Material and type of suturing of perineal muscles used in episiotomy repair in Europe

Episiotomy, the incision of the perineum during the last part of the second stage of labour or delivery is still considered a controversial procedure. Long-term complications after episiotomy repair are common. A large proportion of women suffer short-term perineal pain and up to 20% have longer-term problems (e.g. dyspareunia).1 Other complications involve the removal of suture material, extensive dehiscence and the need for resuturing.2 According to an Italian study, episiotomy is associated with significantly lower values in pelvic floor functional tests, both in digital tests and in vaginal manometry, in comparison with women with intact perineum and firstand second-degree spontaneous perineal lacerations.3 In another prospective trial of 87 patients, the pelvic floor muscle strength, assessed with the aid of vaginal cones, was significantly weaker in the episiotomy subgroup compared to a subgroup with spontaneous laceration.4 A German study did not reveal any difference in the pelvic floor muscle strength between groups with restrictive and liberal use of episiotomy.5 None of these trials are specific about the type of suturing material used. Some of the trials evaluating episiotomy and its consequence regarding suturing material, focus on the type of sutures and a technique used for suturing the superficial layers (skin or subcuticular).6 If mid-term absorbable polyglycolic acid sutures were used for repairing perineal muscles, a comparison to catgut 7, 8, 9, 10 or chromic catgut 11, 12 was usually made. One trial compared mid-term absorbable polyglycolic acid (Dexon II) with a new monofilament suture glycomer 631 (Biosyn).13 There were significantly more problems associated with monofilament material at 8-12 weeks postpartum (suture removal due to discomfort and pain) which might be explained by the longer absorption time of glycomer 631.13 In a recent trial, in which only a short-term absorbable polyglactin 910 (Vicryl RAPIDE) is used, a continuous suture is compared to an interrupted technique and a continuous suture is found to be superior.14 To our knowledge, three trials have compared shortand mid-term synthetic absorbable suturing material.15, 16, 17 In these, either only a standard mid-term absorbable polyglactin 910 (Coated Vicryl) or only a short-term absorbable polyglactin 910 (Vicryl RAPIDE) was used for all layers (vaginal mucosa, perineal muscles, subcuticular/skin). All of them focused on perineal pain and short-term complications of the repair and did not follow the pelvic floor muscle function. A small Danish randomized control trial (RCT) showed no difference in shortand long-term perineal pain, with a reduction in pain when walking on day 14 in a Vicryl RAPIDE group. Also, no difference was found between groups regarding episiotomy dehiscence.15 An Ulster study compared the same materials (Coated Vicryl and Vicryl RAPIDE).16 78 women were completed after birth with Coated Vicryl and 75 with Vicryl RAPIDE. At six and twelve weeks, a significant difference in the rates of wound problems (infection, gaping, pain, material removed) was found in favor of Vicryl RAPIDE.16 Kettle et al. performed a very well designed RCT with 1542 women.17 These were randomized into groups where either a standard mid-term absorbable polyglactin 910 (coated Vicryl) or a short-term absorbable polyglactin 910 (Vicryl RAPIDE) was used. The sutures of the perineal muscles and the skin were either, only interrupted, or only continuous, non-locking. The vaginal mucosa was always sutured continuously. This trial shows a clear benefit of the continuous technique compared to the interrupted. The pain at day 2, 10 and onwards up to 12 months postpartum was significantly lower in the continuous group. Also, all the other followed parameters (suture removal, uncomfortability, tightness, wound gaping, satisfaction with the repair and a return to normality within 3 months) were in favor of the continuous technique.17 Comparing the standard mid-term absorbable and shortterm absorbable polyglactin 910, in the parameter which differed most (suture removal), if sutures needed to be removed only visible transcutaneous sutures were removed from the continuous group. So the rate for suture removal, which was significantly lower for those who had received short-term absorbable polyglactin 910, is related to vaginal mucosa or skin and not to the sutures of perineal muscles.17 Pain at day 10 was not significantly different; however, some secondary pain measures (pain walking) were significant.17 The reduction in pain is achieved by inserting the skin sutures into the subcutaneous tissue and so avoiding nerve endings in the skin surface.18 So the difference at day 10 might be explained by a different rate of absorption between Vicryl RAPIDE and Coated Vicryl and irritating nerve endings in the skin (and not in the muscles) by the remaining Coated Vicryl sutures. Vicryl RAPIDE is Abstract: None of the trials evaluating episiotomy repair clearly focused on perineal muscles. The aim of this study was to describe suture material and styles of suturing perineal muscles in Europe by using an email and postal questionnaire. From 34 European countries, 122 hospitals agreed to participate. Thirteen different types of sutures are currently used. The most common material is polyglactin 910 (70%) followed by polyglycolic acid. Fifty one hospitals (46%) use only short-term and 49 hospitals (44%) use only mid-term absorbable synthetic sutures. In 8 hospitals both types of sutures were used. The most common size of suture is 2-0 USP. Thirty percent of hospitals use continuous and 47% hospitals interrupted sutures for perineal muscle repair. In 23% of the hospitals there is not a uniform policy. The technique of suturing perineal muscles is diverse in Europe. It is unclear whether short-term absorbable synthetic suture should substitute mid-term absorbable synthetic material in the perineal muscle layer.