gynecology and obstetrics medical project, gynecology journal, obstetrics, gynecologic oncology, reproductive medicine, gynecological endoscopy, ultrasonography, gynecology articles

Ginekologia i Poloznictwo
ISSN 1896-3315 e-ISSN 1898-0759

Research Article - (2023) Volume 18, Issue 1

A prospective cohort multicentre comparision of two episiotomy repair techniques: Skin adhesive strips vs. subcuticular suture

Mohamed I Taema1, Nada Alayed2*, Salwa Niazi2, Khalid Akkour2, Eman Al Shehri2, Ibrahim AlHandalishy3, Osama Deif3 and Nagy Mohamed Metwally Ahmed4
 
*Correspondence: Nada Alayed, Department of Obstetrics and Gynecology, King Saud University, Riyadh, Saudi Arabia, Tel: +966 554403402, Email:

Received: 14-Nov-2022, Manuscript No. gpmp-22-79690; Editor assigned: 15-Nov-2022, Pre QC No. P-79690; Reviewed: 28-Nov-2022, QC No. Q-79690; Revised: 05-Dec-2022, Manuscript No. R-79690; Published: 29-Dec-2022

Author info »

Abstract

Introduction: Episiotomy is one the most common surgical procedure that performed daily. Post-operative pain and wound healing are of great concern to the female.

Aim: To compare adhesive tape and continuous subcuticular suture for episiotomy repair after delivery as regard pain, operative time and wound infection. Design: prospective cohort comparative study.

Methods: One-hundred patients were equally divided into two groups. Group 1 patients delivered in one hospital, they underwent skin repair with adhesive tape, while group 2 are patients delivered in second hospital, and they underwent the episiotomy repair by continuous subcuticular suture. Primary outcome was Pain 6 and 12 hours postoperative and 1 week post-delivery using Wong-Baker faces pain rating scale. Skin closure time and wound infection were secondary outcomes.

Results: Statistically significant difference in pain after episiotomy repair in favor of the adhesive group (p-value <0.05) after 7 days. No statistically significant difference between both groups as regard skin closure time or wound infection.

Conclusion: Skin adhesive tape may be better to subcuticular suture in pain perception resulting from episiotomy repair after delivery.

Keywords

Adhesive tape; Continuous sutures; Episiotomy repair; Pain episiotomy

Introduction

Episiotomy was introduced in 1950 as a prophylactic procedure to decrease the risk of vaginal and perineal tears as well as to fasten delivery [1]. In a Cochrane review in 2017 there was no evidence that routine episiotomy has the previously assumed benefits and concluded that more restricted use of episiotomies will result in lesser women with severe perineal or vaginal trauma [2]. WHO recommend episiotomy performance only when there is a strong clinical indication [3].

Perineal tears can cause infection, bleeding and postpartum pain which increase the risk of depression, dyspareunia negatively affecting the sexual health and the quality of life [4,5].

Sherif and Al-Shourbagy, 2020 studied the skin adhesive tape in their RCT vs. interrupted skin suture, they concluded that Skin adhesive could be better than skin suturing in postpartum pain resulting from episiotomy repair after birth [6].

The aim of current work was to compare skin adhesive tape in perineal skin closure in episiotomy repair and the second technique was continuous subcuticular suture.

Patients & Methods

This study was performed in 2 hospitals in Kingdom of Saudia Arabia. Ninty-Six with same indications of episiotomy (Primigravida or Rigid perineum) were equally divided into two groups each group in one hospital (so that the number in each hospital is the same to avoid statistical bias). Forty-Eight patients in Group 1 delivered in one hospital, they underwent skin repair with adhesive tape (Steristrips, 3M, coock medical supply), while another 48 patients in group 2 delivered in second hospital, they underwent episiotomy repair by continuous absorbable subcuticular suture. Both hospitals are of same class and deliveries were handled by same experienced doctors (Registrars and senior registrars).

Primary outcome was Pain postoperative and 1 week post-delivery using Wong-Baker faces pain rating scale. Skin closure time and wound infection were secondary outcomes.

Sample size justification

The study included all women fulfilling the inclusion and exclusion criteria who were admitted between January 2022 and June 2022 at the 2 hospitals and proper informed consents were undertaken from the patient.

Patients after informed consent, were subjected to full history taking (personal, menstrual, detailed obstetric & past surgical history), examination (general, obstetric & local pelvic examination), and routine investigations (C.B.C, Rh, blood grouping and albumin in urine) and ultrasonography to select the patients fulfilling the inclusion criteria which are: age 18 till 40, term pregnancy either primigravid or multigravida, patients in labor either induced or spontaneous onset, Patients excluded from start are those with malpresentations as breech, Preterm pregnancy, multiple pregnancies, suspected macrosomia, polyhydraminos or cases with oligohydramnios or FGA, Third and fourth degree perineal tear.

Group 1 underwent skin repair with skin adhesive tape, while group 2 underwent the currently traditional method for episiotomy repair by continuous absorbable subcuticular suture.

Surgical procedure

Episiotomy: When crowning occurred (the vulvovaginal opening is dilated by the largest fetal head diameter, infiltration of 1% lidocaine and a medio-lateral episiotomy was done, scissors were positioned at 7 o’clock, and the incision was extended 3 to 4 cm toward the towards ischial tuberosity.

Perineal repair following delivery: As soon as birth was completed the initial assessment performed gently and sensitively to classify the perineal trauma caused by episiotomy. Perineal tears of 3rd and 4th degree were excluded from the study. The vagina inspected and the apex of the episiotomy or perineal tear identified. If needed, another infiltration with 1% Lignocaine up to a total of 20 ml to the area. A gauze maternity tampon was inserted into the upper vagina, above the trauma to absorb any bleeding from the uterus, which may obscure the field of operation.

After good identification of apex of wound, suturing of the vagina began approximately 1 cm above the apical point and the vaginal wall was sutured using a continuous non-locking technique till to the hymen, then the needle placed behind the hymenal remnants and emerge in the center of the perineal muscle. After checking the depth of trauma, the perineal muscles were repaired in one or two layers with the same continuous stitch leaving no dead space [7-9]. Follow up of all women were followed up at the first visit postpartum for pain by using of VAS score, wound healing and wound infection.

The time started to be calculated and cases were divided as follows:

Group 1 Steri-strips (3M™ Steri-Strip™ 6 mm x 100 mm; reinforced skin closure) applied perpendicular to the wound by lifting the skin edges up with gloved finger, placing the first 1/2 of steri-strip tape with 90 degree angle over the first edge, pressing firmly, ensure edges are met together then placing the other half and press firmly. Three to four tapes were placed with approximately 0.5 cm distance space in between them.

Group 2 polyglactin 910 (Vicryl Rapid™ 2-0) was used as follow: After repairing the muscular layer the continuous suture was then carried upward as a subcuticular stitch and the final knot was tied at the end of the cut.

Time was recorded for both groups.

Outcome measures

As the local injectable lidocaine become effective within 5-10 minutes, and lasts on average from 45 minutes to 1 hour [10], all participants were evaluated for pain 6 hours 12 hours and 7 days after delivery, using Wong-Baker faces pain rating scale with verbal expression for pain intensity.

Before discharge, after brief explanation, all women participating were instructed to put dressing and cover the area of steri-strips and to avoid wetting of the dressing with underneath steri-strips as possible and they were instructed to come and replace steri-strips in case they got wet and fall.

Patients were instructed to complete a home daily postnatal pain score chart of 7 days duration using the same scale and were instructed to review the hospital for second evaluation. The patients were able to contact hospital by visit or telephone all through the 7 days, in case of fall of steri-strips.

In the second visit (seven after delivery) evaluations of the wound were done using REEDA score (redness, edema, ecchymosis, discharge and wound approximation), and the patients were asked to complete a 2nd questionnaire to evaluate their satisfaction and pain intensity they experienced during daily activities (using the same pain scale).

Statistical analysis

Numerical data were explored for normality by check using tests of normality (Kolmogorov-Smirnov and Shapiro-Wilk tests). Data were presented as median and range values. For non-parametric data Mann-Whitney U test was used for comparison between the two groups. Qualitative data was done by using Chi-square test or Fisher’s exact test, when appropriate. The significance level was set at P ≤0.05. Statistical analysis was performed with IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY:IBM Corp.

Results

Tab. 1. showed that there was no statistical Significant difference between adhesive strip group and vicryl suture closure regarding the demographic data. Tab. 2. shows difference between suture closure and adhesive strip group regarding 6 and 12 hours postoperative pain and 7 days postpartum. Tab. 3. shows REEDA score healing assessment in the 2nd visit (7 days after birth).

Variables Group 1 [Adhesive strip Group]
(n=48)
Group 2 [Suture closure Group]
(n=48)
Test value P
Age (Years)
Range 19 – 38 18 – 39 U:1.672 0.152
Median (IQR) 27 (21.8–32) 29 (23–33)
Gestation at Delivery (weeks)
Range 38 – 41 38 -41 U:0.731 0.633
Median (IQR) 39.6 (38.8 – 40.4) 39.7 (38.8 – 40.3)
Number of cases with episiotomy 28 (58.3%) 30 (62.5%) x2:0.175 0.676
Number of cases with 1st & 2nd degree perineal tear 20 (41.7%) 18 (37.5%) x2:0.175 0.676

Tab. 1. Difference between adhesive strip group and vicryl suture closure and regarding the demographic data.

Pain score Group No Mild Moderate Severe Very Severe Worst Pain X2 P
6 hours Suture 0 (0.0%) 19 (39.6%) 26 (54.2%) 3 (6.3%) 0 (0.0%) 0 (0.0%) 3.378 0.337
Adhesive 1 (2.1%) 26 (54.2%) 19 (39.6%) 2 (4.2%) 0 (0.0%) 0 (0.0%)
12 hours Suture 0 (0.0%) 19 (39.6%) 25 (52.1%) 4 (8.3%) 0 (0.0%) 0 (0.0%) 1.137 0.566
Adhesive 0 (0.0%) 24 (50.0%) 20 (41.7%) 4 (8.3%) 0 (0.0%) 0 (0.0%)
7 days Suture 18 (37.5%) 23 (47.9%) 7 (14.6%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 6.509 0.039*
Adhesive 27 (56.3%) 20 (41.7%) 1 (2.1%) 0 (0.0%) 0 (0.0%) 0 (0.0%)

Tab. 2. Difference between suture closure and adhesive strip group regarding pain evaluation in the 1st day after birth.

Score Group 0 1 2 X2 P
Redness Suture 23 (47.9%) 25 (52.1%) 0 (0.0%) 0.042 0.838
Adhesive 25 (52.1%) 23 (47.9%) 0 (0.0%)
Edema Suture 46 (95.8%) 2 (4.2%) 0 (0.0%) 0.000 1.000
Adhesive 46 (95.8%) 2 (4.2%) 0 (0.0%)
Ecchymosis Suture 48 (100.0%) 0 (0.0%) 0 (0.0%) -- --
Adhesive 48 (100.0%) 0 (0.0%) 0 (0.0%)
Discharge Suture 48 (100.0%) 0 (0.0%) 0 (0.0%) -- --
Adhesive 48 (100.0%) 0 (0.0%) 0 (0.0%)
Approximation Suture 47 (97.9%) 1 (2.1%) 0 (0.0%) 0.000 1.000
Adhesive 47 (97.9%) 1 (2.1%) 0 (0.0%)
Total Suture 22 (45.8%) 23 (47.9%) 3 (6.3%) 1.043 0.594
Adhesive 23 (47.9%) 24 (50.0%) 1 (2.1%)

Tab. 3. REEDA score healing assessment in the 2nd visit (7 days after birth).

Discussion

Calculating the time of skin procedure only, decreased the bias of other delays, which may have happened and gave a precise idea about the real timing of the procedure; however, the main difficulty with application of the skin adhesive tape in the current study was keeping the wound dry, which was felt to cause a substantial loss of time with the procedure, this may be attributed to the nature of the perineum and the episiotomy process itself. However, other studies as Ghosh A, et al. [8] stated that wound closure with adhesive tape was easier and faster in comparison to intra-cuticular skin closure after CABG (coronary artery bypass grafting). Also, there was significantly less edema and redness in the skin adhesive tape group.

The current study showed no significant difference in pain 6 hours and 12 hours after birth in favor of the Steri-strips group, which can be explained to the effect of local anesthesia given before episiotomy and analgesia given. Our results showed a significant difference in pain score 7 days after delivery in advance of the adhesive tape group, this finding may be caused by exaggerated body response to the sutures although the second evaluation using the REEDA score showed insignificant differences between both groups, and there were no cases of wound infection in either group. There was also an insignificant difference between both groups in the time of skin closure, although the adhesive tape group had a wider time range, which may be attributed to more operators’ experience in skin suturing.

Sherif and Al-Shourbagy studied the skin adhesive tape in RCT vs. interrupted skin suture, they concluded that Skin adhesive tape could be better than skin suturing in postpartum pain resulting from episiotomy repair after birth [6]. This is in accordance with the results of the present study.

Kindberg et al (2018) compared interrupted, inverted stitches with continuous stitches for perineal repair and leaving the skin without suturing, they concluded that all three methods appear to be equivalent, there were no difference seen in perineal pain 10 days after birth using The Visual Analogue Score and in wound healing evaluated by the REEDA scale at 24–48 hours and 10 days postpartum, which is similar to the results of the REEDA score found in the current study [7].

Calculating the time of skin procedure only, decreased the bias of other delays, which may have happened and gave a precise idea about the real timing of the procedure; however, the main difficulty with application of the skin adhesive tape in the current study was keeping the wound dry, which was felt to cause a substantial loss of time with the procedure, this may be attributed to the nature of the perineum and the episiotomy process itself. However, other studies Ghosh et al., (2015) reported wound closure with adhesive tape to be easier and faster although the results were insignificant as compared to intracuticular suture closure after coronary artery bypass grafting; however, there was significantly less redness and edema in the adhesive tape group [8].

Few studies compared the skin adhesive tape with continuous suture in episiotomy skin closure, yet other larger number of studies compared adhesive glue to sutures as Feigenberg et al (2014) targeting a heterogeneous sample of primiparous and multiparous with a total number of 100 and 97 women respectively both supported the potential benefits of glue use, as a better alternative to sutures as regards procedure time and reduced pain sensation although there was insignificant difference between both groups at 7 and 30 days [9]. However, the cost of glue use may be an issue especially in a developing country with limited resources like Egypt, while Lazar et al., reported increase in pain sensation in the sutured arm when comparing skin adhesive tape to suturing the skin in surgeries other than obstetric [10].

Main limitation of this study is inadequate number of patients as Arab women backward Islamic culture limits their participation in clinical trials, also lack of randomization in this study because there are no RCT units in these hospitals, the private patients refuse the idea non wound suturing and the hospital ethical committee was not encouraging the idea stating that we are not a governmental hospital.

Further studies are needed to evaluate effective way of episiotomy skin closure.

Conclusion

Skin adhesive tape may be superior to skin suturing in decreasing perineal pain after birth.

Ethics Approval

Study approved by Ethical Committee of 2 hospitals.

Consent for Publication

Non applicable

Availability and Data Material

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing Interests

There are no competing interests to declare.

Funding

This study received no financial support.

Authors Contributions

All authors equally contributed to present study.

References

  1. He S, Jiang H, Qian X, et al. Women’s experience of episiotomy: A qualitative study from China. BMJ Open. 2020;10(7):e033354.
  2. Google Scholar, Crossref, Indexed at

  3. Jiang H, Qian X, Carroli G, et al. Selective vs. routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev. 2017(2).
  4. Google Scholar, Crossref, Indexed at

  5. World Health Organization. WHO recommendations on intrapartum care for a positive childbirth experience. WHO. 2018.
  6. Google Scholar

  7. Swenson CW, Low LK, Kowalk KM, et al. Randomized trial of 3 techniques of perineal skin closure during second‐degree perineal laceration repair. J Midwifery Womens Health. 2019;64(5):567-77.
  8. Google Scholar, Crossref, Indexed at

  9. Arnold MJ, Sadler K, Leli K. Obstetric lacerations: Prevention and repair. Am Fam Physician. 2021;103(12):745-52.
  10. Google Scholar, Indexed at

  11. Sherif A, El-Shourbagy M. Skin-adhesive tape vs. interrupted suture in episiotomy skin repair: Randomized control trial. Open J Obstet Gynecol. 2020;10(02):254.
  12. Google Scholar, Indexed at

  13. Kindberg S, Stehouwer M, Hvidman L, et al. Postpartum perineal repair performed by midwives: A randomised trial comparing two suture techniques leaving the skin unsutured. BJOG: Int J Obstet Gynaecol. 2008;115(4):472-9.
  14. Google Scholar, Crossref, Indexed at

  15. Ghosh A, Nanjappa M, Nagaraj V, et al. Comparison between stainless steel staples and silk sutures for primary closure of skin in patients undergoing neck dissection: A comparative clinical study. Contemp Clin Dent. 2015;6(Suppl 1):S51.
  16. Google Scholar, Crossref, Indexed at

  17. Feigenberg T, Maor-Sagie E, Zivi E, et al. Using adhesive glue to repair first degree perineal tears: A prospective randomized controlled trial. Biomed Res Int. 2014;2014.
  18. Google Scholar, Crossref, Indexed at

  19. Lazar HL, McCann J, Fitzgerald CA, e al. Adhesive strips vs. subcuticular suture for mediansternotomy wound closure. J Card Surg. 2011;26(4):344-347.
  20. Google Scholar, Crossref, Indexed at

Author Info

Mohamed I Taema1, Nada Alayed2*, Salwa Niazi2, Khalid Akkour2, Eman Al Shehri2, Ibrahim AlHandalishy3, Osama Deif3 and Nagy Mohamed Metwally Ahmed4
 
1Department of Obstetrics and Gynecology, Ain Shams University, Cairo, Egypt
2Department of Obstetrics and Gynecology, King Saud University, Riyadh, Saudi Arabia
3Department of Obstetrics and Gynecology, Faculty of Medicine, Al- Azhar University, Cario, Egypt
4Department of Obstetrics and Gynecology, Zagazig University, Zagazig, Sharqeya, Egypt
 

Copyright:This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.