What is the recommended suture material and technique for a vaginal suture post normal delivery?

Vaginal Suture Repair Post Normal Delivery

For vaginal and perineal repair after normal delivery, use monofilament absorbable synthetic sutures (such as poliglecaprone) with a continuous non-locking technique for all layers—this approach minimizes infection risk, reduces short-term pain, decreases analgesic requirements, and lowers the need for suture removal compared to other materials and techniques. 1

Optimal Suture Material Selection

First Choice: Monofilament Synthetic Sutures

• Monofilament sutures are preferred because they cause less bacterial seeding and have lower infection risk compared to multifilament options 1
• Examples include poliglecaprone (Monocryl) and polyglyconate (Maxon) 1

Second Choice: Rapidly-Absorbing Synthetic Sutures

• Rapidly-absorbing synthetic sutures like polyglactin 910 (Vicryl Rapide) eliminate the need for suture removal 1
• These sutures result in significantly less pain at 3-5 days postpartum (32.5% vs 57% with catgut), reduced analgesic requirements (15.5% vs 50.5%), and better wound healing with less dehiscence (4% vs 13.5%) 2
• The increased cost may be justified by the lower need for postpartum suture removal 1

Standard Synthetic Sutures (Alternative)

• Standard synthetic multifilament sutures (polyglycolic acid or polyglactin 910) are effective alternatives 1
• These demonstrate superior healing compared to chromic catgut, with better scar appearance and earlier resumption of sexual activity (19/37 vs 1/42 patients by 6 weeks) 3
• However, they have higher rates of requiring suture removal compared to rapidly-absorbing options (RR 0.24; 95% CI 0.15 to 0.36) 4

Materials to Avoid

• Catgut sutures should be avoided as they are associated with more pain, highest risk of requiring resuturing (15/1201 vs 3/1201 with synthetic), and inferior outcomes 1, 4
• Glycerol-impregnated chromic catgut causes 10% more perineal pain at 10 days and 33% more dyspareunia in the first 3 months postpartum 5

Recommended Suturing Technique

Continuous Non-Locking Approach

Continuous suturing techniques are superior to interrupted methods for all layers of repair 1, 6

Evidence Supporting Continuous Technique:

• Reduces pain up to 10 days postpartum (RR 0.76; 95% CI 0.66 to 0.88) 6
• Decreases analgesic use (RR 0.70; 95% CI 0.59 to 0.84) 1, 6
• Lowers need for suture removal (RR 0.56; 95% CI 0.32 to 0.98) 1, 6
• Improves postpartum sexual function at 3 months 1
• Distributes tension more evenly across the suture line, preventing tissue edema and necrosis 1

Why Non-Locking is Critical:

• Avoid locking sutures as they cause excessive tension leading to tissue edema and necrosis 1
• For perineal skin specifically, continuous non-locking subcutaneous suturing avoids damage to nerve endings on the skin surface, reducing pain 1

Step-by-Step Repair Algorithm for Second-Degree Laceration or Episiotomy

Layer-by-Layer Approach:

1. Anchor suture above the apex of the vaginal epithelium laceration 1
2. Close vaginal epithelium and muscularis using continuous non-locking suture down to the hymenal ring 1
3. Reapproximate bulbocavernosus muscles with a crown stitch at the perineal body 1
4. Close perineal body musculature with continuous technique 1
5. Repair rectovaginal fascia if involved 1
6. Close perineal skin with continuous non-locking subcuticular stitch from inferior margin to hymen and tie 1

Alternative for Skin Closure:

• Skin adhesive can be used for perineal skin after closure of deeper layers, resulting in no difference in pain but shorter procedure duration (P=0.001) 1

Essential Procedural Considerations

Environment and Preparation:

• Ensure adequate anesthesia (regional or general) 1
• Optimize visualization and exposure in labor suite; consider operating room if needed 1
• Count all surgical instruments, sponges, and sutures pre- and postoperatively 1
• Administer prophylactic antibiotics (first-generation cephalosporin) 1

Common Pitfalls to Avoid:

• Never use overly tight sutures that can strangulate tissue and impair healing 1
• Avoid locking continuous sutures which increase tension 1
• Do not use transcutaneous interrupted sutures on perineal skin as they damage superficial nerve endings 1
• Avoid catgut or glycerol-impregnated catgut due to inferior outcomes 1, 5, 4

Suture Size Recommendation

• Use 2-0 absorbable suture for vaginal and perineal repair 3