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Re: sutura de episiotomiaFrom: João Batista Marinho de Castro Lima (jbmclima@uol.com.br)Sun, 23 Jul 2000 16:50:27 -0300
Tem revisão sistemática sobre o assunto. Vai aí para você. João Batista Belo horizonte -MG jbmclima@uol.com.br Absorbable synthetic versus catgut suture material for perineal repair Absorbable synthetic versus catgut suture material for perineal repair Kettle C, Johanson RB A substantive amendment to this systematic review was last made on 19 May 1999. Cochrane reviews are regularly checked and updated if necessary. Background: Approximately 70% of women will experience some degree of perineal trauma following vaginal delivery and will require stitches. This may result in perineal pain and superficial dyspareunia. Objectives: The objective of this review was to assess the effects of absorbable synthetic suture material as compared with catgut on the amount of short and long term pain experienced by mothers following perineal repair. Search strategy: We searched the Cochrane Pregnancy and Childbirth Group trials register. Selection criteria: Randomised trials comparing absorbable synthetic (polyglycolic acid and polyglactin) with plain or chromic catgut suture for perineal repair in mothers after vaginal delivery. Data collection and analysis: Trial quality was assessed independently by two reviewers. Data were extracted by one reviewer and checked by the second reviewer. Main results: Eight trials were included. Compared with catgut, the polyglycolic acid and polyglactin groups were associated with less pain in first three days (odds ratio 0.62, 95% confidence interval 0.54 to 0.71). There was also less need for analgesia (odds ratio 0.63, 95% confidence interval 0.52 to 0.77) and less suture dehiscence (odds ratio 0.45, 95% confidence interval 0.29 to 0.70). There was no significant difference in long term pain (odds ratio 0.81, 95% confidence interval 0.61 to 1.08). Removal of suture material was significantly more common in the polyglycolic acid and polyglactin groups (odds ratio 2.01, 95% confidence interval 1.56 to 2.58). There was no difference in the amount of dyspareunia experienced by women. Reviewers' conclusions: Absorbable synthetic suture material (in the form of polyglycolic acid and polyglactin sutures) for perineal repair following childbirth appears to decrease women's experience of short-term pain. The length of time taken for the synthetic material to be absorbed is of concern. A trial addressing the use of polyglactin has recently been completed and this has been included in this updated review. Background The main goal of midwives and obstetricians should be to provide safe, effective and efficient women centred care. In achieving this, their practice should be based on scientific evidence rather than tradition, personal preference or simple cost considerations. Practice should focus on outcomes that are important to women. Long-term complications after perineal trauma and repair following vaginal delivery are common, however, there have been very few good quality randomised controlled trials in this area. Maybe, as Grant (Grant 1986) stated, this research is seen as 'unglamorous' and not scientific enough to attract the necessary funding required for this work to be carried out. There appears to be only a limited awareness, amongst most professionals, of the extent of postpartum morbidity experienced by women following perineal repair. The morbidity is not considered to be life threatening, however it does affect a large proportion of women in this country and indeed throughout the world. In fact 750,000 women give birth each year in the United Kingdom and it is estimated that 69% will sustain some degree of perineal perineal trauma and will require stitches (Sleep 1984). The majority of these women will have short term perineal pain and as many as 20% will continue to have long term problems such as superficial dyspareunia (Enkin 1995). The maternal morbidity associated with perineal repair can have a major impact on the woman's general health causing her much discomfort and distress. This in turn can affect the woman's ability to care for her new-born infant and other members of her family and may ultimately lead to a complete marital breakdown (Sleep 1991). The type of suturing material used for perineal repair following childbirth may have an effect on the amount of pain and superficial dyspareunia experienced by women both in the short and long term. Catgut is manufactured from collagen derived from healthy mammals and it is reported to cause an inflammatory response in the tissues due to the fact that it is broken down by proteolytic enzymes and phagocytosis (Irvin 1981). It is a very unstable and unpredictable material. Chromic catgut suture material is treated in order to slow down the digestive process and decrease the inflammatory reaction. Polyglycolic acid (Dexon) and polyglactin (Vicryl) are synthetic materials and they are both reported to cause less tissue reaction because they are absorbed by hydrolysis. However, the total absorption rate of polyglactin is reported to be considerably shorter than polyglycolic acid regardless of the gauge of material (90 versus 120 days) (Craig 1975). The aim of this review is to examine the available evidence and to determine if there is any clear scientific evidence that the type of suturing materials used does influence the amount of postpartum morbidity experienced by women following perineal repair, both in the short and long term. This systematic review includes eight randomised clinical trials and represents an update of the Cochrane Systematic Review undertaken previously (Kettle 1999). Objectives To determine the effects of absorbable synthetic (polyglycolic acid and polyglactin) versus catgut suture material on the amount of short and long term maternal morbidity experienced by women following perineal repair. The evidence collated in this review will enable purchasers, providers and consumers of health care to choose the most appropriate material for perineal repair in terms of both health gain and cost-effectiveness (Howard 1995). The main outcomes of interest are: short and long term pain; amount of analgesia used; extent of superficial dyspareunia; removal of suture material; re-suturing of wound; dehiscence. Criteria for considering studies for this review Types of studies All identified, relevant randomised controlled trials which compare polyglycolic acid or polyglactin with catgut have been included in this review. However, none of the included trials actually compared polyglactin (Vicryl) with chromic catgut or catgut suture material. The inclusion criteria is quite broad due to the small number of controlled trials available in this area, all of which have variable methodological quality. All of the trials included have been assessed according to the method of treatment allocation, randomisation, blinding of outcome assessment and handling of exclusions. Types of participants All primiparous and multiparous women who have sustained perineal trauma and require stitching following an instrumental or spontaneous vaginal delivery. Types of intervention All randomised controlled comparisons of polyglycolic acid and polyglactin versus plain catgut and chromic catgut suture material. Types of outcome measures The main focus is on outcome measures relating to short and long term postpartum morbidity. The main outcome measures include: short term pain; analgesia use; removal of suture material; resuturing; extensive dehiscence; long term pain; superficial dyspareunia. Consumer views regarding what outcomes they would expect Consumer views regarding what outcomes they would expect from this review were sought from women's local focus groups and the National Childbirth Trust's Research and Information Group. The main outcomes of interest from the consumers point of view were the extent of short and long term pain, the removal of suture material and the resumption of pain free intercourse. Search strategy for identification of studies See: Collaborative Review Group search strategy This review has drawn on the search strategy developed for the Pregnancy and Childbirth Group as a whole. Relevant trials were identified in the Group's Specialised Register of Controlled Trials. See Review Group's details for more information. Methods of the review The two reviewers (Chris Kettle and Richard Johanson) independently assessed and selected the trials for inclusion in this review. It was not possible to assess the relevance of the trials blinded because we knew the authors' names, institution, journal of publication and results, when we applied the inclusion criteria. All disagreements were resolved by discussion. The trials were assessed according to the following four main criteria: (1) adequate concealment of treatment allocation (e.g. opaque sealed numbered envelopes); (2) method of allocation to treatment (e.g. by computer randomisation, random number tables or by quasi-randomisation methods such as alternation or medical record numbers); (3) adequate documentation of how exclusions were handled after treatment allocation - to facilitate intention to treat analysis; (4) Adequate blinding of outcome assessment. Letters were used to indicate the quality of the included trials, for example A was used to indicate a trial which has a high level of quality in which all the criteria were met; B was used to indicate that one or more criteria were partially met or if it is unclear if all the criteria were met and C was used if one or more criteria were not met (Mulrow 1997). We independently assessed the methodological quality of each individual trial and collected details of method of treatment allocation, randomisation, blinding of outcome assessment, handling of exclusions and whether an intention to treat analysis was performed. If any of the above data were not available in the publication or if it was unclear if the criteria were met, it was planned that additional information would be sought from the trialists. However, no additional information was obtained. Included trial data were processed as described by Chalmers et al (Chalmers 1989). Data were entered directly from the published reports into the Review Manager software (RevMan) and the second reviewer (Richard Johanson) checked the accuracy of the entered data. Where data were not presented in a suitable format for data entry, or if data were missing, additional information was sought from the trialists by personal communication in the form of a letter or telephone call. The sub-set of data for the Mahomed and Grant trial (Mahomed 1989) was obtained by Professor Adrian Grant for the Pre-Cochrane review in 1993 and is presented in a similar format in 'Effective Care in Pregnancy and Childbirth' (Grant 1989). Missing data from the Olah (Olah 1990) trial were obtained in witting from Karl Olah indirectly via Professor Grant. Statistical analysis was undertaken using the RevMan software for calculation of the treatment effect as represented by the odds ratio, proportional and absolute risk reductions. Analysis was performed using the Peto method for odds ratio. A sensitivity analysis was performed and it was reassuring to find that the treatment effect still held when the poorer quality trials were excluded. Description of studies Included trials: Beard 1974; Livingstone 1974; Rogers 1974; Banninger 1978; Roberts 1983; Mahomed 1989; Olah 1990; Mackrodt 1998. Six of the eight trials included in this review Six of the eight trials included in this review compared polyglycolic acid (Dexon) versus chromic catgut and the same material was used throughout for all layers of the perineal repair (vagina, muscle and skin); one trial (Mackrodt 1998) compared polyglactin (Vicryl) to chromic catgut and the (Livingstone 1974), compared plain catgut to Dexon. There was considerable variation in the reviewed trials between gauge of suture material and size of needle, (see 'Characteristics of Included Studies' for details). One of the trials (Banninger 1978) compared chromic catgut gauge 0 (a heavier gauge material) to Dexon 2/0 (a much finer gauge material) in order to match tensile strength. It is possible that the heavier gauge catgut material may have contributed to the degree of pain experienced by the women in this trial group. The same suturing technique was used for both groups in each of the included trials; in five of the trials a continuous stitch was used to repair the vaginal trauma with interrupted stitches to appose the muscle layers. Four of the trials used transcutaneous, interrupted stitches to appose the perineal skin; two trials used a continuous subcuticular stitch to appose the perineal skin; one of the trials (Olah 1990) used a continuous non-locking stitch throughout the repair with a continuous subcuticular stitch to appose the skin; the Mahomed trial (Mahomed 1989) used interrupted transcutaneous and continuous subcuticular stitches to appose the skin (approximately 50/50 in each group). The women participating in the Ipswich Childbirth Study (Mackrodt 1998) were randomly assigned to either a two stage (skin left unsutured) or a three stage (skin sutured) technique of perineal repair. In the group that were assigned to have the perineal skin sutured, it was left to the midwives discretion and skill as to the method used. In fact, 72% had transcutaneous interrupted sutures and 26% had continuous subcutaneous sutures. Only one trial (Rogers 1974) did not describe which suturing technique was used. Excluded trials: Tompkins 1972; Wikoff 1992; Ketcham 1994. See Characteristics of Included and Excluded Studies. Methodological quality The methodological qualities of the eight trials included in this review were found to be inconsistent. Therefore, we decided to rate all of them as 'B' in that one or more criteria were partially met, (Mulrow 1997). Only three trials used sealed opaque envelopes for random allocation with adequate concealment of treatment allocation (Mackrodt 1998; Mahomed 1989; Rogers 1974); two trials used quasi-random allocation (Banninger 1978; Olah 1990); one trial used 'lottery cards' (Livingstone 1974) and two trials did not describe their method of 'random allocation' (Beard 1974; Roberts 1983). In five of the included trials it was not clear if treatment allocation was concealed and only the Mahomed (Mahomed 1989) and Mackrodt (Mackrodt 1998) trials demonstrated that analysis was by 'intention to treat'. In the Roberts 1983 trial, eighteen (9.5%) of the women who were entered into the trial were excluded from the analysis because they were unable to complete the study due to lost tablets or early discharge from hospital. All women who were randomised in the other seven trials were included in the analysis, however in the Mahomed 1989 study, twenty-two randomisation envelopes were unaccounted for. Two of the trials (Beard 1974; Livingstone 1974) claimed that outcome assessment was 'blinded' due to the different suturing materials (catgut and Dexon) appearing the same by day three, but from our own experience, this is not convincing. The Mahomed 1989 trial acknowledged that fully 'blind' outcome assessment was not possible due to obvious differences in suture materials and techniques. Mackrodt 1998 reports that a research midwife 'blinded' to the treatment allocation undertook a 'face to face' interview at 24-48 hours and 10 days followed by assessment of the woman's perineum. It is possible that an element of observer bias was introduced due to the obvious differences in both was introduced due to the obvious differences in both methods of perineal repair. The other four remaining trials did not state if any attempt was made to 'blind' outcome assessment. Out of the eight included studies only two trials (Mackrodt 1998; Mahomed 1989; Banninger 1978) provided any long term follow-up. Unfortunately, only 46/153 women in the Banninger trial returned for assessment at three months after delivery as compared to 465/538 response rate to a postal questionnaire in the Mahomed trial (Mahomed 1989) and 1644/1780 in the Mackrodt trial (Mackrodt 1998). Results Short term pain: All of the trials showed consistent results of lower rates of pain in the absorbable synthetic groups. However, in four of the trials (Beard 1974; Roberts 1983; Mahomed 1989; Olah 1990) it was not possible to demonstrate statistically significant differences between the groups. Nevertheless, the meta analysis revealed that the odds of experiencing short term pain are lower in the absorbable synthetic groups than in the catgut group. Analgesia use: Only five of the trials (Banninger 1978; Beard 1974; Mahomed 1989; Roberts 1983; Mackrodt 1998) presented data regarding analgesia use in the immediate postpartum period. The results showed that women who had their perineal trauma repaired with polyglycolic acid or polyglactin had reduced analgesia requirements and therefore one could presume that they experienced less pain. Suture dehiscence - up to day 10: Superficial suture dehiscence was reported in four trials; results from the Beard (Beard 1974), Livingstone (Livingstone 1974) and Mackrodt (Mackrodt 1998) trials revealed no statistical significance between the two groups. However, the chromic catgut group in the Banninger (Banninger 1978) trial had a significantly higher rate of suture dehiscence than the polyglycolic acid group (37/71 against 12/77). From the paper, it is not possible to explain the extremely high rates (52%) of suture dehiscence which occurred in the Banninger study. No cases of suture dehiscence were reported in the Olah 1990 trial up to day five. Overall perineal repair with absorbable synthetic material resulted in less suture dehiscence. Resuturing of wound - up to day 10: Only three trials reported cases which required resuturing; two cases in the Banninger 1978 trial and three cases in the Mahomed 1989 trial, all of which were in the chromic catgut groups. The Mackrodt (Mackrodt 1998) trial reported 3/829 in the polyglactin group required resuturing as compared to 10/835 in the chromic catgut group. Long term pain - reported at three months after delivery: Only the Mahomed (Mahomed 1989) and Mackrodt (Mackrodt 1998) trials provide any data regarding long term pain. At three months after delivery results revealed that there was no significant difference in the amount of reported pain in both the absorbable synthetic and catgut groups (56/228 against 56/227) in the Mahomed (Mahomed 1989) trial and (67/829 against 84/835) in the Mackrodt (Mackrodt 1998) trial. Dyspareunia - reported at three months after delivery: Only three trials (Mahomed 1989; Banninger 1978; Mackrodt 1998) included any data on dyspareunia at three months after delivery and this was similar in both groups. Removal of suture material - up to three months after delivery: The Mahomed (Mahomed 1989) and Mackrodt (Mackrodt 1998) trials provided data regarding the removal of suture material in the postpartum period. This was more common in the absorbable synthetic group 77/230 against 27/232 within the first ten days postpartum in the Mahomed (Mahomed 1989) trial and 51/884 against 42/887 in the Mackrodt (Mackrodt 1998) trial. In the Mahomed (Mahomed 1989) trial, absorbable suture materials removed up to three months post delivery (94/232 against 48/233) women and 97/829 against 60/835 in the Mackrodt (Mackrodt 1998). This was reported in the Mahomed (Mahomed 1989) trial to be due to 'irritation' and 'tightness'. Summary of analyses MetaView: Tables and Figures Discussion Six of the trials included in this review compared polyglycolic acid (Dexon) with chromic catgut, one trial (Livingstone 1974) compared plain catgut with Dexon and the eighth trial (Mackrodt 1998) compared polyglactin (Vicryl) to chromic catgut. The same suture material was used for all layers of the perineal repair in each of the groups. However, there is clinical heterogeneity among the trials in that they differ considerably in terms of suturing technique, calibre of material, size of needle, skill of operators, duration of follow-up and outcomes assessed. Furthermore, there are other possible factors that might influence postpartum perineal pain and dyspareunia besides the suturing technique or materials used which must be taken into account when assessing the evidence. These include the extent of perineal trauma, the type of delivery (spontaneous vaginal versus instrumental), the type of episiotomy (medio-lateral versus median) and the performance of an episiotomy versus allowing a tear (Thacker 1983; Sleep 1984; Glazener 1995; Woolley 1995; Graham 1997). There was also methodological differences in the randomisation processes and concealment of treatment allocation (see table of 'Characteristics of Included Studies' for details). In the analysis of the Mahomed 1989 trial there was no significant difference between the two groups in short term pain. However, the effects across the trials were generally consistent and the differences between them are compatible with random error. The confidence intervals in five of the trials included in the analysis were wide reflecting the small number of participants. The meta-analysis of the data from the included trials provides significant evidence that absorbable suture material (Dexon and Vicryl) is associated with less short term pain, reduction in the use of analgesia and less suture dehiscence. However, the long term effects of this material are less clear. Reviewers' conclusions Implications for practice The evidence produced by this review indicates that the use of Dexon and Vicryl for perineal repair following childbirth is associated with less short term pain but is associated with increased rates of removal. The limited data, provided by the trials regarding long term effects, do not provide any evidence of a clinically important difference between groups in terms of pain and dyspareunia. The overall results of this review indicate that absorbable synthetic materials should be used for all layers of the repair but there are still concerns regarding the frequent need for removal in the postpartum period. Implications for research Research into the repair of perineal trauma remains surprisingly neglected and such work, as stated by Grant 1989 should be paramount if the extent of morbidity, both short and long term, is to be reduced for women throughout the world. Given the large numbers of women who require perineal repair and the amount of women who suffer morbidity, further research should be encouraged to minimise these problems. Concern still lies with the need to remove absorbable synthetic materials such as Dexon and Vicryl. Further research into alternative suture materials is urgently needed and this must include long term follow-up. It is vital that any new suture material should be evaluated in a randomised controlled trial before it is widely adopted. Acknowledgements Special thanks to Professor Adrian Grant (University of Aberdeen), Charlotte Howell (Consultant Anaesthetist, North Staffordshire Hospital) and to Sonja Henderson (Administrator of the Pregnancy and Childbirth Group, Liverpool) for their advice, encouragement and support during the preparation of this systematic review. Professor Adrian Grant compiled the first version of this review and he provided us with the additional unpublished data from the Olah 1990 trial which he had previously obtained in writing Olah 1990 trial which he had previously obtained in writing from Karl Olah. Characteristics of included studies Table: Characteristics of included studies Characteristics of excluded studies Study : Ketcham 1994 Not a randomised controlled trial. The methodological quality of the trial was poor in that no scientific principles were applied to the randomisation process and therefore, results could be subject to bias. Study : Tompkins 1972 Unable to obtain additional information such as method of randomisation, or data presented in a suitable form to include this study in this review. Study : Wikoff 1992 Abstract only. Unable to obtain additional information or data from trialists therefore unable to include the study in this review. References References to studies included in this review Banninger 1978 {published data only} Banninger U, Buhrig H, Schreiner WE. A comparison between chromic catgut and polyglycolic acid sutures in episiotomy repair. Geburtshilfe Frauenheilkd 1978;38:30-3. Beard 1974 {published data only} Beard RJ, Boyd I, Sims CD. A trial of polyglycolic acid and chromic catgut sutures in episiotomy repair. Br J Clin Pract 1974;28:409-10. Livingstone 1974 {published data only} Livingstone E, Simpson D, Naismith WCMK. A comparison between catgut and polyglycolic acid sutures in episiotomy repair. J Obstet Gynaecol Br Cmmwlth 1974;81:245-7. Mackrodt 1998 {published data only} Mackrodt C, Fern E, Gordon B. Ipswich childbirth study - perineal suturing study. In: Proceedings of Research in Midwifery Conference, Birmingham, UK. 1993. Mackrodt C, Gordon B, Fern E, Ayers S, Truesdale A, Grant A. The Ipswich Childbirth Study: 2. A randomised comparison of polyglactin 910 with chromic catgut for postpartum perineal repair. Br J Obstet Gynaecol 1998;105:441-5. Mahomed 1989 {published data only} Mahomed K, Grant AM, Ashurst H, James D. The Southmead perineal suture study. A randomised comparison of suture materials and suturing techniques for repair of perineal trauma. Br J Obstet Gynaecol 1989;96:1272-80. Olah 1990 {published data only} Olah KS. Episiotomy repair - suture material and short term morbidity. J Obstet Gynaecol 1990;10:503-5. Roberts 1983 {published data only} Roberts ADG, McKay Hart D. Polyglycolic acid and catgut sutures, with and without oral proteolytic enzymes, in the healing of episiotomies. Br J Obstet Gynaecol 1983;90:650-3. Rogers 1974 {published data only} Rogers RE. Evaluation of post-episiorrhaphy pain: polyglycolic acid vs catgut sutures. Milit Med 1974;139:102-4. * indicates the major publication for the study References to studies excluded from this review Ketcham 1994 Ketcham KR, Pastorek JG, Letellier RL. Episiotomy Repair: Chromic Versus Polyglycolic Acid Suture [reprinted from the Southern Medical Journal]. Journal of the Southern Medical Association 1994;87(4):514-7. Tompkins 1972 Tompkins MG, Lea RH. The use of polyglycolic acid sutures in obstetrics and gynaecology. Can Med Assoc J obstetrics and gynaecology. Can Med Assoc J 1972;106:675-7. Wikoff 1992 Wikoff MD, Kuehl TJ, Cooney AT, Knight AB. Comparison of postpartum pain and healing with repair of perineal disruptions using chromic catgut or polyglycolic acid suture. Am J Obstet Gynecol 1992;166:409. References to studies awaiting assessment Hemsley 1997 Hemsley L. personal communication December 2 1997. Additional references Chalmers 1989 Chalmers I, Hetherington J, Elbourne D, Keirse MJNC, Enkin M. Materials and methods used in synthesizing evidence to evaluate the effects of care during pregnancy and childbirth. In: Chalmers I, Enkin M, Keirse MJNC, editor(s). Effective Care in Pregnancy and Childbirth. Oxford: Oxford University Press, 1989:39-65. Craig 1975 Craig PH, Williams JA, Davis KW, Magoun AD. A Biologic Comparison of Polyglactin 910 and Polyglycolic Acid Synthetic Absorbable Sutures. Surgery, Gynecology & Obstetrics 1975;141:1-10. Enkin 1995 Enkin M, Keirse M, Renfrew M, Neilson J, editors. A Guide to Effective Care in Pregnancy and Childbirth. 2nd Edition. Oxford: Oxford University Press, 1995:269. Glazener 1995 Glazener CMA, Abdalla MI, Stroud P, Naji SA, Templeton AA, Russell IT. Postnatal maternal morbidity: extent, causes, prevention and treatment. Br J Obstet Gynaecol 1995;102:282-7. Graham 1997 Graham ID. Episiotomy Challenging Obstetric Interventions. Oxford: Blackwell Science Ltd, 1997. Grant 1986 Grant A. Repair of episiotomies and perineal tears. Br J Obstet Gynaecol 1986;93:417-9. Grant 1989 Grant A. Repair of perineal trauma after childbirth. In: Chalmers I, Enkin MW, Keirse MJNC, editor(s). Effective Care in Pregnancy and Childbirth. Oxford: Oxford University Press, 1989:1173-5. Howard 1995 Howard S, McKell D, Mugford M, Grant A. Cost-effectiveness of different approaches to perineal suturing. British Journal of Midwifery 1995;3(11):587-605. Irvin 1981 Irvin TT. Wound Healing - Principles and Practices. London: Chapman and Hall, 1981. Isager-Sally 1986 Isager-Sally L, Legarth J, Jacobson B, Bustofte E. Episiotomy repair - immediate and long-term sequelae. A prospective randomised study of three different methods of repair. Br J Obstet Gynaecol 1986;93:420-5. Mulrow 1997 Mulrow CD, Oxman A, editors. Cochrane Collaboration Handbook [updated September 1997] In: The Cochrane Library [database on disk and CDROM]. The Cochrane Collaboration. Oxford: Update Software; 1997, issue 4. Sleep 1984 Sleep J, Grant A, Garcia J, Elbourne D, Spencer J, Chalmers I. West Berkshire perineal management trial. BMJ 1984;289:587-90. Sleep 1991 Sleep J. Perineal care: a series of five randomised controlled trials. In: Robinson S, Thomson A, editor(s). Robinson S, Thomson A. Midwives, Research and Childbirth. London: Chapman and Hall, 1991:2. Thacker 1983 Thacker SB, Banta HD. Benefits and risks of episiotomy: an interpretative review of the English Language literature, 1860-1980. Obstetrical and Gynecological Survey 1983;38:322-38. Woolley 1995 Woolley RJ. Benefits and risks of Episiotomy: A Review of the English-Language Since 1980. Part I & II. CME Review Article. Obstet Gynecol Surv 1995;50(11):806-35. Previously published versions Johanson 1994 Johanson RB. Polyglycolic acid vs catgut for perineal repair [revised 10 March 1994]. In: Keirse MJNC, Renfrew MJ, Neilson JP, Crowther C (eds). Pregnancy Crowther C (eds). Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database [database on disk and CDROM]. The Cochrane Collaboration; Issue 2, Oxford: Update Software; 1995. Kettle 1999 Kettle C, Johanson RB. Absorbable synthetic versus catgut suture material for perineal repair (Cochrane Review). In: The Cochrane Library, Issue 2, 1999. Oxford: Update Software. Coversheet Title Absorbable synthetic versus catgut suture material for perineal repair Reviewer(s) Kettle C, Johanson RB Date of most recent amendment : 27 October 1999 Date of most recent substantive amendment : 19 May 1999 This review should be cited as : Kettle C, Johanson RB. Absorbable synthetic versus catgut suture material for perineal repair (Cochrane Review). In: The Cochrane Library, Issue 2, 2000. Oxford: Update Software. Contact address : Mrs Chris Kettle Research Midwife Academic Department of Obstetrics and Gynaecology North Staffordshire Hospital NHS Trust, Maternity Hospital Newcastle Road Stoke-on-Trent Staffordshire UK ST4 6QG Telephone: +44 1782 552 356 Facsimile: +44 1782 710 936 E-mail: chris@kogs.freeserve.co.uk. For information on the editorial group see: Cochrane Pregnancy and Childbirth Group Extramural sources of support to the review Keele University UK North Staffordshire Hospital Trust UK Intramural sources of support to the review No sources of support supplied Keywords CATGUT/ adverse-effects; CATGUT / utilization; SUTURES; BIOCOMPATIBLE-MATERIALS / utilization; ; POLYGLYCOLIC-ACID / adverse-effects; POLYGLACTIN-910/ adverse-effects; PERINEUM / surgery; WOUND-HEALING; MORBIDITY; HUMAN;FEMALE; NATURAL-CHILDBIRTH; SUTURE-TECHNIQUES; PAIN; EPISIOTOMY;RANDOMIZED-CONTROLLED-TRIALS; CRG Code: HM-PREG Cochrane Library number: CD000006 ----- END OF DOCUMENT ----- Continuous versus interrupted sutures for perineal repair Continuous versus interrupted sutures for perineal repair Kettle C, Johanson RB A substantive amendment to this systematic review was last made on 23 October 1997. Cochrane reviews are regularly checked and updated if necessary. Background: Millions of women worldwide undergo perineal repair after childbirth and the type of repair may have an impact on pain and healing. Objectives: The objective of this review was to assess the effects of continuous subcuticular versus interrupted transcutaneous sutures on women following perineal repair. Search strategy: We searched the Cochrane Pregnancy and Childbirth Group trials register. Date of last search: June 1999. Selection criteria: Randomised trials comparing continuous subcuticular versus interrupted transcutaneous sutures for the closure of perineal skin after vaginal delivery. Data collection and analysis: Trial quality was assessed independently by two reviewers. Data were extracted by one reviewer and checked by the second reviewer. Study authors were contacted for additional information. Main results: Four studies involving 1864 women were included. The trials were heterogeneous with respect to operator skill and training. Compared with interrupted sutures, a continuous subcuticular suture technique of perineal repair was associated with less pain for up to 10 days post partum (odds ratio 0.68, 95% confidence interval 0.53 to 0.86). No differences were seen in the need for analgesia, need for resuturing of the wound or in dyspareunia. Based on one trial only, there was no difference in long-term pain and failure to resume pain-free intercourse within three months of the birth. The continuous technique was associated with less need for the removal of sutures. Reviewers' conclusions: The continuous subcuticular technique of perineal repair may be associated with less pain in the immediate postpartum period than the interrupted suture technique. The long-term effects are less clear. Background Perineal repair is one aspect of childbirth that affects literally millions of women throughout the world and can result in long-term maternal morbidity. In the United Kingdom approximately 750,000 women give birth each year and of these approximately 70% will sustain perineal trauma during childbirth and will require stitches (Sleep 1984). The majority of women experience some short term discomfort or pain following perineal repair, and a further 15 - 20% will continue to have long term problems such as superficial dyspareunia (Sleep 1987; Klein 1994; Glazener 1995). Short and long-term maternal morbidity associated with perineal repair can lead to major physical, psychological and social problems, affecting the woman's ability to care for her new baby and other members of the family (Sleep 1991). Until recently there has been very little research into the immediate and long term maternal morbidity associated with childbirth. In fact, a vast amount of postpartum maternal morbidity is unreported by women to health professionals (MacArthur 1991; Glazener 1995; Glazener 1997). The technique of suturing perineal trauma following childbirth may have a significant effect on the extent and degree of morbidity experienced by women both in the short and long-term. However, there are only a small number of randomised controlled clinical trials which compare the effects of different suturing techniques on the extent of maternal morbidity associated with on the extent of maternal morbidity associated with perineal repair. Fleming (Fleming 1990) published her experience of using a simple, non-locking, loose, continuous suturing technique with subcutaneous sutures to appose the skin. The research undertaken by Fleming (Fleming 1987) suggests that this modified continuous suturing technique is associated with a lower incidence of perineal pain compared with the results produced by other researchers using more traditional methods of suturing. However, no randomised controlled clinical trials have been undertaken to verify Fleming's clinical observations. In the United Kingdom the midwife will be responsible for suturing the majority of women who sustain perineal trauma and need stitches following a spontaneous vaginal delivery. Midwives and students are usually taught to suture using the interrupted technique because it is considered easier to learn and may cause less problems in the hands of the inexperienced or novice operators (Grant 1989). However, it is reported that perineal pain can be significantly reduced if midwives and doctors extend their skills to include continuous subcuticular suturing (Enkin 1995). The suturing technique adopted by practitioners appears to evolve from the way the operator is trained and may be based on custom and practice or personal preference rather than scientific evidence. All practitioners should be adequately trained to undertake perineal repair using the most appropriate technique, based on scientific evidence, rather than just complying with tradition. A recent study by Sultan et al (Sultan 1995), clearly highlighted deficiency and dissatisfaction amongst trainee doctors and midwives with their training in perineal anatomy and repair. As stated by Grant (Grant 1989), the skill of the operator is as important as the technique or suturing material used, although very little research has been carried out to substantiate this. Further research is needed to evaluate alternative methods of training in perineal repair for midwives and medical staff. For example, the use of perineal repair simulators and videos as compared to the traditional 'see three, do three and now you are on your own' approach. The aim of this review is to examine the available evidence and to establish if there is any clear scientific evidence that the technique used for perineal repair, following childbirth, has any relation to the amount of pain and superficial dyspareunia experienced by women. This systematic review includes four randomised clinical trials and represents an update of the pre-Cochrane review undertaken previously by Professor Adrian Grant in 1993. Objectives To compare the effects of continuous subcuticular versus interrupted transcutaneous sutures on the amount of short and long-term postpartum maternal morbidity experienced by women following perineal repair after vaginal delivery. The evidence collated in this review will enable purchasers, providers and consumers of health care to choose the most appropriate technique of perineal repair in terms of both health gain and cost. The main outcomes of interest are: short and long-term pain; amount of analgesia used; time of resumption of pain free intercourse; superficial dyspareunia; removal of suture material; re-suturing of wound. Criteria for considering studies for this review Types of studies All identified, relevant randomised controlled trials which compare continuous subcuticular sutures with interrupted transcutaneous sutures for closure of perineal skin, have been included in this review. The inclusion criteria is quite broad due to the small number of controlled trials available in this area, all of which have variable methodological quality. All of the trials included have been assessed according to the method of treatment allocation, randomisation, blinding of outcome assessment and handling of exclusions. Types of participants All primiparous and multiparous women who have sustained perineal trauma and require stitching following an instrumental or spontaneous vaginal delivery. Types of intervention All randomised controlled comparisons of continuous subcuticular versus interrupted transcutaneous sutures for closure of perineal skin following vaginal delivery. Types of outcome measures The main focus is on outcome measures relating to short and long-term postpartum morbidity. The main outcome measures include: short term pain; analgesia use; removal of suture material; resuturing; long-term pain; failure to resume pain free intercourse; superficial dyspareunia. Consumer views regarding what outcomes they would expect from this review were sought from local focus groups, members of the National Childbirth Trust and other postnatal support groups. The main outcomes of interest from the consumers point of view were the extent of short and long-term pain, the removal of suture material and the resumption of pain free intercourse. Search strategy for identification of studies See: Collaborative Review Group search strategy This review has drawn on the search strategy developed for the Pregnancy and Childbirth Group as a whole. Relevant trials were identified in the Group's Specialised Register of Controlled Trials. See Review Group's details for more information. Date of last search: June 1999. Methods of the review The two reviewers (Chris Kettle and Richard Johanson) independently assessed and selected the trials for inclusion in this review. It was not possible to assess the relevance of the trials blinded because we knew the authors' names, institution, journal of publication and results, when we applied the inclusion criteria. All disagreements were resolved by discussion. The trials were assessed according to the following four main criteria: (1) adequate concealment of treatment allocation (e.g. opaque sealed numbered envelopes); (2) method of allocation to treatment (e.g. by computer randomisation, random number tables or by quasi-randomisation methods such as alternation or medical record numbers); (3) adequate documentation of how exclusions were handled after treatment allocation - to facilitate intention to treat analysis; (4) adequate blinding of outcome assessment. Letters were used to indicate the quality of the included trials, for example A was used to indicate a trial which has a high level of quality in which all the criteria were met; B was used to indicate that one or more criteria were partially met or if it was unclear if all the criteria were met and C was used if one or more criteria were not met (Mulrow 1997). We independently assessed the methodological quality of each individual trial and collected details of method of treatment allocation, randomisation, blinding of outcome assessment, handling of exclusions and whether an 'intention to treat analysis' was performed. All included trial data were processed as described by Chalmers et al (Chalmers 1989). Data were entered directly from the published reports into the Review Manager software (RevMan) and the second reviewer (Richard Johanson) checked the accuracy of the entered data. Missing data and additional information regarding data which was presented in an unsuitable format for inclusion in the review are currently being sought from the Detlefsen 1980 and Isager-Sally 1986 trialists (Detlefsen 1980; Isager-Sally 1986). Statistical analysis was undertaken using the RevMan software for calculation of the treatment effect as represented by the odds ratio, proportional and absolute risk reductions. Analysis was performed using the Peto Method for odds ratio. Description of studies Included trials: Banninger 1978; Detlefsen 1980; Isager-Sally 1986; Mahomed 1989. All four trials in this review compared continuous subcuticular sutures with interrupted transcutaneous sutures for closure sutures with interrupted transcutaneous sutures for closure of perineal skin. The same suturing technique was used to appose the perineal muscle and skin in the four 'interrupted' groups of the included trials. Whereas, in the 'continuous subcuticular' groups two of the trials used interrupted sutures to appose the perineal muscle (Banninger 1978; Mahomed 1989) and two trials used a continuous (running) technique (Detlefsen 1980; Isager-Sally 1986). Three of the trials used polyglycolic acid (Dexon) suture material throughout for repair of vagina, perineal muscle and skin in each group (Banninger 1978; Detlefsen 1980; Isager-Sally 1986). The Mahomed 1989 trial had a balanced factorial design and the participants in each trial group were repaired with chromic catgut (approximately 50%) and polyglycolic acid (Dexon) suture material (approximately 50%). Even though there was consistency in the suturing material used in each group there was some variation between the gauge of suturing materials and needle size used between trials, (see 'Characteristics of included studies' for details). In addition, there was some clinical heterogeneity between trials in respect of skill of the operator and training in the continuous, subcuticular groups. Methodological quality The methodological qualities of the four trials included in this systematic review were found to be inconsistent. We decided to rate the Mahomed 1989 trial as 'A' because it had a high level of quality despite the outcome assessment not being 'blinded'. This was not possible due to obvious differences in suturing techniques. The Isager-Sally 1986 trial was rated as 'B' and the other two trials Banninger 1978 and Detlefsen 1980 were rated as 'C'. The method of allocation to treatment was described as 'random' in three of the trials (Detlefsen 1980; Isager-Sally 1986; Mahomed 1989). However, only the Isager-Sally 1986 and Mahomed 1989 trials reported the use of sealed, opaque envelopes for 'randomised' concealed treatment allocation to reduce the risk of selection bias at point of entry into the study. Whereas, the Banninger 1978 trial used a quasi-random method of treatment allocation by 'alternating sequence' which carries a greater risk of introducing selection bias. The method of 'random allocation' was not described in the Detlefsen 1980 trial. A total of 70 women were excluded from the Isager-Sally 1986 trial soon after entry because 'follow-up was not possible' because they were either transferred to a paediatric department or left the hospital before the fifth day after delivery. These women were also excluded from the three month follow-up. In the Mahomed 1989 trial analysis was 'by intention to treat', however there were 22 randomisation envelopes which were unaccounted for. No losses to follow-up were reported in the Banninger 1978 and Detlefsen 1980 trials. It was not possible to fully 'blind' early outcome assessment due to obvious differences in the two suturing techniques. All of the four trials made provision for long-term follow-up; only 33% of participants returned for follow-up at three months in the Banninger 1978 trial; a total of 90% of participants returned for follow-up examination at two months in the Detlefsen 1980 trial; 97% of participants included in the study responded to the three months questionnaire in the Isager-Sally 1986 trial and 85% of participants responded at three months in the Mahomed 1989 trial. Results Short term pain - up to day 10 postpartum: Only three of the four trials presented data in a suitable format for inclusion in this analysis (Banninger 1978; Isager-Sally 1986; Mahomed 1989). All of the three included trials showed lower rates of pain in the continuous subcuticular (experimental) groups. However, only the Isager-Sally 1986 trial actually demonstrated any statistical significance between the two groups (Peto odds ratio 0.35, 95% confidence interval (CI) 0.22 - 0.56). Nevertheless, the meta-analysis indicates that the odds of experiencing short term pain are less in the pain are less in the continuous subcutaneous groups (Peto odds ratio 0.68, 95% CI 0.53 - 0.86). Analgesia use - up to day 10 postpartum: Two of the included trials (Banninger 1978; Mahomed 1989) presented data regarding analgesia use in the immediate postpartum period. No differences were seen in analgesia use between the treatment groups. Resuturing of wound - reported up to three months after delivery: Data regarding the incidence of resuturing in the two intervention groups was provided by two trials; the Mahomed 1989 trial reported three cases in each comparison group which required re-suturing whilst the Banninger 1978 trial reported none in either group. Long-term pain - reported up to three months after delivery: Only the Mahomed 1989 trialists presented data regarding the incidence of long-term pain in a suitable format for inclusion in this review. This revealed a non-significant increase in long term pain in the continuous subcuticular (experimental) group as compared to the interrupted transcutaneous (control) group, (Peto odds ratio 1.12, 95% CI 0.75 - 1.67). Dyspareunia - reported up to three months after delivery: Three trials provided data regarding the extent of reported dyspareunia up to three months after delivery (Detlefsen 1980; Isager-Sally 1986; Mahomed 1989). The Detlefsen (Detlefsen 1980) trial and Isager-Sally 1986 showed lower rates of dyspareunia in the continuous subcuticular (experimental) groups. However, only the Detlefsen 1980 trial showed a statistically significant difference but the confidence intervals were wide reflecting the small number of participants within this study. In contrast the Mahomed 1989 trial found a higher incidence of reported dyspareunia in the experimental group; this may have been due to the fact that more women in the experimental group had resumed intercourse by three months in this study. Overall, the meta-analysis did not demonstrate any statistically significant reduction in the amount of dyspareunia experienced by participants in the continuous subcuticular groups, (Peto odds ratio 0.88, 95% CI 0.69 - 1.12). Failure to resume pain free intercourse - up to three months after delivery: Only the Mahomed 1989 trialists presented data in a suitable format regarding failure to resume pain free intercourse. The results were almost equal in the two intervention groups (32% in the control group as compared with 34% in the experimental group). Removal of suture material - up to three months after delivery: Unfortunately only the Mahomed 1989 trial provided data regarding the removal of suture material. This was less frequent in the continuous subcuticular group and may be as a result of these sutures being less accessible than those of the interrupted group, (Peto odds ratio 0.61, 95% CI 0.46 - 0.80). Summary of analyses MetaView: Tables and Figures Discussion The meta-analysis of the data provides evidence that continuous subcuticular stitches causes less pain in the immediate postpartum period than interrupted transcutaneous stitches. However, the results from the three included studies looking at this primary outcome, must be interpreted with caution. Only the Isager-Sally 1986 trial actually demonstrates any statistical significance between the two groups in terms of reduced short-term pain in the experimental group. This may be as a result of clinical heterogeneity between trials, in terms of input in training and technique used prior to the individual studies commencing, (See table of 'Characteristics of included studies' for details). The Mahomed 1989 trialists reported that the subcuticular method of perineal skin closure was less practised and unpopular with some operators, in fact, 96 women in the subcuticular group had interrupted transcutaneous stitches inserted. Perhaps the better results produced by the Isager-Sally 1986 trial were due to the new continuous subcuticular technique being introduced several months prior to the trial starting, ensuring months prior to the trial starting, ensuring that all members of staff were familiar with the new method of perineal repair. On the other hand, as stated by the Isager-Sally 1986 trialists, the significantly better results in the experimental (subcuticular) group could have been due to the fact that it is very easy to over tighten interrupted stitches which restricts the tissues and may cause increased pain in the control (interrupted) group. Reviewers' conclusions Implications for practice The evidence produced by this review suggests that the subcuticular technique may be associated with less short-term pain, however the long term effects on pain and dyspareunia are less clear. Grant reported that the subcuticular method of perineal skin closure is more technically difficult than the interrupted approach and possibly this method is more suitable for the experienced operator (Grant 1989). In contrast, the interrupted technique is reported to be easier to learn and may cause fewer problems in the hands of the inexperienced or novice operator (Enkin 1995). Implications for research Method of repair: Literally millions of women throughout the world experience pain and suffering as a result of perineal trauma sustained during delivery and yet this is a very under researched area. Given the results of the four trials included in this review, more studies are needed to compare continuous subcuticular skin closure to the interrupted transcutaneous method and they must include long-term follow-up. The high success rate reported by Fleming from her clinical observations (Fleming 1990), using a continuous suturing technique throughout, will need to be evaluated in an appropriate randomised controlled comparative study. Acknowledgements Sonja Henderson (Administrator of the Pregnancy and Childbirth Group, Liverpool) and Claire Rigby (ASQUAM Co-ordinator, North Staffordshire Hospital) for their assistance and support during the preparation of this systematic review. Characteristics of included studies Table: Characteristics of included studies Characteristics of excluded studies Study : Doyle 1993 This study was excluded from the meta-analysis due to non-absorbable and absorbable material being compared which may have had a confounding affect on the results. References References to studies included in this review Banninger 1978 {published data only} Banninger U, Buhrig H, Schreiner WE. A comparison between chromic catgut and polyglycolic acid sutures in episiotomy repair. Geburtshilfe Frauenheilkd 1978;38:30-33. Detlefsen 1980 {published data only} Detlefsen GU, Vinther S, Larsen P, Schroeder E. Intradermal suturing of episiotomy wounds compared with interrupted sutures (transl.). Ugeskr Laeger 1980;142:3117-3120. Isager-Sally 1986 {published data only} Isager-Sally I, Legarth J, Jacobsen B, Bostofte E. Episiotomy repair - immediate and long-term sequelae. A prospective randomized study of three different methods of repair. Br J Obstet Gynaecol 1986;93:420-425. Mahomed 1989 {published data only} Mahomed K, Grant AM, Ashurst H, James D. The Southmead perineal suture study. A randomized comparison of suture materials and suturing techniques for repair of perineal trauma. Br J Obstet Gynaecol 1989;96:1272-1280. * indicates the major publication for the study References to studies excluded from this review Doyle 1993 Doyle PM, Johanson R, Geetha T, Wilkinson P. A prospective randomised controlled trial of perineal repair after childbirth, comparing interrupted chromic catgut to subcuticular prolene for skin closure. Br J Obstet Gynaecol 1993;100:93-4. Additional references Chalmers 1989 Chalmers I, Hetherington J, Elbourne D, Keirse MJNC, Enkin M. Materials and methods used in synthesizing evidence to evaluate the effects of care during pregnancy and childbirth. In: Chalmers I, Enkin M, Keirse MJNC, editor(s). Effective Care in Pregnancy and Childbirth. Oxford: Oxford University Press, 1989:39-65. Enkin 1995 Enkin M, Kierse MJNC, Renfrew M, Neilson J. A Guide to Effective Care in Pregnancy and Childbirth. 2nd Edition. Oxford: Oxford University Press, 1995. Fleming 1987 Fleming N. Comparison of Women with Different Perineal Conditions after Childbirth. Michigan, UMI: Ann Arbor, 1987. Fleming 1990 Fleming N. Can the suturing method make a difference in postpartum, perineal pain. J Nurse Midwifery 1990;35(1):19-25. Glazener 1995 Glazener CMA, Abdalla M, Stroud P, Naji S, Templeton A, Russell IT. Postnatal maternal morbidity: extent, causes, prevention and treatment. Br J Obstet Gynaecol 1995;102:286-7. Glazener 1997 Glazener CMA. Sexual function after childbirth: women’s experiences, persistent morbidity and lack of professional recognition. Br J Obstet Gynaecol 1997;104:330-5. Grant 1989 Grant AM. Repair of perineal trauma after childbirth. In: Chalmers I, Enkin M, Keirse MJNC, editor(s). Effective Care in Pregnancy and Childbirth. Vol. 2. Oxford: Oxford University Press, 1989:1170-81. Klein 1994 Klein MC, GauthierRJ, Robbins JM, Kaczorowski J, Jorgensen SH, Franco ED, Johnson B, Waghorn K, Gelfand MM, Guralnick MS, Luskey GW, Joshi AK. Relationship of episiotomy to perineal trauma and morbidity, sexual dyfunction, and pelvic floor relaxation. Am J Obstet Gynecol 1994;171:591-8. MacArthur 1991 MacArthur C, Lewis M, Knox EG. Health after childbirth. London: HMSO, 1991. Mulrow 1997 Mulrow CD, Oxman AD, editors. Cochrane Collaboration Handbook [updated September 1997]. In: The Cochrane Library [database on disk and CDROM]. The Cochrane Collaboration. Oxford: Update Software; 1994, issue 4. Sleep 1984 Sleep J, Grant A, Garcia J, Elbourne D, Spencer J, Chalmers I. West Berkshire perineal management trial. BMJ 1984;289:587-90. Sleep 1987 Sleep J, Grant AM. West Berkshire Perineal Management Trial. Three year follow-up. BMJ 1987;295:749-51. Sleep 1991 Sleep J. Perineal care: a series of five randomised controlled trials. In: Robinson S, Thompson A, editor(s). Midwives, Research and Childbirth. Vol. 2. London: Chapman and Hall, 1991. Sultan 1995 Sultan AH, Kamm MA, Hudson CH. Obstetric perineal trauma: an audit of training. J Obstet Gynaecol 1995;15:19-23. Previously published versions Johanson 1995 Johanson RB. Continuous vs interrupted sutures for perineal repair [revised 10th March 1994]. In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP, Crowther C (eds.) Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database [database on disk and CDROM]. The Cochrane Collaboration; Issue 2, Oxford: Update Software; 1995. . Coversheet Title Continuous versus interrupted sutures for perineal repair Reviewer(s) Kettle C, Johanson RB Date of most recent amendment : 23 September 1999 Date of most recent substantive amendment : 23 October 1997 This review should be cited as : Kettle C, Johanson RB. Continuous versus interrupted sutures for perineal repair (Cochrane Review). In: The Cochrane Library, Issue 2, 2000. Oxford: Update Software. Contact address : Mrs Chris Kettle Research Midwife Academic Department of Obstetrics and Gynaecology North Staffordshire Hospital NHS Trust, Maternity Hospital Newcastle Road Stoke-on-Trent Staffordshire UK ST4 6QG Telephone: +44 1782 552 356 Facsimile: +44 1782 710 936 E-mail: chris@kogs.freeserve.co.uk. For information on the editorial group see: Cochrane Pregnancy and Childbirth Group Extramural sources of support to the review No sources of support supplied Intramural sources of support to the review No sources of support supplied Keywords HUMAN; FEMALE; POSTPARTUM-PERIOD; PERPERIUM; PERINEUM / surgery; SUTURES; META-ANALYSIS; PAIN; WOUND-HEALING; CHILDBIRTH; CRG Code: HM-PREG Cochrane Library number: CD000947 ----- END OF DOCUMENT -----
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