CANTHESUTURINGMETHODMAKEADIFFERENCEIN
POSTPARTUMPERINEALPAIN?
Nancy Fleming, CNM, PhD
The sight of women hobbling along
the postpartum halls is so common-
place that most care providers have
resignedly accepted the after-
stitches shuffle as an unavoidable
eonsequence of a birth that has in-
volved wturing. Nearly all nurse-
midwives have been taught a tradi-
tional suturinq techniaue and have
utilized it Gthout $uestioning
whether the sutudnu method itself
might have an imp&t on the ap-
parent Inevitability of postpartum
perineal pain after an episiotomy or
a laceralion.
The traditional suturing method
involves placing one or two layers of
Interrupted sutures to close tte deep
and superflcfal transverse perineal
muscles, blanket sutures (locked
conUnuous stitches) lor the vaginal
mucosa, a crown s&h to repair the
bulbocavemasusmuscle, contfnuow
stitches for the perineal subcuta-
neous fascia, and continuous mat-
tresssutures piaced , one cell layer
beneath the skin layer to close the
subcuticular tissue. Students are en-
couraged to develop suturinq skills
leading to a repair in-which theedges
are %eU-au!xoximated snusli and
in which a& fullnesshas bei; eased
in in order to appear as neat as a
seam on machine-stitched clothes.
SigniBcant postpartum perineal pal
is anticipated so routinely, thdt anal-
gesicsand perineal treatment options
are usually ordered routinely and
indeed are themselves a frequent
focus of research investigatfon.2
Recently, aidence has been pm-
sented that suggeststhat perhaps an
alternative suturing method can IP-
duce the amount and duration of
postpartum pedneal pain. This au-
thors doctoral research3, found a
surprisinglylow level of p+?rinealpaIn
in postpartum women compared to
general expectations and reports
from otho; researchers In the per-
ineal pain area. As expected, this au-
thor found that women with no su-
tuuwshad the least amount of pain.
with pain lasting for the shortestpe-
riod of time after birth. The analyses
of the comparison of perineal pain
between women with lacerations
and women with episiotomies
showed that although the women in
the epislotomy group experienced
mom total pain, the dffferemes were
not statistically sign&ant. This
finding is simtlaf to other published
rep~t?s,~-~which have found either
no difference when comparing post-
eptsfotomy and ~cemtion per-
ineal pain a haw found more pr-
ineal discomfort with epfsiotomiea
However, the results were remark-
ably different than those of these au-
thors and those of Reading et al.,9all
of whom fcund significant perineal
pain In women wfth au types of per-
ineal wounds up unttl three months
postpartum. In conttast, Fleming
f.xtnd that by 48 houn postpartum
the mean perceiwd perineal pain in
both the laceration and the eplsi-
&my groups was rated as *mfld.
By hue weeks pasipxtum. the mean
for bath grwps was closeto I73ne.
Hemlng attdbuted this unexpectedly
low level of postpartum perineal
discomfort to the nontraditional
suturing method employed by her
p&fca.a
 Other researchershave attempted
to analyze the impact of suturing
variables on postpartum perineal
pain. In a 1986 cormneotmy on the
rep&r of episiotomies and perineal
tears. Grant identified three factors
a&i&d with morbidity related to
pedneal repair of midline perineal
tissue disruption% the choice of su-
ture material, the technique of re-
p&, and the competence of the op-
erator. Several authors have exam-
ined various @e.s of suture material
and debated b&fits of the differing
_.
hnws. SEI~IZ~suoaesteda method of
I
matching suturing materials to the
type of tissues inioived to enhance
the strength of wound healins. He
recommended absorbable material
for vaainal tissues and claimed that
chromic catgut was appropriate for
these tissues because it mainlains
tensile strength during the critical
phase of heal!ng.
Grn~@ looked swclhca3v ai oei-
ineal pain produced by vahous~su-
degreein nuningfmm Stunford
OniwrrnV in 1966. her M.S. in
matemoiichild nunhgfmm the
Uniuenity of Califomio in San Fmnclsco
in1%8. end herPh.D. from the
Uniuersi$ ofIllinois d Chimgo in 1987.
She holds an o,+ointment as an adjun~?
faculty member In the graduatenuning
depadmentof the Uniuenlty oflllinois at
Chicago,end is the clinicof directorfor
Comprehensiue Obntetr;a,Gvnecolo~~
and Midwifey. a full scopepnuote
pmmce in the w&em suburbsof
Chicam. Her ~mctice oatirws include
20
ture materials used to close epi-
siotomies and lacerations, and at-
temoted to summarize ten trials
con&ring commonly used sutuiing
materials. Four conholkxl hi-& com-
pared absorbable skin sutures left in
place to dissolve es against nonab-
sorbabk suture material removed in
the first week after delivery. All four
showed that absorbable material
produced less pain than non&sorb-
able material in the immediate post-
partum period. However, of the
studies specifically comparing dif-
ferent types of absorbable suture
material, results were confounded
because different suturing tech-
niques were used as well. Thus,
taken as a group. the date supported
no recommendations regarding
polyglycolic versus chromic catgut
suture material in reducing short-
term and long-term p&suturing per-
ineal pain.
!lor. recentlv. Grant, Sleep,
Ashurst, and Spen~er~ reported on
a comoarfsonof oain essociatedwith
the ;e of glycerol-impregnated
catqut (softc~~l es cornowed with
untreated ch;omic catg; and con-
cluded that women repaired with the
glycerol-treated catgut were more
likely to have significant perineal
pain et 10 days postpartum. They
concluded that glycerol-impregnated
catgut has no place in the repair of
perineal traum;. Another ;ecent
studv bv Mahomed and Grar#
corn&& suturing methods and su-
turing technique= in a randomized
clinical trial and concuded that
polyglycolic suture material has clear
advantagesover chromic catgut. Un-
fortunately. as the Mahomed study is
currently unpublished. no details are
available to evaluate the research for
the presence of confounding van-
ables or the validity of its conclu-
slons. A randomized clinical trial
employing a standardized suturing
WhnQue to comp?reValiOlLsabsorb
able suture materials Is indeed in
order.
In addition to suture material,
three factors in suturing technique
Jmel of Nuree-MkkvUew e Vol. 35. No. 1. Jaeewffebranl19~
have been identified in the literature
as bearing on pain during healing:
the tightnw or loosenessof the su-
tures, the number of layers of su-
turing. and the placing of continuous
versus interrupted sutures. A study
by Stone, van Fraunhofer, and Mas-
tersonle indicated that looselv an-
proximated wound edges yielded
significantly stronger bonds after
healing than wounds closed with
tight sutures. They found that su-
tures placed too tightly in faxii Iwt
SOW of their usual strength. They
theorized that this loss is due to tioht
sutures producing tissueoverlap iat
results in hypoxia, poor healing, and
mesumahlv also increased pain
hudng the h&Jiig process.In a more
recent article. Mastereon relterated
this principleof avolding constdcnng
sutures and advocated sutures that
incorpOrate large bites of tissue in
order to keep stitchesloose and thus
produce a stronger tissue bond.
The second area of ixportetlce in
comparing suturing techniques is
that of the number of layers of su-
tures that are adequate for proper
healing. Although it has been well
acknowledged fhat too much suture
material retards healing, Increases
the inflammatory process, and re-
suns in increased pain,e standard
perineal repair techniques usually
continue to include several different
layers of suturing to close dead
spacE, usually at least three, rather
than simply taking larger bites of
tissue. However, for some time,
prectnloners such es Munslckle have
recognized that overzealous su-
turing with many layers of sutures is
a major wnmbutor to pain.
More recently, a single-layer su-
turing technique has received favor-
able attention for obstetric and mme-
cologic surgey. Gallup has &o-
c&d eliminatfng layering of sutures
in abdominal gynecologic surgay to
increase the healing processand de-
crease the rate of dehiecence. His
technique recommended large con-
tinuous bites taken to include dif-
ferent types of tissues rather than
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


first exposed to nontraditional re-
pairs. Whereas the standard suturing
method produces a wound dosely
approximated at the skin tissue
edges, the alternative repair tech-
nique results in a skin-edge gap. Ini-
tially, Some expressed concern about
the long-term cosmetic reeults of the
alternative method, although many
noted that when a womans legs
were in a normal, nonlithotomy po-
sition, the tissue edges came to-
gether well witlout fhe snug, shallow
subcuticular suhnes. However, when
the cosmetic effect was examined at
six weeks postpartum, it was found
that the scar visible at that time was
almost always of hairline thickness,
and completely indistinguishable
from scars remaining after using the
standard suturing technique.
A further concern with the altema-
live technique initiaUy was whether
the skin gap might predispose to
paineal wound infections. However,
after eight years of keeping statistics
related to this suturing technique in
24
FIGURE 6
Repair completed with
anchoring knot in vagina.
clinical practice, this author found in-
fections related to suturing almost
nonexistent.~
Can the suturing method make a
difference in postpartum perineal
pain? Definitive answers must wait
for well-designed research trials.
However. both oubllshed literature
and clinical out&nes suggest that
this alternative suturing method is
beneficial in reducing what has come
to be regarded as usual post-
partum pain. It may be time to revise
traditional suturing techniques.
REFERENCES
1. Vamey H. Nurse-Midwifery.
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Journal of Nurse-Midwifery
2. Hill PD: Effects of heat and cold
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1989.
3. Fleming N: Comparison of
Women with Different Pertneal Condi-
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UMl, 1987, pp 120-128.
4. Fleming N, Schafer Aw: Post-
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Journal of Nurse-Midwffery l Vol. 35. No. 1. JanuarylFebmaw 1990 25