Although suture materials and aspects of the technique have many varieties, the primary goals remain the same, as follows: closing dead space, supporting and strengthening wounds until healing increases their tensile strength, approximating skin edges for an aesthetically pleasing and functional result and minimizing the risks of bleeding and infection [1].

Episiotomy, the incision of the perineum during the last part of the second stage of labour or delivery is a surgical increase of the perineum made to increase the vulval outlet during childbirth 85% of women who have a spontaneous vaginal birth will have some form of perineal trauma and up to 69% will need to have sutures [2,3].

Episiotomies are known to provide the following benefits speed up the birth, prevent vaginal tears, protect against incontinence, protect against pelvic floor relaxation and heals easier than tears [2].

Perineal trauma is conventionally repaired in three layers. First, is inserted to close the vaginal trauma, commencing at the apex of the wound and finishing at the level of the fourchette with a loop knot. Next, the deep and superficial perineal muscles are re- approximated with three or four interrupted sutures, or sometimes a continuous running stitch is used. Finally, the skin is closed using continuous or interrupted sutures [4].

Short and long-term maternal morbidity associated with perineal repair can lead to major physical, psychological and social problems. Complications depend on the severity of perineal trauma and on the effectiveness of treatment. The type of suturing material, the skill of the operator, and the technique of repair are the 3 main factors that influence the outcome of perineal repair [5].

The procedure 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 randomized controlled clinical trials which compare the effects of different suturing techniques on the extent of maternal morbidity associated with perineal repair [6].

Actually not many of the trials evaluating episiotomy repair clearly focused on perineal skin as a separate, so this study aims to evaluate the effect of different skin suturing styles in postpartum complications after episiotomy or second- degree perineal tears repair (involving the perineal muscles and skin) [7]. , as many studies resulted in that continuous suturing in episiotomy and perineal tear repair is better than interrupted in terms of less time required for repair, less number of packets of suture material used ,less perineal pain on postnatal ,less number of analgesic tablets used to control pain, vagina and perineal muscles are sutured by continuous technique (CT) using the short-term absorbable polyglactin 910 (Rapide Vicryl No 1-0) and local analgesia by 1% lignocaine infiltration [7, 8] [9].

The aim of this study is to compare after suturing by interrupted, simple continuous, and subcuticular techniques for perineal skin repair, following childbirth with respect of postoperative pain, wound healing occurring in perineal area and time taken to complete skin closure.

This is a prospective RCT of 150 women who gave birth at Women health hospital aged 21-35 years old and with normal vaginal delivery, at term (37 weeks – 40 weeks), live baby and vertex presentation.

An informed written consent was obtained from the patient or relatives of the patients. The study was done after approval from the Ethical Committee Assiut University Hospitals.

Exclusion criteria were third- and fourth-degree perineal tear, instrumental vaginal delivery, previous perineal surgery, anemia with hemoglobin (Hb) level < 9 g/dl, diabetes mellitus, coagulation abnormalities, postpartum hemorrhage, delivery conducted outside Woman Health Hospital, breech delivery, body mass index (BMI) >35 kg/m2, local infectious lesions and anal fissures or haemorrhoids.

The women (Primigravida or multipara) were assigned equally to three groups: simple continuous group, subcuticular group and interrupted skin suturing group.

All patients were subjected to history taking, vital signs assessment, abdominal and prevaginal examination, CBC, hemostasis profile and random blood glucose (RBG) level.

The women received prophylactic systemic broad-spectrum antibiotic 30 min before delivery. Women were placed in the lithotomy position for repair after delivery, the standard analgesia for perineal repair was infiltration analgesia in the wound area using 5-20 ml lignocaine 10 mg/ml. suturing of episiotomy is initiated as soon as the placenta was delivered using polyglactin 910 (Rapide Vicryl No 1-0) and via continuous suture technique of vaginal mucosa and perineal muscles. The perineal skin then is approximated with the subcuticular suture in the subcutaneous tissue a few millimetres under the perineal skin edges, then skin is cleaned and dried and suturing of skin starts.

Postpartum medications: antibiotics (Oral Amoxicillin/Clavulanic acid 875 mg/125 mg twice a day for 5 days), analgesics (Ibuprofen as NSAIDs to provide more adequate pain relieving in postpartum pain than placebo and paracetamol, the drug was administered by a dose of 400 mg every 8 hours for four days (with maximum dose of 2.4 gm if more analgesia required).

Perineal pain was assessed via the Numeric Pain Rating Scale (NPRS), which is a unidimensional measure of pain intensity in adults in which a respondent selects a whole number (0–10 integers) that best reflects the intensity of his/her pain. The 11- point numeric scale ranges from '0' representing one pain extreme (e.g., “no pain”) to '10' representing the other pain extreme (e.g., “pain as bad as you can imagine” or “worst pain imaginable”).

Assessing perineal wound healing:

Perineal wound healing was assessed via Redness, Edema, Ecchymosis, Discharge, Approximation (REEDA) scale which is a scale for grading the severity of perineal trauma also measures the healing process of the perineum associated with episiotomy or laceration associated with delivery.

Postoperative scar was assessed via The Stony Brook Scar Evaluation Scale (SBSES) which is subjective scar scale that is a 6-item ordinal wound evaluation scale developed to measure short-term cosmetic outcome of wounds 5 to 10 days after injury [10]. It incorporates assessments of individual attributes with a binary response (1 or 0) for each, as well as overall appearance, to yield a score ranging from 0 (worst) to 5 (best).

The primary outcome was short term pain (up to 10 days postpartum) and secondary outcomes  were use of analgesia due to perineal pain, long-term pain (up to one month), assessment of the wound healing (at day 10 and by one month) and assessment of scar condition (at day 10 and by one month) [8].

With Epi Info program, assuming α-error = 0.05 and a Β-error 0.2, and with calculating pain reduction in the continuous group by 40%, we calculated that at least 46 patients would be sufficient (Odds ratio=0.26) in each group [8]. So, the total sample size was at least 138 patients.

Statistical analysis

Analysis was performed using the IBM SPSS statistics 23.0 program (IBM SPSS for windows, version 23.0 Amronk, NY, USA). Continuous data and categorical data were expressed as mean ± standard deviation and percentages (%), respectively. The Shapiro-Wilk test was used to evaluate normal distribution. When comparing normally distributed groups, one-way analysis of variance (one-way ANOVA) was used to compare the three groups, Kruskal-Wallis H test was used to compare non-normally distributed groups. Categorial variables were expressed as frequency and percentage and were statistically analysed by Chi-square test. A two-tailed P value of ≤ 0.05 was statistically significant.

There was an insignificant difference in baseline characteristics (age, BMI, educational level, residence area and women work) and gestational characteristics (parity and gestational age) among the studied groups (Table 1).

Table 1: Baseline and gestational characteristics among the studied groups.

Data are presented as mean ± SD, frequency (%) or median (IQR), BMI: Body mass index

There was an insignificant difference in pulse, SBP, DBP, temperature, RR, Hb and RBG among the studied groups (Table 2).

Table 2: Vital signs and laboratory investigation among the studied groups.

Data are presented as mean ± SD, frequency (%) or median (IQR), SBP: Systolic blood pressure, DBP: Diastolic blood pressure, RR: Respiratory rate, Hb: Hemoglobin, RBG: Random blood glucose level

NPRS after 10 days and SBSES were significantly lower in simple continuous group and subcuticular group than interrupted skin sutures group (P value<0.05). Suturing time significantly lower in simple continuous group was than subcuticular group and interrupted skin sutures group and in subcuticular group than interrupted skin sutures group (P value<0.05). There was an insignificant difference in NPRS and SBSES between simple continuous group and subcuticular group, in NPRS after 1month and in REEDA after 10 days and 1 month among the studied groups (Table 3).

Table 3: Numeric Pain Rating Scale, REEDA scale and Stony Brook Scar Evaluation Scale among the studied groups.

Data are presented as mean ± SD, NPRS: Numeric Pain Rating Scale, REEDA: Redness, Edema, Ecchymosis, Discharge, Approximation, *: Significant as p value <0.05, P1: P value between Simple continuous group and Subcuticular group, P2: P value between Simple continuous group and Interrupted skin sutures group, P3: P value between Subcuticular group and Interrupted skin sutures group

In the majority of childbirths, damage to the perineum is likely to occur to a greater or lesser degree if adequate protection to the area is not provided at the moment the baby’s head is delivered and if extraction of the shoulders is not appropriately performed [11]. Performing an episiotomy is generally reserved for complicated childbirths, in cases of fetal distress, or when tearing of tissues with serious consequences is foreseen [12].

In the present study, NPRS after10 days was significantly lower in simple continuous group and subcuticular group than interrupted skin sutures group and was insignificantly different between simple continuous group and subcuticular group.

Similarly with Soliman et al. [13] who found that numbers of patients who expressed pain in the interrupted suturing technique were more than whom in the continuous suturing technique with a highly significant difference between two groups of pregnant women admitted for labour and underwent a mediolateral episiotomy before vaginal delivery.

In contrast with our results, Hasanpoor et al. [14] showed that pain severity and rate of perineum repair were similar in the two repair methods of episiotomy (continuous and interrupted methods) for 12-18 hours and on the 10th day after delivery. Their relatively small sample size and different follow period could justify this difference.

In our study, there was an insignificant difference in NPRS after 1 month among the studied groups.

This is also confirmed by Soliman et al. [13] who reported that at 21 days and at 3 months the difference between interrupted and continuous groups became nonsignificant.

Furthermore, Jena et al. [15] study results revealed that on 42nd day no difference in pain perception in continuous and interrupted groups was seen.

In addition, Lapeyrere et al. [16] found that there were insignificant differences between suture groups in 20 out of 22 evaluations.

In the present study, using the REEDA scale was used to evaluate the perineum requires the midwife to make an objective evaluation and there was an insignificant difference in REEDA after 10 days and 1 month among the studied groups.

This is in consistent with Soliman et al. [13] result which highlighted insignificant difference in REEDA scores whether after 12h, 14 days or after delivery between continuous and interrupted suturing techniques.

Further, Lapeyrere et al. [16] found no statistically significant differences between 14 of the 15-evaluation carried out. The only statistically significant parameter was the presence of ecchymosis at 2 h postpartum, with the frequency in the Interrupted Subcutaneous Suture Group being higher than the other 2 groups.

The SBSES was proposed in 2007 by Singer et al [10] and it was utilized in our study and there was a significant difference in SBSES among the studied groups. SBSES was significantly lower in simple continuous group and subcuticular group than interrupted skin sutures group p value <0.05. There was an insignificant difference in SBSES between simple continuous and subcuticular group.

The best method for repairing episiotomy is the method that is not time consuming and lesser materials and causes lesser pain in the immediate and long-term periods, hence in our study, there was a significant difference in suturing time among the studied groups. Suturing time significantly lower sutures group and in subcuticular group than interrupted skin sutures group.

In addition, Soliman et al. [13] recorded highly significant difference between interrupted and continuous groups regarding time needed for episiotomy repair and amount of suture material used for repair.

This was confirmed in Lapeyrere et al. [16] Study as the mean time taken to carry out suturing was lower in the continuous suture group with statistically significant differences between the three suture groups. The mean time was 12.86 (SD 4.9) minutes in the continuous suture group, 13.54 (SD 5.6) minutes in the interrupted cutaneous suture group, and 15.59 (SD 6.9) minutes in the interrupted subcutaneous suture group.

Suturing time was significantly lower in simple continuous group was than subcuticular group and interrupted skin sutures group and in subcuticular group than interrupted skin sutures group.         

Financial Support and Sponsorship: Nil

Conflict of Interest: Nil

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