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ORIGINAL ARTICLE
Year : 2013  |  Volume : 40  |  Issue : 2  |  Page : 95-98

Comparison of impact of polyglactin 910 (Vicryl rapide) and chromic catgut sutures on perineal pain following episiotomy wound repair in eastern Indian patients


1 Department of Obstretics and Gynecology, Kurji Holy Family Hospital, Patna, India
2 Department of Pharmacology, Nilratan Sircar Medical College, Kolkata, India

Date of Web Publication23-Jul-2013

Correspondence Address:
Meena Samant
Department of Obstretics and Gynecology, Kurji Holy Family Hospital, Patna
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-5009.115486

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  Abstract 

Objective: To compare the impact of polyglactin 910 (1-0) (Vicryl rapide) (VR) and Chromic Catgut (1-0) (CC) sutures on perineal pain in walking, sitting, and lying posture at 24 h, 48 h, and 6 weeks after episiotomy wound repair. Materials and Methods: Patients were divided randomly into two groups: VR group and CC group. Each group consisted of 50 patients. Severity of the pain was assessed by the visual analogue scale and by the requirement of analgesics. Ordinal data were analyzed by Mann-Whitney U-test. Categorical data were analyzed by Chi-square test. Results: Compared to CC, VR produced significantly less pain (P < 0.001) among patients following episiotomy wound repair in walking, sitting, and lying posture at 24 h, 48 h, and 6 weeks postpartum. Conclusion: Perineal repair with VR suture is associated with less pain perception compared to CC suture.

Keywords: Chromic catgut, episiotomy, Vicryl rapide


How to cite this article:
Bose E, Samant M, Lal P, Mishra S, Ghosh A. Comparison of impact of polyglactin 910 (Vicryl rapide) and chromic catgut sutures on perineal pain following episiotomy wound repair in eastern Indian patients. J Sci Soc 2013;40:95-8

How to cite this URL:
Bose E, Samant M, Lal P, Mishra S, Ghosh A. Comparison of impact of polyglactin 910 (Vicryl rapide) and chromic catgut sutures on perineal pain following episiotomy wound repair in eastern Indian patients. J Sci Soc [serial online] 2013 [cited 2019 Oct 13];40:95-8. Available from: http://www.jscisociety.com/text.asp?2013/40/2/95/115486


  Introduction Top


The impact of perineal trauma can be distressing for a new mother when she is trying to cope with hormonal changes and the demands of her baby, and it can have a long-term effect on the sexual relationship. Approximately, 70% of women who have a vaginal birth will experience some degree of damage to the perineum, due to tear or episiotomy and will need stitches. This damage may result in immediate perineal pain lasting up to 2 weeks after the birth, and some women experience long-term pain and discomfort during sexual intercourse. Perineal trauma occurring during spontaneous or assisted vaginal delivery is usually more extensive after the first vaginal delivery. [1] It is defined as any damage to genitalia during childbirth that occurs spontaneously or is intentionally made by performing a surgical incision (episiotomy). [2] For those women who sustain a perineal injury, it is important that skilled personnel repair the trauma using the best suturing technique and suture materials to minimize any associated short and long term morbidity.

The type of suturing material used for perineal wound repair may also affect the amount of pain, wound dehiscence and superficial dyspareunia experienced by women following childbirth. Absorbable suture materials used are chromic catgut, polyglycolic acid, and polyglactin while non-absorbable sutures are silk, nylon, etc. Polyglycolic acid and polyglactin cause minimal tissue reaction and inflammation as per current literature. [3] A relatively new material polyglactin 910 rapide (Vicryl rapide) (VR) is absorbed more quickly than other absorbable materials. [2]

The most modern material that is used to stitch the perineum is gradually absorbed and need not be taken out. However, sometimes stitches have to be removed by the doctor. A small number of perineal wounds breakdown or have delayed healing, and some of these may need to be re-stitched. There are 18 randomized controlled trials (with 10,171 women) that compared catgut and synthetic materials used to stitch the perineum after childbirth. It also included a more recently produced material, which has been specially designed to be absorbed more quickly. The main findings were that women stitched with synthetic materials had less pain after first 3 days of delivery and needed fewer drugs to relieve pain, compared with women stitched with catgut. There is evidence that synthetic stitches were not always readily absorbed and some women with these stitches needed them to be removed. [4] Against this background, present study was undertaken to compare VR suture material with chromic catgut (CC) with respect to pain and analgesic requirement at 24 h, 48 h, and 6 weeks postpartum in eastern Indian patients.


  Materials and Methods Top


This is a prospective, randomized, and open-labeled study. The study was approved by the Institutional Ethics Committee and conducted according to the Indian Council of Medical Research (ICMR) guidelines for Biomedical Research on Human Subjects, 2006, and the Declaration of Helsinki. Subjects were recruited in the Obstetrics and Gynecology inpatient department of tertiary care multi-speciality institute that serves as a training centre for the post graduate students of obstetrics and gynecology, and the study was conducted between August 2010 and July 2011.

Inclusion criteria

All women in the reproductive age group, with singleton pregnancy with vertex presentation delivering vaginally and having a surgically planned incision in the perineum (an episiotomy) to facilitate the delivery of the head were included in the study. Episiotomy was performed and repaired by qualified medical doctors trained in obstetrics and gynecology. The vaginal mucosa was sutured with continuous non interlocking stitches, where as the perineal muscles sutured with simple interrupted stitches, and the skin was sutured by interrupted mattress suture.

Exclusion criteria

The exclusion criteria comprised of spontaneous perineal tear, third and fourth-degree perineal tear, twin vaginal deliveries, instrumental vaginal deliveries, vaginal breech deliveries, women with any infection and/or fever, women with chronic disorders (diabetes mellitus, chronic hypertension, and chronic renal disorders), women on corticosteroids, chemotherapy, and women undergoing radiotherapy.

Study visits and efficacy parameters

Patients were interviewed at 24 h, 48 h, and 6 weeks postpartum regarding pain perception on lying, walking, and sitting posture using the visual analogue scale. Local examination was done for wound gaping and nature of wound healing. Routinely, all women were put on antibiotic capsule Ampicillin 500 mg four times a day for 5 days and analgesic Ibuprofen 400 mg as and when required basis (maximum three tablets a day) as long as required. Women with hematoma underwent drainage and resuturing, whereas, those with wound dehiscence (involving muscles) were re-sutured. Residual suture, when seen in 6 weeks, were removed. The pain perception was recorded using the visual analogue scale at every visit and requirement of analgesics were also noted.

Grouping

In the study, all patients in the reproductive age group with an episiotomy were randomly divided into two groups of 50 each. Women who delivered on Mondays and Wednesdays were sutured with CC and those delivered on Tuesdays and Thursdays were sutured with VR. All episiotomies were sutured by the same technique.

A woman with an episiotomy was discharged at 48 h postpartum. At the time of discharge, she received advice about perineal wound care, maintaining local hygiene; emphasis is given on the benefit of regular bowel and bladder habits, breast-feeding, and immunization. They are informed about the various symptoms, which suggest wound complication (e.g.: Retention of urine, pain, swelling, abnormal and foul smelling discharge, fever, etc.) and to report immediately if any untoward symptom is noted. Special attention is given to motivate them to attend "Post Natal Clinic" at 6-week postpartum and its importance was emphasized.

Statistical analysis

Data were analyzed as per modified intention to treat basis. Subjects reporting for at least one post-baseline follow-up visit were analyzed. Data, in ordinal scale, were analyzed by Mann Whitney U-test. Categorical data were analyzed by Chi-square test. P < 0.05 was considered to be statistically significant.


  Results Top


Assessment of pain

The mean pain score at 24 h interval in the CC group was 5.57 while walking, 7.81 in sitting position, and 4.17 in lying posture, whereas, in the VR group, the mean pain score was 4.15 while walking, 6.16 in sitting position, and 2.04 in lying posture. Pain score was significantly less in VR group in all three positions compared to CC group (P < 0.001) [Table 1].
Table 1: Pain score at different postures at 24 h, 48 h, and 6 weeks postpartum (after epsiotomy wound repair)


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The mean pain scores at 48 h postpartum were as follows: In CC group, 3.62 while walking, 5.75 in sitting position, and 2.55 in lying posture, whereas, the results of VR group are as follows: 2.04 while walking, 3.44 in sitting position, and 0.7 in lying posture. Pain score was significantly less in VR group in all three positions compared to CC group (P < 0.001) [Table 1].

At six weeks, one out of 50 (2%) women in VR group had mild discomfort in sitting posture, while nine out of 50 (18%) women in CC group experienced mild discomfort in the same position. This suggested that the short-term pain perceived by women sutured by VR were significantly less (P < 0.001) as compared to CC. None of the patients in either of the groups experienced pain in walking and lying posture at 6-week postpartum.

Analgesic requirement

In the present study, six (12%) patients in CC group used analgesic tablets up to 10 days postpartum, whereas, only one (2%) woman sutured with VR group required analgesics up to 10 days postpartum. Requirement of analgesic was significantly less in VR group.

Assessment of wound complication

In this study, hematoma was observed in one patient in VR group and five patients in CC group. Wound gaping (Dehiscence) was recorded in five women sutured with CC, whereas, none of the women sutured with VR showed gaping of their episiotomy wound. In the present study, out of five women with wound dehiscence in CC group, three required re-suturing.

Our study shows that the complications were significantly less (P < 0.001) in VR group compared to CC group. Hence, the above results again prove the superiority of rapidly absorbable synthetic suture VR over naturally absorbable suture CC.


  Discussion Top


The primary function of a suture is to maintain closure of the damaged tissue to promote healing by first intension, control bleeding, and minimize the risk of infection. Perineal trauma that has been carefully sutured generally heals rapidly by primary intension. This is probably because the perineal area immediately after childbirth provides optimal conditions that are necessary for the promotion of quality healing. [5] Commonest suture material used in surgical procedures is CC. Catgut is treated with chromate salt to delay its absorption and decrease inflammatory reactions. CC maintains 60% tensile strength for 7-10 days. On the other hand, VR is a relatively new type of suture. It is designed to give wound support up to 14 days and is totally absorbed by 42 days.

There is relative paucity of data on VR. There is only one trial conducted in southern India that compared the impact of VR and CC on perineal pain. The trial conducted by Joseph et al.[6] reported that on lying posture fewer women in VR group complained pain as compared to CC, but the results were statistically insignificant (P > 0.05). In walking posture, during the early postpartum period, women in VR group had significantly lesser pain as compared to CC (P < 0.05), by the 30 th day all women in VR group were absolutely pain free; however, the number of women with pain on 42 nd day postpartum in CC group was minimal. In sitting posture, during an early postpartum period, though the women in the VR group appeared to have less pain as compared to the CC group, but the difference was too narrow to be significant. However, from the 7 th day onwards the women in the VR group had significantly lesser pain as compared to the other group in sitting posture. By 42 nd postpartum, all women in VR group could sit comfortably, whereas, 30% women in CC group continued to have mild pain. Analgesic required was also low in the VR group after the 7 th day and was nil after the 30 th day. The suture material got completely absorbed in VR group, but residual suture material was observed in 18% of women in CC group. No significant difference was observed in the wound healing in the two groups. Another trial conducted by Mackrodt et al. found that 523 out of 886 (59.02%) women with their episiotomy sutured with synthetic suture and 591 out of 888 (66.55%) sutured with catgut had significant pain. [7]

The results of the present study show that synthetic absorbable suture VR is superior to naturally absorbable CC with respect to pain perception at various positions at 24 h and 48 h. They are associated with lesser analgesic requirement up to 10 days postpartum and are associated with fewer wound-related complications, like infection, wound dehiscence, and hematoma.


  Conclusion Top


The results of the present study parallel the outcome of the above-mentioned studies and further supports that synthetic suture is superior to naturally absorbable CC with respect to pain perception and analgesic requirement and are associated with fewer wound-related complications, like infection, wound dehiscence, and hematoma.

 
  References Top

1.Sultan AH, Monga AK, Stanton SL. The pelvic floor sequelae of childbirth. Br J Hosp Med 1996;55:575-9.  Back to cited text no. 1
[PUBMED]    
2.Tohil S, Kettle C. Perineal care. Clin Evid 2008;9:1401.  Back to cited text no. 2
    
3.Greenberg JA, Clark RM. Advances in suture material for obstetric and gynecologic surgery. Rev Obstet Gynecol 2009;2:146-58.  Back to cited text no. 3
[PUBMED]    
4.Kettle C, Dowswell T, Ismail KM. Absorbable suture materials for primary repair of episiotomy and second degree tears. Cochrane Database Syst Rev 2010;16:CD000006.  Back to cited text no. 4
    
5.Cuschieri A, Steele RJ, Moossa AR. Essential surgical practice. 4 th ed. Oxford: Butterworth-Heinemann; 2000. p. 422-3.  Back to cited text no. 5
    
6.Kurian J, Bhaskaran S, Shivaram P. Comparative study of episiotomy repair: Absorbable synthetic versus chromic catgut suture material. J Obstet Gynecol India 2008;58:495-9.  Back to cited text no. 6
    
7.Gordon B, Mackrodt C, Fern E, Truesdale A, Ayers S, Grant A. The Ipswich childbirth study: A randomised evaluation of two stage postpartum perineal repair leaving the skin unsutured. Br J Obstet Gynecol 1998;105:435-40.  Back to cited text no. 7
    



 
 
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