In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the original guideline document.
Levels of evidence (Ia-IV) and grading of recommendations (A-C) are defined at the end of the "Major Recommendations" field.
Non-Suturing
A - The practice of leaving first- and second-degree perineal tears unsutured is associated with poorer wound healing and nonsignificant differences in short-term discomfort.
Suture Material
A - The use of absorbable synthetic material (polyglycolic acid and polyglactin 910) for repair of perineal trauma is associated with less perineal pain, analgesic use, dehiscence, and resuturing, but increased suture removal, when compared with catgut.
A - The use of a more rapidly absorbed form of polyglactin 910 for repair of perineal trauma is associated with a significant reduction in pain and a reduction in suture removal when compared with standard absorbable synthetic material. In the light of current evidence, rapid-absorption polyglactin 910 is the most appropriate suture material for perineal repair.
Method of Repair
A - The use of a continuous subcuticular technique for perineal skin closure is associated with less short-term pain than techniques employing interrupted sutures.
A - A loose, continuous non-locking suturing technique used to appose each layer (vaginal tissue, perineal muscle and skin) is associated with less short-term pain compared with the traditional interrupted method.
A - The use of a two-layer procedure of perineal repair, where the skin is apposed but not sutured, is associated with an increase in wound gaping up to 10 days following birth but less dyspareunia at 3 months postpartum than a three-layer technique involving skin closure.
Principles of Repair
The following basic principles should be observed when performing perineal repairs.
- Suture as soon as possible following delivery to reduce bleeding and risk of infection.
- Check equipment and count swabs prior to commencing the procedure and count again following completion of the repair.
- Good lighting is essential to visualise and identify the structures involved.
- Ask for more experienced assistance if in doubt regarding the extent of trauma or structures involved.
- Difficult trauma should be repaired by an experienced operator in theatre under regional or general anaesthesia - insert an indwelling catheter for 24 hours to prevent urinary retention.
- Ensure good anatomical alignment of the wound and give consideration to cosmetic results.
- Rectal examination after completing the repair will ensure that suture material has not been accidentally inserted through the rectal mucosa.
Following completion of the repair, inform the woman regarding the extent of trauma and discuss pain relief, diet, hygiene, and the importance of pelvic-floor exercises.
Definitions:
Grading of Recommendations
Grade A - Requires at least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation (evidence levels Ia, Ib)
Grade B - Requires the availability of well-conducted clinical studies but no randomised clinical trials on the topic of recommendations (evidence levels IIa, IIb, III)
Grade C - Requires evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities. Indicates an absence of directly applicable clinical studies of good quality (evidence level IV)
Levels of Evidence
Ia: Evidence obtained from of meta-analysis of randomised controlled trials
Ib: Evidence obtained from at least one randomised controlled trial
IIa: Evidence obtained from at least one well-designed controlled study without randomisation
IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study
III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies
IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities
