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

Notes: Objective To compare polyglactin 910 sutures with chromic catgut sutures for postpartum perineal repair.Design A stratified randomised controlled trial, using a 2 × 2 factorial design.Setting The maternity unit at Ipswich Hospital NHS Trust, a district general hospital, between 1992 and 1994.Sample 1780 women who had sustained an episiotomy or first or second degree tear following a spontaneous or simple instrumental delivery.Methods Policies of repair with polyglactin 910 or chromic catgut were compared. Both groups were assessed by a research midwife completing questionnaires at 24 to 48 hours and at ten days postpartum, and by self-completed questionnaires at three months after birth.Main outcome measures 1. 24 to 48 hours postpartum: perineal pain, healing; 2. ten days postpartum: perineal pain, healing and removal of sutures; 3. three months postpartum: perineal pain, removal of sutures, resuturing, dyspareunia, and failure to resume pain-free intercourse.Results Completed questionnaires were returned for 99% of women at both 24 to 48 hours and ten days and by 93% of women three months postpartum. The two groups were similar at trial entry. Significantly fewer women allocated to the polyglactin 910 reported pain in the previous 24 hours at both 24 to 48 hours (59%vs 67%; RR 0.89, 95% CI 0.83–0.95; 2P 〈 0.01), and ten days (24%vs 29%; RR 0.81, 95% CI 0.69–0.95; 2P = 0.01). At three months postpartum there was no clear difference between the groups in terms of perineal pain, dyspareunia or failure to resume pain-free intercourse. More women in the polyglactin 910 group reported that some suture material had been removed (12%vs 7%; RR 1.62,95% CI 1.19–2.21; 2P 〈 0.01). Three women in the polyglactin 910 group had required resuturing compared with ten in the chromic catgut group (RR 0.30; 95% CI 0.08–1.09; 2P=0.1).Conclusions Using polyglactin 910 rather than chromic catgut for perineal repair leads to about one fewer women among every 20 having perineal pain and using analgesia ten days postpartum. Its only apparent disadvantage is that more women, again estimated as 1 in 20, report having material removed during healing. Data from this and other trials suggest that for every 100 women repaired with a polyglycolic acid-based material, about one fewer will require resuturing.

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