CANTHESUTURINGMETHODMAKEADIFFERENCEIN

POSTPARTUMPERINEALPAIN?

Nancy Fleming, CNM, PhD

The sight of women hobbling along beneath the skin layer to close the between women with lacerations
the postpartum halls is so common- subcuticular tissue. Students are en- and women with episiotomies
place that most care providers have couraged to develop suturinq skills showed that although the women in
resignedly accepted the after- leading to a repair in-which theedges the epislotomy group experienced
stitches shuffle as an unavoidable are %eU-au!xoximated snusli and mom total pain, the dffferemes were
eonsequence of a birth that has in- in which a& fullnesshas bei; eased not statistically sign&ant. This
volved wturing. Nearly all nurse- in in order to appear as neat as a finding is simtlaf to other published
midwives have been taught a tradi- seam on machine-stitched clothes. rep~t?s,~-~which have found either
tional suturinq techniaue and have SigniBcant postpartum perineal pal no difference when comparing post-
utilized it Gthout $uestioning is anticipated so routinely, thdt anal- eptsfotomy and ~cemtion per-
whether the sutudnu method itself gesicsand perineal treatment options ineal pain a haw found more pr-
might have an imp&t on the ap- are usually ordered routinely and ineal discomfort with epfsiotomiea
parent Inevitability of postpartum indeed are themselves a frequent However, the results were remark-
perineal pain after an episiotomy or focus of research investigatfon.2 ably different than those of these au-
a laceralion. Recently, aidence has been pm- thors and those of Reading et al.,9all
The traditional suturing method sented that suggeststhat perhaps an of whom fcund significant perineal
involves placing one or two layers of alternative suturing method can IP- pain In women wfth au types of per-
Interrupted sutures to close tte deep duce the amount and duration of ineal wounds up unttl three months
and superflcfal transverse perineal postpartum pedneal pain. This au- postpartum. In conttast, Fleming
muscles, blanket sutures (locked thors doctoral research3, found a f.xtnd that by 48 houn postpartum
conUnuous stitches) lor the vaginal surprisinglylow level of p+?rinealpaIn the mean perceiwd perineal pain in
mucosa, a crown s&h to repair the in postpartum women compared to both the laceration and the eplsi-
bulbocavemasusmuscle, contfnuow general expectations and reports &my groups was rated as *mfld.
stitches for the perineal subcuta- from otho; researchers In the per- By hue weeks pasipxtum. the mean
neous fascia, and continuous mat- ineal pain area. As expected, this au- for bath grwps was closeto I73ne.
tresssutures piaced , one cell layer thor found that women with no su- Hemlng attdbuted this unexpectedly
tuuwshad the least amount of pain. low level of postpartum perineal
with pain lasting for the shortestpe- discomfort to the nontraditional
riod of time after birth. The analyses suturing method employed by her
of the comparison of perineal pain p&fca.a
 Other researchershave attempted ture materials used to close epi- have been identified in the literature
to analyze the impact of suturing siotomies and lacerations, and at- as bearing on pain during healing:
variables on postpartum perineal temoted to summarize ten trials the tightnw or loosenessof the su-
pain. In a 1986 cormneotmy on the con&ring commonly used sutuiing tures, the number of layers of su-
rep&r of episiotomies and perineal materials. Four conholkxl hi-& com- turing. and the placing of continuous
tears. Grant identified three factors pared absorbable skin sutures left in versus interrupted sutures. A study
a&i&d with morbidity related to place to dissolve es against nonab- by Stone, van Fraunhofer, and Mas-
pedneal repair of midline perineal sorbabk suture material removed in tersonle indicated that looselv an-
tissue disruption% the choice of su- the first week after delivery. All four proximated wound edges yielded
ture material, the technique of re- showed that absorbable material significantly stronger bonds after
p&, and the competence of the op- produced less pain than non&sorb- healing than wounds closed with
erator. Several authors have exam- able material in the immediate post- tight sutures. They found that su-
ined various @e.s of suture material partum period. However, of the tures placed too tightly in faxii Iwt
and debated b&fits of the differing studies specifically comparing dif- SOW of their usual strength. They
_.
hnws. SEI~IZ~suoaesteda method of
I
ferent types of absorbable suture theorized that this loss is due to tioht
matching suturing materials to the material, results were confounded sutures producing tissueoverlap iat
type of tissues inioived to enhance because different suturing tech- results in hypoxia, poor healing, and
the strength of wound healins. He niques were used as well. Thus, mesumahlv also increased pain
recommended absorbable material taken as a group. the date supported hudng the h&Jiig process.In a more
for vaainal tissues and claimed that no recommendations regarding recent article. Mastereon relterated
chromic catgut was appropriate for polyglycolic versus chromic catgut this principleof avolding constdcnng
these tissues because it mainlains suture material in reducing short- sutures and advocated sutures that
tensile strength during the critical term and long-term p&suturing per- incorpOrate large bites of tissue in
phase of heal!ng. ineal pain. order to keep stitchesloose and thus
Grn~@ looked swclhca3v ai oei- !lor. recentlv. Grant, Sleep, produce a stronger tissue bond.
ineal pain produced by vahous~su- Ashurst, and Spen~er~ reported on The second area of ixportetlce in
a comoarfsonof oain essociatedwith comparing suturing techniques is
the ;e of glycerol-impregnated that of the number of layers of su-
catqut (softc~~l es cornowed with tures that are adequate for proper
untreated ch;omic catg; and con- healing. Although it has been well
cluded that women repaired with the acknowledged fhat too much suture
degreein nuningfmm Stunford glycerol-treated catgut were more material retards healing, Increases
OniwrrnV in 1966. her M.S. in likely to have significant perineal the inflammatory process, and re-
matemoiichild nunhgfmm the pain et 10 days postpartum. They suns in increased pain,e standard
Uniuenity of Califomio in San Fmnclsco concluded that glycerol-impregnated perineal repair techniques usually
in1%8. end herPh.D. from the catgut has no place in the repair of continue to include several different
Uniuersi$ ofIllinois d Chimgo in 1987. perineal traum;. Another ;ecent layers of suturing to close dead
She holds an o,+ointment as an adjun~?
studv bv Mahomed and Grar# spacE, usually at least three, rather
faculty member In the graduatenuning
corn&& suturing methods and su- than simply taking larger bites of
depadmentof the Uniuenlty oflllinois at
Chicago,end is the clinicof directorfor turing technique= in a randomized tissue. However, for some time,
Comprehensiue Obntetr;a,Gvnecolo~~ clinical trial and concuded that prectnloners such es Munslckle have
and Midwifey. a full scopepnuote polyglycolic suture material has clear recognized that overzealous su-
pmmce in the w&em suburbsof advantagesover chromic catgut. Un- turing with many layers of sutures is
Chicam. Her ~mctice oatirws include fortunately. as the Mahomed study is a major wnmbutor to pain.
currently unpublished. no details are More recently, a single-layer su-
available to evaluate the research for turing technique has received favor-
the presence of confounding van- able attention for obstetric and mme-
ables or the validity of its conclu- cologic surgey. Gallup has &o-
slons. A randomized clinical trial c&d eliminatfng layering of sutures
employing a standardized suturing in abdominal gynecologic surgay to
WhnQue to comp?reValiOlLsabsorb increase the healing processand de-
able suture materials Is indeed in crease the rate of dehiecence. His
order. technique recommended large con-
In addition to suture material, tinuous bites taken to include dif-
three factors in suturing technique ferent types of tissues rather than

20 Jmel of Nuree-MkkvUew e Vol. 35. No. 1. Jaeewffebranl19~

placing separate suturing tn each were confoundedby examiningboth though clmelv placedsutures iritillv
tissue kver. a method with orincioles differing suturing methods with dif- addedto woid strength, there w&
quite &ilar to the &n&e fering suturing materials. Nonethe- evidence that ultimately swh su-
method presented in this pewr. He less, they found a substantially turing weakened the fascial layer.
darned that his method h& nor only aeater amOUntof lone-term wdneal Other physicians have noted that
the advantageof being safe but also pai associated with the interrupted many gyecok+ic wounds will heal
is more expedient and cost-efficient technique. On the basis of his re- well even if left completely usu-
than tri?dittonal methods because view, Grant advocateda continuous tured. and wound closure merely
less suture material is needed and Wuring technique, as did Bums et gives extra support for optimum
the closure takes Less dme to com- al.,= Gallup,= and Sanzz6 for coecuve t&sue iOzLiO.~ It h
plete. reasons of wound strength as well :a i&lji -truel+.at the ck&i they #we
?he technique of single-layer su- decreased pain. Jelsemaz7 also ad- to the skin, the more abundant are
turing is also becoming increasingly vocated a continuous versus inter- the pain ewe fibers, since Uw new
popular for closure of the uterus rupted suturina technique for the endings exteod between 4s of the
during cesareans.Dr. Russel J&ma u&s in c.esar& surg&y, but con- basal layer of the epidermis and ter-
rewrted at a recent ACOG meet- cludedon the basis of his stud& that minate around the hamk%cies.
in& that the single-layer suturing continuous suturing placedin a on- These cunet literdture-suoported
technique for uterine closure has locking manner has distinct advan- concltions regwd%g repair consid-
been documented to be as safe and tages over locking continuous su- erations and pcri. eal pain are re-
effective as the traditional double- tures in terms of producing less flected in the bax pranlse~ of the
layer technique. Following a com- tissue damage. alte-mtivesutudag technique Fiem-
parison of double-layer versus The literature does not specifically ing and ba parhlen utie. Basically.
single-layeroutcomes, he concluded address the depth of placement 01 they place sutures loos and
that the single-layer method seemed subcuticular continuous sutures. deep, employing a nonlo-z!:edco-
to result in better wound healing and However, San+ suggested that su- tinuous suturing meth~ti ii: 21 i+w
less tissue necrosis following ce- tures be placedone centimeter from layers es possible. They use either
sarea sections, and he theorized wowd ;dgzs, zince he fol! that al- chromic catgut or polyglycollc (Vi-
that the single-layer method pro-
duced less tissue strangulation and
necmsiq with a resultantly stronger
wound bond iess at risk for rupture
in subsequent pregnancies. He also
pointed out that the single-layer
mntinuous approach could be per-
formed significantly faster. Although
he did not mecificallv address the
issue of p&urgical pain, it would
seem logIcalto infer that tissue &ran-
gulation and ecrosls would have a
impact o pat I a negative man-
ner.
Several authors have spedfically FIGURE 1
examined the continuous versus ln- Closingthe vaginalmucosa.
temtpted sutudng issue. Grants ar-
ticI@ rumrnartzed several published
tdals that compared different per-
ineal suturing methods. Three tdak
compared interrupted with contin-
uous sutudnp, with all three finding
less p=zdnealpain in the Immediate
postpartum period aasoclated wlth
the continuous suturing technique.
Of these, only the Isager-Sally
group= followed women to three
months postpartum. and their results

Jce,,,,alof NumeMtdwtfery . Vol. 35, No. I. JanwWFebmary 1990 ?I

 vew bottom of the tissue separation
and eliminates dead space. To do
this. the needle Is exited at the
trough of the separation after taking
the first half of each stitch from the
edge of the vaginal tissue,the needle
repositioned on the needle holder,
and then the second half of each
stitch IS continued from the bough to
the opposite mucrxal edge (FIgwe
1). Taking large bites of tissue, using
usually three o* four stitchesto dose
FIGURE 2 the vaginal portion up to the hy-
Approstmatingthe bul- menalhng, ~sututing is continued
baavemorus muscle. without a lockina stitch at the hv-
manal ring, bringing the needie
through the ttssue underneath the
hymenal ring, and exltlng in front of
it At this point, the bulbocavemosus
muscle is closed using a vay large
bite of tissue on either side of the
separation in order to build up the
perineal body there. Care is taken to
make the tissue bite wide laterally
but not too deep. so as to avoid
catching rectal f&sue, and caution is

cryi) suture material, depending on

personal preference. Fleming settled
on chromic catgut because she feels
it slides more smoothly, making it
easier to keep the=stitches loose; the
physician prefers Vicryl. Subcuta-
neous sutures are placed deeply i:,
the subcutaneous layer, with a resul-
tant tissue sepamtion of 2 or 3 mm
behwen skin edges upon comple-
tlon.
In the alternative method, the ce-
pair Is begun by anchoringthe suture FIGURE 3
in the lmditional method with a knot Beginning to close the
placedabove the apex of the vaginal pelinealseparation.
portion of the tissue separation.
Having cut the short end of the su-
ture material close to the knot, the
vaginal mucosa Is closed by taking
large, runnillg contiuous, not
locked-continuous. suture stitches
(Figure 11. Unless the vaginal mu-
coral tissue separation is exceedingly
shallow, two steps are used in the=
nonlocked continuous stltches to
make sure that the stitch reaches the

7.2 dournal ofNurse-Midtifery

Vol. 35. No. 1, danuaryffebrua~1990
l
 Al the apex of tile perinealsqwa-
tion. the stitching direction is re-
vervzd and the rrwnd layer of non-
locked conY,,,uousstitches is &aced
(Figure 41. Rather than theusual
subcuticular stitches placed just
helow the sldn sudace, the altma-
tive method subcuticulaf stitcher
are placed deeper in the subcuta-
neous faxia. avoiding the !xofuan
o! new2 endings pr&t ii; the skin
surface (Figure 5). Still using the
FIGURE 4 original suture and continuing to
First layer of penneal place the stitches far apart &td
separationclosed. loosely, the subcuticular repair is
completed to the hyr.lenal ring.
where the needle is again swung
under the tissue, anchored with a
terminal knot in be w@na, and cut
in the usual fashion (Figure 6).
Although the researchers report
benefits in terms of decreasedpain
and increased mobility of women
following this sutunng technique,
practitioners and postpartum nurses
admit to a personal uneariness when

used so as not to aowoximate the

two sides too clos& with a tight
stitch (Figure 2).
At this point, dosure of the per-
ineal separation in either one or two
layers is begun, still using the same
suture and placing only loose, non-
locked continuous stitches. Exped-
ence has shown that all lacerations
less than third-degreeand all episiot-
omies without extension are able to
be successfully closed without any
layer of interrupted stitches, and FIGURE 5
some may be closed wing anly one The subalt,
lqler. If the paiwal separation war-
rants two layers far closure, the Rrst
is placeddeep through the trough of
the separabn. beginningeachtissue
bite about halfway between the top
and bottom of the disruption IFIgure
3). Usually the tissue separation is
less deep, and vtsuallmtlon Is easier
so that a single-step stitch is suffi-
cient, without exiting the needle at
mtdpoint III the trough, as with the
vaginal sutcbing.

Journal of Nurse.Mlddfny . Vol. 35. No. 1, JanuaryiFebmar~,990 29

 2. Hill PD: Effects of heat and cold
on tie perineum after episiotomy,lacere-
tic,. J Nurs Midwif 34(2):124-129,
1989.
3. Fleming N: Comparison of
Women with Different Pertneal Condi-
tiane after Childbi. Ann Arbor, Mich.,
UMl, 1987, pp 120-128.
4. Fleming N, Schafer Aw: Post-
partum paineal pain and sexual function
in women with and without epkicombr.
in van Hall EV, Everaerd W teds), The
Free Woman: Womens Health In the
FIGURE 6 1990s. New Jersey, Parthenon Pub-
Repair completed with lishing Group. 1989, pp 262-283.
anchoring knot in vagina. 5. Harrison R Brennen M, et al: ls
routine episiotomy necessary? Br Med J
288:1971-1975,1984.
6. Sleep J, Grant A, et al: West
Berkshire pedneal menegement trial. Br
Med J 289:587-590,1984.
7. Gamer P: Dyspaeunia after episi-
otomy. Br J Sex Med 6(10):11-13,
1982.
8. Kilnger s: Episiotomy: Physical
and emotionel espects. London, Na-
tional Chidbilth Trust 1981. pp 1-6.
9. Reading A, Sledmere C, et al:
How women view postepisiotomy pain.
Br Med J 284243-245.1982.
first exposed to nontraditional re- clinical practice, this author found in- 10. Flemtng N: Comparison of
pairs. Whereas the standard suturing fections related to suturing almost Women with Different Perineal Condi.
method produces a wound dosely nonexistent.~ 50s after Childbirth.e pp 207-210.
approximated at the skin tissue Can the suturing method make a 11. Grant A: Commentary: repair of
edges, the alternative repair tech- difference in postpartum perineal episiotomies and perineal teas. Br J Ob-
nique results in a skin-edge gap. Ini- pain? Definitive answers must wait stet Gynxol93:417-419.1986.
tially, Some expressed concern about for well-designed research trials. 12. Sanz LE: Wound management- -
the long-term cosmetic reeults of the However. both oubllshed literature matchins materials and methcxlr far best
alternative method, although many and clinical out&nes suggest that results. Cantemp ObiGyn 30(4):86-
noted that when a womans legs this alternative suturing method is 114, 1987.
were in a normal, nonlithotomy po- beneficial in reducing what has come 13. Gmnt A: Commentary: repair of
sition, the tissue edges came to- to be regarded as usual post- eptsiotomies and perineal tears. pp
gether well witlout fhe snug, shallow partum pain. It may be time to revise 418-419.
subcuticular suhnes. However, when traditional suturing techniques. 14. Grant A. Sleep J, Ashurst H,
the cosmetic effect was examined at Spencer JAD: Dyspareunia associated
six weeks postpartum, it was found with the use of glycerol-impregnated
catgut to repair perineal trauma: repal of
that the scar visible at that time was
a threeyear study. Br J Obrtet Gynaecol
almost always of hairline thickness,
(Ill pressI.
and completely indistinguishable
15. Mahomed K, Grant A: The
from scars remaining after using the
Southmead pedneal suhne trial: a ran-
standard suturing technique. domized comparison of suhlre mete&&
A further concern with the altema- and suturing techniques for repair of per-
live technique initiaUy was whether ineel trauma (unpublished).
the skin gap might predispose to REFERENCES
16. Stone K, on Fraunhofer J, Mas-
paineal wound infections. However, 1. Vamey H. Nurse-Midwifery. terse B: The biomechanical effeck of
after eight years of keeping statistics Boston, Blackwell Scientific Publications, tight euture closure on fascia. Surg Gy-
related to this suturing technique in 1980, pi 621-630. necol Obstet 163:448-452.19%.

24 Journal of Nurse-Midwifery . Vol. 35. No. 1, January/February 1990

 17. Maslerso BJ: Takina slew ,.a colo@s (ACOG). AUanb May 5. 1989 25. Gallup D: Monofilament closure
pIomOte wound healing. Co&& Dbi fpublkation pending). technioue held effective for g,,,eca,ogic
Gym 31(3):119-130.1988. incisions, p 3
18. arney H: Nrre-Midwifely. p
626
19. Munsick R: Introital operations for 23 fsager.Sally L. Legsrth J, et al:
dyspareunta. Cli Obstet Gynecal 2311): Episiotomy repair-immediate and 27. Jetsema RD: Cortinwus no-
244-271.1980. long-term seq*lile: a prorpecave mn- lccking single byer Uterine suhne.~
20. Gallup D: Monofilament ckxu~e do&d study of three different methcds 28. Sam LE: Wound maagemet-
technique held &e&w for gynecologie of repair. Br J Obstet Gyaecol93:420- matching mataiafs and methods for hen
inc&kms. ACOG News Bulletin 21(41:3. 425, 19% results.~ p 107.
1988. 24. Bums J. Davis G. Hemandez E: 29. Masterson BJ: Taking steps lo
21. Jelsema RD: Continuous non- One wynr ex@mce tith contin- pmnwte wound healing, p 124.
loininy sin& tayer wane swum Video uous fatial closure in wnecoloqic oa- 30. Fleming N: Comparison of
presented at national meeting al &met- Bents. Am J Gynecol t&h ll~l~& - women with different perineal conditfons
ican College of Obstetricians and Gyne- 43, 1987 aher childbirth. p 120.

Journal of Nurse-Midwffery l Vol. 35. No. 1. JanuarylFebmaw 1990 25