineal pain, removal of sutures, resuturing, dyspareunia, and failure to resume pain-free intercourse. Results Completed questionnaires were returned for 99% of women at both 24 to 48 hours and ten days and by 93% of women three months postpartum. No differences were detected in perineal pain at 24 to 48 hours (62%vs 64%; RR 0.96, 95% CI 0.90–1.03; 2P = 0.3) and 10 days (25%vs 28%; RR 0.90,95% CI 0.77–1.06; 2P = 0.2). Significantly fewer women allocated to two-stage repair reported tight stitches at ten days (14%vs 18%; RR 0.77, 95% CI 0.62–0.96, 2P = 0.02); similar numbers of repairs were judged to be breaking down (five compared with seven women). At three months postpartum fewer women allocated to the two-stage repair reported perineal pain and more had resumed pain-free intercourse. Amongst women who had resumed intercourse there was a significant difference in dyspareunia (15%vs 19%; RR 0.80, 95% CI 0.65–0.99; 2P = 0.04). Significantly fewer women in the two-stage repair group (7%vs12%; RR 0.61, 95% CI 0.45–0.83; 2P = < 0.01) reported removal of suture material. Four women in the two-stage repair group had required resuturing, compared with nine allocated to the three-stage repair. Conclusions Two-stage repair of perineal trauma leaving the skin unsutured appears to reduce pain and dyspareunia three months postpartum. There are no apparent disadvantages, in particular no evidence of an increased risk of breakdown of the repair and resuturing.

The Ipswich Childbirth Study: 1. A randomised evaluation of two stage postpartum perineal repair leaving the skin unsutured

To evaluate a policy of two stage postpartum perineal repair leaving the skin unsutured. A stratified randomised controlled trial using a 2 x 2 factorial design. The maternity unit at Ipswich Hospital NHS Trust, a district general hospital, between 1992 and 1994. 1780 women requiring surgical repair of episiotomy or first or second degree tear following a spontaneous or simple instrumental delivery. A policy of two-stage perineal repair leaving skin unsutured was compared with a policy of three stage repair including skin closure with interrupted or subcuticular sutures. Both groups were assessed by a research midwife, blind to the allocation, completing questionnaires at 24 to 48 hours and 10 days postpartum, and by self-completed questionnaires at three months after birth. 1. 24 to 48 hours postpartum: perineal pain; healing; 2. 10 days postpartum: perineal pain, healing and removal of sutures; 3. three months postpartum: perineal pain, removal of sutures, resuturing, dyspareunia, and failure to resume pain-free intercourse. Completed questionnaires were returned for 99% of women at both 24 to 48 hours and ten days and by 93% of women three months postpartum. No differences were detected in perineal pain at 24 to 48 hours (62% vs 64%; RR 0.96, 95% CI 0.90-1.03; 2P = 0.3) and 10 days (25% vs 28%; RR 0.90, 95% CI 0.77-1.06; 2P = 0.2). Significantly fewer women allocated to two-stage repair reported tight stitches at ten days (14% vs 18%; RR 0.77, 95% CI 0.62-0.96, 2P = 0.02); similar numbers of repairs were judged to be breaking down (five compared with seven women). At three months postpartum fewer women allocated to the two-stage repair reported perineal pain and more had resumed pain-free intercourse. Amongst women who had resumed intercourse there was a significant difference in dyspareunia (15% vs 19%; RR 0.80, 95% CI 0.65-0.99; 2P = 0.04). Significantly fewer women in the two-stage repair group (7% vs 12%; RR 0.61, 95% CI 0.45-0.83; 2P = < 0.01) reported removal of suture material. Four women in the two-stage repair group had required resuturing, compared with nine allocated to the three-stage repair. Two-stage repair of perineal trauma leaving the skin unsutured appears to reduce pain and dyspareunia three months postpartum. There are no apparent disadvantages, in particular no evidence of an increased risk of breakdown of the repair and resuturing.