DOI: 10.1111/j.1471-0528.2008.02056.

x
www.blackwellpublishing.com/bjog
General obstetrics

Continuous versus interrupted sutures for repair

of episiotomy or second-degree perineal tears:
a randomised controlled trial
P Valenzuela,a,b MS Saiz Puente,b JL Valero,b R Azorı́n,b R Ortega,b R Guijarrob
a Department of Medical Specialties, Alcalá de Henares University, Madrid, Spain b Obstetrics and Gynaecology Department, Prı́ncipe de

Asturias Hospital, Alcalá de Henares, Madrid, Spain

Correspondence: Dr P Valenzuela, C/Empecinado 28, 28801 Alcalá de Henares, Madrid, Spain. Email pvalenzuela14@gmail.com

Accepted 5 October 2008.

Objective To evaluate the repair techniques of continuous and
interrupted methods for episiotomy or perineal tears.
Design A randomised controlled trial.
Setting The Hospital Universitario Principe de Asturias, a state
hospital belonging to the community of Madrid.
Sample Four hundred forty-five women who had undergone
vaginal deliveries with episiotomies or second-grade tearing of the
perineum between September 2005 and July 2007.
Methods One group was repaired with continuous, nonlocking
sutures involving the vagina, perineum, and subcutaneous tissues.
The other group had continuous, locking sutures of the vagina,
interrupted sutures in the perineal muscles, and interrupted
transcutaneous sutures. The threads used for stitching were
identical in both groups.
Results When comparing the group with continuous suture to the
group with interrupted sutures, the differences included less repair
time (1 minute; P = 0.017) and less suture material used (relative
risk [RR], 3.2, 95% CI: 2.6–4.0). The comparison of pain on the
second and tenth days, and 3 months postpartum were not
statistically different between the two techniques (RR, 1.08, 95%
CI: 0.74–1.57; RR, 0.96, 95% CI: 0.59–1.55; and RR, 0.68, 95% CI:
0.19–2.46, respectively).
Conclusions Although we did not demonstrate that one technique
was better than the other in the incidence of pain in the short or
long term, we showed that episiotomy and perineal tear repairs
with continuous suturing were quicker and used less suture
material without an increase in complication than interrupted
suturing.
Keywords Episotomy, perineal lesion, vaginal trauma.

Main outcome measures The participants were questioned

regarding the sensation of pain and the use of painkillers on the
second and the tenth days, and 3 months postpartum.

Please cite this paper as: Valenzuela P, Saiz Puente M, Valero J, Azorı́n R, Ortega R, Guijarro R. Continuous versus interrupted sutures for repair of episiotomy or
second-degree perineal tears: a randomised controlled trial. BJOG 2009;116:436–441.

women and can produce maternal morbidity. The majority

Introduction
In the majority of childbirths, damage to the perineum is likely
to occur to a greater or lesser degree if adequate protection to
the area is not provided at the moment the baby’s head is
delivered and if extraction of the shoulders is not appropriately
performed. Performing an episiotomy is generally reserved for
complicated childbirths, in cases of fetal distress, or when tear-
ing of tissues with serious consequences is foreseen.1
Although the current tendency is to reduce the incidence of
episiotomies,2,3 the practice varies considerably depending on
geography.4 Despite this, repair of the perineum continues to
be an aspect of childbirth that affects a great number of
of women experience pain of short duration as a result of
perineal repair after birth and some continue with long-term
problems, such as sexual discomfort.5–8
In addition to the extent of the trauma, the surgical skill,9
the type of material used,10 and the suture technique for
perineal repair after childbirth can have an important effect
on the magnitude and degree of morbidity experienced by
women after repair.
The best technique for this repair would be that which
requires less time to perform and less use of materials, and
that which produces less pain in the short and long term,
permitting the resumption of intercourse sooner and with

436 ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology

less pain, and requiring less of a need to remove the sutures
and a lower frequency of resuturing. Thus, in the current
study, we have attempted to evaluate an optimal technique
for repair of episiotomies and perineal tears.
Materials and methods
We conducted a study on women chosen at random who had
given birth at the Hospital Universitario Principe de Asturias,
a state hospital belonging to the community of Madrid, be-
tween September 2005 and July 2007. The study was approved
by the Ethics Committee of the Hospital. In the management
enquiry of the last quarter, women were informed verbally and
in writing about the project, their participation was requested,
and they were given a certificate of informed consent.
The following inclusion criteria were required for partici-
pation in the study: vaginal childbirth without instrumenta-
tion, at least 37 weeks of gestation, assistance by one of the
four matrons who participated in the project, and an episiot-
omy or perineal tearing that affected the skin and muscle, but
which did not produce injury involving the anal sphincter or
the rectum, and a viable newborn without serious congenital
malformations. Using a computer for random selection and
concealing the assignment of treatment with numbered, opa-
que, closed envelopes, the perineum was repaired by one of
the following techniques: interrupted technique with contin-
uous locking suture of the vagina, interrupted sutures in the
perineal muscles and interrupted transcutaneous sutures, or
continuous suture technique with continuous nonlocking
sutures in the vagina, perineum, and subcutaneous tissue.
In all women, Poliglactin 910 (caliber 0) was used for suture
with a triangular section tip needle (36 mm, Vicryl Rapid;
Ethicon Ltd, Edinburgh, UK). The skin sutures with the sub-
cutaneous or transcutaneous techniques were perceived in
different ways by the woman and this could not be concealed.
To avoid this fact influencing their responses, an explanation
of the existence of two different suture techniques was given
in the information to the women without going into further
detail. No comments were made about the technique during
the delivery or during the outcome assessment sessions. The
four midwives who participated in the perineal repairs had
more than 5 years of experience in attending deliveries and
were trained to carry out both techniques.
Immediately after the repair of the perineum, the number
of suture strands that had been used were counted and the
time taken in the repair was recorded. Two days postpartum,
before discharge, the parturients were questioned by a midwife
other than the midwife who had attended the birth, and ques-
tioned regarding pain (pain now). The midwife who con-
ducted the questioning did not know the technique that
had been used and was also blinded to other patient data,
except the patient’s name, the room number, and the date
of delivery. An analogous visual scale adopted from the
ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology
Continuous versus interrupted perineal repair
National Comprehensive Cancer Network was used to quan-
tify pain from 0 to 10, which was later grouped by categories:
no pain (0), slight pain (1–3), and moderate/severe pain (4–
10). In addition, the same system was used to quantify the
presence of pain in repose, with movement, while sitting, and
during micturition and defecation during the last 24 hours.
Finally, the analgesis used by the woman on the second day
were ascertained by reference to the case notes, since the use
of analgesics was not regulated. Both the epidural anaesthetic
during labour and delivery, and the postpartum analgesics
were provided upon request.
Ten days after delivery, the same questions were asked by
the same midwife by telephone and by the same midwife who
had conducted the interview on the second day. A numerical
classification was used from 0 to 10 to quantify the pain and
the same categories were used. Three months after delivery,
using the same method, the same midwife who had con-
ducted the previous interviews questioned about the level of
pain in the last 24 hours (none, slight, or moderate/severe), if
sexual intercourse had been resumed and how long after
delivery, if pain was experienced the first time (no/yes), and
if the dyspareunia continued (none, slight, or moderate/se-
vere). The necessity of resuturing the episiotomy or perineal
laceration and removing the suture materials at any time
during the first 3 months postpartum was determined; post-
partum revisions did not occur unless requested by the
patient. The analysis of the data was made with the intention
of acknowledging and quantifying any later losses.
The study involved 445 women. According to a calculation
of the sample size required in studies of cases and controls, to
detect an odds ratio significantly different from 1 with a 95%
CI and 85% power, it is necessary to have at least 400 subjects
in the two groups. With this sample size, it is possible to
detect a 15% difference in incidence of pain between the
two groups (pain versus no pain). We therefore enrolled
445 subjects to allow for 10% attrition. Data collection was
completed 3 months after parturition of the last patient
included in the study. The continuous data are expressed as
an average with standard deviation, and the qualitative data as
an absolute and relative frequency are presented as relative
risks (RR) with a 95% CI. The results were analysed using the
Student t test for quantitative variables and for the association
between qualitative variables, chi-square test was used.
Results
The 445 parturients in the study were allocated to two groups
based on the technique of episiotomy or perineal laceration
repair (Figure 1). No differences existed between the two
groups with respect to the characteristics of the women or
the reduction in postpartum pain (Table 1). Of the perineal
repairs, 83% (371 women) were because of episiotomies and
the remainder resulted from second-degree lacerations. Of the
437
 Valenzuela et al.

Assessed for eligibility

(n = 445)

Enrollment
Excluded (n = 0)

Randomised

Allocated to intervention Allocated to intervention

(n = 223) (n = 222)
Allocation
Received allocated intervention Received allocated intervention
(n = 223) (n = 222)

Lost to follow up (n = 8) Follow up Lost to follow up ( n = 15)

Reasons: no telephonic response Reasons: no telephonic response

Analysed (n = 215) Analysis Analysed (n = 207)

Figure 1. Patient flow through the trial.

episiotomies, 96.5% (358 women) were midline or right
mediolateral.
A smaller number of sutures were necessary for repair of
the perineum using the continuous technique compared with
the interrupted technique (RR, 3.2, 95% CI: 2.6–4.0; Table 2).
In addition, the time used in the repair with the continuous
technique (9.6 ± 3.9 minutes) was less than the discontinuous
technique (10.6 ± 4.9 minutes; P = 0.017).
The comparison of pain (no/yes) on the second and tenth
postpartum days, and 3 months postpartum (pain now) was
not statistically different between the two techniques (RR,
1.08, 95% CI: 0.74–1.57; RR, 0.96, 95% CI: 0.59–1.55; and
RR, 0.68, 95% CI: 0.19–2.46, respectively; Table 3). No differ-
ences existed in pain between the second and tenth days post-
partum with respect to rest, while moving or sitting, or during
urination or defecation (Table 4).
On the second and tenth days postpartum, no association
was found between the suture technique and the use of
analgesics (RR, 0.97, 95% CI: 0.66–1.42 and RR, 0.66, 95%
CI: 0.30–1.30, respectively). In most women, the parturients
did not use analgesics by the second day postpartum (RR,
0.60, 95% CI: 0.41–0.88) although 45% of the women (121
women) who did not use analgesics on the second day post-
partum had experienced some pain at that time. Similarly,
the majority of parturients did not use analgesics on the
tenth day postpartum (RR, 1.10, 95% CI: 0.57–2.09). Of
the continuous suture group, 55% (109 women) acknowl-
edged dyspareunia the first time they resumed sexual activ-
ity compared with 59% (110 women) of the interrupted
suture group (RR, 0.87, 95% CI: 0.58–1.31). In subsequent
sexual encounters, 76% (147 women) and 71% (131
women) of the parturients from each group, respectively,
affirmed that they did not experience any dyspareunia
(RR, 1.29, 95% CI: 0.81–2.06). The average number of days
that they had taken before resuming intercourse was 49 days
for the continuous suture group and 45 days for the

438 ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology

Table 1. Characteristics of the women according to the technique applied
Characteristics studied Continuous technique (n 5 223)
Age, years (average [SD])
Nationality: Spanish, n (%)
Epidural anaesthetic, n (%)
First born, n (%)
Perineum repaired in previous delivery, n (%)
Weight of child at birth, g (average [SD])
Episiotomia/tearing
Perineums repaired according to the midwife A/B/C/D
Lost from the study, n (%)
interrupted suture group (49.0 ± 15.7 versus 45.8 ± 15.1
days; P = 0.040).
With the continuous suture technique, it was necessary to
remove suture material in 25 women (11%) compared with
28 women with the interrupted suture (13%; RR, 0.84, 95%
CI: 0.47–1.50). In two parturients in the interrupted suture
group, it was necessary to resuture the perineum. One of the
women who required resuturing was because of complete
dehiscence and the other woman developed a haematoma
detected 5 hours after delivery that required evacuation.
If we consider that all the women lost to follow up in the
continuous and interrupted suture groups did not experience
pain, continuous suturing was not shown to be less painful
than interrupted suturing on the second and tenth days,
although there was less pain in the continuous suturing group
at 3 months postpartum (P = 0.013).
Discussion
In the current study, the differences between the continuous
suturing group and the interrupted suturing group was
a reduction in repair time of 1 minute and use of less suture
material. Both short- and long-term complaints of pain were
similar between parturients in the two groups, as was dyspar-
eunia, although those in the interrupted suture group
resumed sexual intercourse sooner.
Instrumental deliveries were not included in the study
because apart from not being performed by midwives, the
episiotomies tend to be cut larger and earlier. Premature child-
Table 2. Material of suture used in the repair of the perineum according to the technique employed
Technique of suture One suture, n (%) Two sutures, n (%)
Continuous 210 (94) 11 (4)
Discontinuous 65 (29) 117 (52)
ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology
Continuous versus interrupted perineal repair
Interrupted technique (n 5 222)
30.2 (4.8) 30.1 (4.8)
165 (73) 167 (75)
91 (40) 98 (44)
109 (48) 112 (50)
100 (44) 87 (39)
3222 (409) 3298 (439)
180/43 191/31
45/73/60/45 54/65/52/51
8 (3) 15 (6)
births were not included because the episiotomies in such cases
tend to be cut before the perineum has thinned by pressure of
the head, which usually generates greater haemorrhage. Also,
we considered that our study would interfere with the grieving
process in the event of deliveries involving a fetal demise, live
nonviable births, or those with serious malformations.
In an anonymous survey, by means of questionnaires given
to midwives of state hospitals in Madrid, which was carried
out by the same authors before beginning the project, we
discovered an almost standard technique for the repair of
the perineum that consisted of continuous suture crossing
the vagina, interrupted suture in the underlying muscles,
and transcutaneous suture in the skin. However, although
there is a great preference for one technique, there are only
a few clinical trials that compare the effects of different suture
techniques on the magnitude of maternal morbidity associ-
ated with repair of the perineum.11–13
Fleming14 published his experience in the use of the sub-
cutaneous suture technique in repairing the skin and sug-
gested that this technique was associated with a lower
degree of pain in the perineum compared with other more
traditional methods of suture.
In a recent meta-analysis15 that included seven clinical trials
involving health personnel who differed in their ability to
repair episiotomies, it was found that the continuous suture
technique was associated with less pain in the short term
compared with the discontinuous technique. Kettle et al.16
carried out a trial comparing the two techniques of epi-
siotomy repair (continuous and discontinuous) using two
Three or more (%) One suture/>1, RR (95% CI)
2 (,1) 3.2 (2.6–4.0)
40 (18)
439
 Valenzuela et al.

Table 3. Relation between suture technique and pain at the time of interview (pain now), the second and tenth day and at 3 months

Technique of suture No pain (%) Pain yes Pain no/yes, RR (95% CI)

Slight (%) Moderate/severe (%)

Second day 1.08 (0.74–1.57)

C (n 5 222) 113 (50) 80 (36) 29 (13)
I (n 5 221) 108 (48) 89 (40) 24 (10)
Tenth day 0.96 (0.59–1.55)
C (n 5 216) 174 (80) 37 (17) 5 (2)
I (n 5 217) 176 (81) 34 (15) 7 (3)
3 months 0.68 (0.19–2.46)
C (n 5 215) 209 (97) 6 (2) 0
I (n 5 207) 203 (98) 4 (1) 0

C, technique of continuous suture; I, technique of interrupted suture.

Table 4. Relation between suture technique and pain in different circumstances, on the second and tenth day

No pain, n (%) Pain yes, n (%) Pain no/yes, RR (95% CI)

Slight (%) Moderate/severe (%)

Second day
Pain in repose 0.91 (0.63–1.33)
C (n 5 222) 125 (56) 73 (32) 24 (10)
I (n 5 221) 129 (58) 73 (33) 19 (8)
Pain in movement 1.26 (0.85–1.88)
C (n 5 222) 80 (36) 86 (38) 56 (25)
I (n 5 221) 68 (30) 101 (45) 52 (23)
Pain when sitting 0.75 (0.50–1.12)
C (n 5 222) 61 (27) 87 (39) 74 (33)
I (n 5 221) 74 (33) 75 (33) 72 (32)
Pain when urinating 0.72 (0.49–1.03)
C (n 5 222) 95 (42) 77 (34) 50 (22)
I (n 5 221) 111 (51) 70 (31) 38 (17)
Pain when defecating 0.59 (0.33–1.06)
C (n 5 96) 55 (57) 24 (25) 17 (17)
I (n 5 101) 70 (69) 17 (16) 14 (13)
Tenth day
Pain in repose 0.78 (0.47–1.30)
C (n 5 216) 177 (81) 35 (16) 4 (1)
I (n 5 217) 185 (85) 28 (12) 4 (1)
Pain in movement 0.87 (0.58–1.30)
C (n 5 216) 142 (65) 58 (26) 16 (7)
I (n 5 217) 149 (68) 55 (25) 13 (5)
Pain when sitting 0.90 (0.61–1.32)
C (n 5 216) 127 (58) 64 (29) 25 (11)
I (n 5 217) 133 (61) 65 (29) 19 (8)
Pain when urinating 1.03 (0.68–1.57)
C (n 5 216) 154 (71) 53 (24) 9 (4)
I (n 5 217) 153 (70) 43 (19) 21 (9)
Pain when defecating 0.89 (0.59–1.34)
C (n 5 216) 147 (68) 51 (23) 18 (8)
I (n 5 217) 153 (70) 43 (19) 21 (9)

C, technique of continuous suture; I, technique of interrupted suture.

440 ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology

suture materials (quick absorption and standard) and found
that less pain was experienced with the continuous suture
technique.
In our comparative study, in the two groups of women, the
ability of the health professionals and the type of material
used were the same. The only difference was the suture tech-
nique. Less repair time and less material used were the only
significant differences between the two groups. The pain and
the dyspareunia, both at short and long term, were similar
according to the women. Although our results contradict the
recent meta-analysis of the Cochrane database,15 our conclu-
sions agree with those of a more published study17 that com-
pared continuous and interrupted skin sutures. The
difference between these results and those obtained in the
meta-analysis is probably attributable to the homogeneity of
the health personnel in terms of their skill in performing the
repair and the method of concealment used in the repair of
the perineum, as well as the person who conducted the inter-
view, and even the patient herself.
The use of analgesics in the last 24 hours seemed to be
a good question for evaluating the pain, but the discovery
that the women who had received epidural anaesthesia dur-
ing dilation had a greater likelihood of requiring oral anal-
gesics on the second and tenth days after childbirth, raising
the question that those women selected were less tolerant of
pain or less reluctant to analgesics. Above all, in the group of
women who did not use oral analgesics, there was a high
percentage which referred to pain. It is probable that in
the acceptance and perception of pain, there are other fac-
tors that are difficult to define and to quantify, yet exert an
influence on analgesic use.
On a daily basis, there are a great number of women in need
of repair of injuries to the perineum sustained during child-
birth. Although we have not demonstrated that one technique
is superior to any other regarding the incidence of pain in the
short or long term, we have identified a technique that is
quicker to perform and consumes less suture material without
a risk of increased complications.
Disclosure of interests
Competing interests: None.
Contribution to authorship
P.V. had the original idea for the study, managed the data, and
supervised the study. M.S.S.P., R.A., R.O., and R.G. participated in
the perineum repairs. J.L.V. was the midwife who conducted the
questioning. The report was written jointly by all authors.
Details of ethics approval
The study was approved by the Ethics Committee of the Hospital
Universitario Principe de Asturias (reference number 331, 10/2005;
26 July 2005).
ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology
Continuous versus interrupted perineal repair
Funding
The project was financed by the Fondo de Investigación Sanitaria,
Instituto de Salud Carlos III and Plan Nacional de Investigación
Cientı́fica, Desarrollo e Innovación Tecnológica (PI051023).
Acknowledgements
The project financed by the Fondo de Investigación Sanitaria, Instituto
de Salud Carlos III and Plan Nacional de Investigación Cientı́fica,
Desarrollo e Innovación Tecnológica (PI051023) toIgnacio Arribas
of the Biochemistry Department of Prı́ncipe de Asturias Hospital. j
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