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Randomized controlled clinical trial on two perineal trauma suture techniques in normal delivery. I RN, M. The aim was to compare healing and perineal pain with the use of continuous and interrupted suture techniques in women after normal delivery. A randomized controlled trial was carried out at a hospital birth center in Itapecirica da Serra, Sao Paulo, Brazil.

The main outcomes evaluated were edema, ecchymosis, hyperemia, secretion, dehiscence, fibrosis, frequency and degree of pain evaluated by numerical scale from 1 to Data were collected during hospitalization and after discharge four and 41 days after birth.

There were no statistically significant differences for the occurrence of morbidities, except for perineal pain due to palpation at four days after delivery, which was more frequent among women with interrupted suture. Descriptors: delivery; perineum; pain; suture techniques; obstetrical nursing; clinical trials. Maternal morbidity caused by perineal trauma in vaginal delivery is a common problem of global occurrence.

Annually, , women in the United Kingdom need postpartum perineal repair. Episiotomy is frequently performed and its incidence is variable, with rates ranging from 9. Although episiotomy is a routine intervention in most services, there is a downward tendency due to the advantages of its selective use.

Its prevalence diminishes sharply when it is done in view of a protocol of indications. In such cases, the occurrence of perineal lacerations is common and requires suture. In , There is little scientific interest in the study of episiotomy indications and complications as well as a lack of research on its surgical repair, denominated perineorrhaphy, despite its high prevalence and potential for morbidities, such as edema, haematoma, pain, infection and dehiscence.

The factors associated with morbidity and related to perineal trauma repair consist in the choice of the suture material, the repair technique and the surgeon's competence , giving rise to research fields in the birth care area 6. A literature review on skin suture techniques in perineal trauma after delivery found only four randomized trials, concluding that the continuous suture technique is associated to lesser pain in the short run.

However, authors point to the need for more studies comparing suture techniques After consideration of this scientifically little explored problem and taking into account the number of women who experience perineal trauma after delivery, the need for repair and local pain, this study was proposed to contribute to the reduction of perineal morbidity related to the suture technique.

The aim was to compare the characteristics of the healing process, the frequency and degree of perineal pain with the use of continuous and interrupted techniques of perineal trauma in women after normal delivery. Randomization was performed through an electronic table and applied at the moment of delivery to 95 women. A total of 34 women were excluded from the study and replaced by others, according to the randomization table. The estimator used to determine the sample size n was the result of a study on perineal pain in the first ten days after delivery.

Complete absorption occurs by hydrolysis within approximately 35 days. For a better result of the suture, "dead space" between the wound edge and exaggerated tension must be avoided, so that an adequate hemostasis of the bleeding vessels in the incision or tear is promoted.

Likewise, a minimum of suture levels is recommended, approximating separately the subcutaneous level in case of need. After the suture, hygiene of the perineum must be done with physiological solution. The interrupted and continuous suture techniques are described below:.

Interrupted technique: 1. Fasten the stitch with three knots, with two loops in the first, two inverted loops in the second and a single loop in the third knot, leaving the thread end with approximately one centimeter; 3. Proceed the suture of the mucous membrane with continuous locking stitches up to the hymeneal ring; 4. Fasten the last stitch the same way as the first and cut the thread; 5. In the muscle level, approximate the edges with interrupted stitches, fastening each stitch with three knots in the same way as the previous ones; 6.

Fasten each stitch and cut the thread, leaving the ends with one centimeter. Continuous technique: 1. Identical to the technique described above; 3.

Cut the thread, leaving the ends with one centimeter of length. The data collection was carried out in four steps: the first, denominated Greenberg period, corresponded to the first hour after finishing the perineal suture and was performed by the professional who assisted the delivery. The second step was performed by one of the researchers after consulting the patient's file in order to obtain data related to the parturient period of hospitalization.

The fourth step, denominated second return visit , was also carried out by the same researcher, about 41 days after the delivery, with a new interview and perineal exam. The first and second return visits occurred at the outpatient clinic of the HGIS or at the women's home, when the puerperal woman did not return on the scheduled date.

The independent variables were the continuous and interrupted perineal suture techniques. The dependent variables were: perineal healing process edema, ecchymosis, hyperemia, secretion, dehiscence and fibrosis ; perineal hygiene; suture conditions; frequency and degree of spontaneous perineal pain, and pain due to palpation, to sitting, walking, urinating, evacuating, sexual activity and use of analgesics.

For the signs indicative of healing, swollen perineum edema , altered skin color ecchymosis or hyperemia , indication of secretion in the suture site, separated suture edges in any of the levels dehiscence and engorgement of the cicatricial line fibrosis were considered. Perineal hygiene was considered adequate when the perineum had no accumulated dirt and inadequate when there was accumulated dirt or bad odor not attributed to the infectious process.

In the evaluation of suture conditions, the categories considered were: preserved, partially unfastened or totally unfastened. When the puerpera reported painful sensation, in the first, third and fourth steps of the study, according to the description above, the degree of pain was evaluated according to a numerical scale from 1 to 10, 1 indicating the lowest degree and 10 the highest. The use of analgesics distinguished the use of pain relief medication from hospitalization until the second return visit.

The other variables analyzed were: maternal characteristics age; vaginal deliveries and previous perineal scar; hematological conditions in the first return visit ; perineal suture characteristics type of trauma; professional who performed it and duration of suture; sutured layers, hemostasis method and bleeding after the suture ; characteristics of the newborn gestational age; vitality; weight.

The SPSS program was used for statistical analysis. Central tendency and dispersion measures were computed for descriptive analysis of the quantitative continuous variables, and absolute and relative frequencies were computed for the qualitative variables. The project was approved by the institution's Research Ethics Committee and the women's participation was voluntary after free and informed consent. The participation of midwives in the data collection was also voluntary. A total of 96 women who met the inclusion criteria were selected for the research, 95 were allocated in the study groups and n was The results of 31 women with continuous suture and 30 with interrupted suture were analyzed Figure 1.

The results regarding maternal conditions and characteristics of perineal suture are presented in Tables 1 and 2 , respectively. Tables 3 and 4 show the results regarding healing, frequency and degree of perineal pain in each of the study steps.

The median of the numerical scale from 1 to 10 was considered for the degree of spontaneous pain and palpation pain, according to the description provided in the Methods section. According to inferential analysis, there was a higher frequency of adequate perineal hygiene and lower frequency of perineal palpation pain with continuous suture in the first return visit, with statistically significant association for both variables Tables 3 and 4.

The results showed no statistically significant differences between the two perineal suture techniques for the other variables analyzed. Their weight varied between 2, and 4, grams, with an average of 3, The local inflammatory signs and symptoms such as edema, pain, redness and heat are expected in the initial phase of the healing process and subside as local reactions and absorption of the suture material evolve.

However, perineal trauma morbidities, such as haematoma, ecchymosis, infection and dehiscence, hinder complete maternal recovery. The puerpera's characteristics and general conditions, such as age, protein deficiency, deficit of tissue oxygen and drugs action, influence the time and quality of healing The variables that can affect the healing process, not controlled by the study inclusion criteria, were analyzed and indicated sample homogeneity Table 1.

The type of trauma, manipulation of the site and closeness of tissue levels in the suture are important aspects for the reduction of pain and the good evolution of the healing process.

Studies indicate better results in cases of spontaneous laceration when compared to episitomy, with less suture layers The technical details of the suture appoint the advantages of continuous suture Table 2. In this technique, large layers of muscle tissue are seized with approximation in one single level. The suture depends on the subcutaneous anatomic characteristics in the perineum; when this level is slim, its approximation occurs with the skin suture.

Although the application of some hemostasis method produces greater manipulation, it might be necessary because the perineal trauma bleeding is a morbidity factor. Bleeding after the suture, hardly frequent with continuous suture, indicates the hemostatic effect of this technique. The partially unfastened suture in the skin, verified in three cases with interrupted suture during the first return visit, can be attributed to the lack of an inverted slipknot in all knots.

In this study, despite the training provided, some nurses initially reported being afraid to perform continuous suture. Due to this fact, the majority of sutures with this technique was performed by the researcher Table 2.

This aspect, which can constitute bias, was appointed in other studies, suggesting that the interrupted technique is more commonly taught and easier to be performed by inexperienced professionals 1,6, The delay in trauma repair was smaller with the continuous technique, with the advantage that, the lesser time spent in the suture, the smaller the risk of infection and the puerpera's discomfort Table 2. The development of the healing process and the result observed in the second return visit postpartum did not indicate statistically significant differences between continuous and interrupted perineal suture techniques.

Precocious edema is more frequent in the Greenberg period and can be associated to manipulation during birth and to the anesthetics accumulated in the tissue. Its persistence can be attributed to local inflammatory reaction and to the quantity of material used in trauma repair Table 3. It is important to consider that polyglactin is a thread with short exudative phase, early proliferative phase and absorption by minimal tissue reaction Perineal ecchymosis, resulting from blood outflow to interstitial space, was more evident in the first return visit, without statistically significant differences between groups.

It is worth mentioning that, immediately after the suture, local bleeding was present in nine cases. Report of comparison of the esthetic results of the perineal suture with the traditional and continuous techniques, six weeks after delivery, indicates that scars were totally indistinguishable between both suture types, though skin closeness in the first technique is done by direct approximation of the edges while, in the second, tissue edges are incompletely united by a deeper intradermic suture.

In view of the results of eight years of clinical practice with continuous suture, in which there was no infection related to suture, the predisposition to perineal wound infection with the use of this technique was discarded Likewise, none of the puerperas presented infection of the perineal wound in the present study, although there were some cases of hyperemia.

In all cases, healing occurred in the first intention. Local hygiene is important for good healing and lochia is a means of culture for bacteria. The women in this study were oriented to keep perineal hygiene with water and soap. The knot on the skin left by the interrupted suture causes discomfort and fear of accidentally unfastening the suture, which can favor accumulation of dirt, predisposing to infection.

As presented in the Introduction, there is little research on perineal morbidity related to the perineal trauma suture technique during delivery. The RCT 1 performed with 1, women in England indicated that continuous suture reduces perineal pain in one out of six women, on the tenth day after delivery. The benefits of this technique were also evidenced in other periods of the puerperium 2 days, 3 and 12 months after delivery , with lesser pain when walking, sitting, urinating and evacuating.

Only in the case of complaints related to dyspareunia did the results of both continuous and interrupted techniques show no differences. These findings are similar to those obtained in the systematic review previously performed with four RCT Dyspareunia was reported as pain of higher degree among the same group of women, with median 7 Table 4.

We consider the main limitation of this study to be the lack of concealing, which cannot be performed for obvious reasons. However, the participation of more than one observer in outcome assessment might control the occurrence of measuring bias.











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