Case Report
Partially Resorbed Unremoved Silk Sutures Three Years Post Perineal Injury Repair: A Case Report.
Abstract
Perineal injury occurs to various extents after vaginal childbirth more with nulliparous parturients, the consequence of the injury and its repair can impact on the quality of life of the new mother and her ability to bond and care for her child. The extent of the morbidity is related to extent of injury, skill of repair, suture material used and care after repair. Synthetic absorbable suture materials are known to elicit less inflammatory tissue response than chromic catgut with less postpartum pain and providing a better wound healing irrespective of whether it is the standard synthetic or rapidly absorbable, braided or monofilament. We present a case of retained non-absorbable (silk) suture 3 years after an episiorrhaphy by an unskilled birth attendant resulting in chronic vaginal discharge and dyspareunia.
Keywords: Perineal injury; suture material; episiorrhaphy.
Introduction
Perineal trauma following spontaneous or assisted vaginal delivery is defined as any damage to the genitalia during childbirth occurring either spontaneously or iatrogenically as an episiotomy [1,2]. It affects up to 50% to 90% of women after vaginal delivery [3]. It is usually more extensive with nulliparous parturients as much as 90% of nulliparous and 70% of multiparous women [4]. Most cases end up as a first- or second-degree laceration often requiring stitches [2,5].
The symptomatolgy of perineal injury is related to the extent of perineal damage, repair technique, skill and knowledge of the birth attendant and suture materials used for repair [2,5]. Most early and long term postpartum morbidities are related to the perineal pain following repair of episiotomy and lacerations which is in turn influenced by the suture material used [5]. This may result in perineal pain, dyspareunia and faulty healing. The immediate complications include; bleeding, perineal pain, oedema, infection, hematoma, wound dehiscence, and wound extension to 3rd or 4th degree lacerations [5]. The delayed complications include; wound infections, dyspareunia, scar formation, delayed resumption of sexual intercourse, depression, faulty bonding with her newborn [2,5]. The physical, emotional, and sexual dissatisfaction following wound complication can last for months after delivery [2].
There has been effort to ascertain the appropriate suture material for repair of perineal injuries. Absorbable suture materials have become the mainstay of perineal repair usually needing no return visit for removal in most cases except in a few and where it is broken down or resulting delayed healing needing appropriate re-stitch [1]. The newer polyglycolic acid suture materials have been known to elicit less inflammatory tissue response than chromic catgut [5]. The use of synthetic materials in the perineal repairs elicit less postpartum pain and also providing better wound healing [1,2,5,6].
Case Report
She was a 22-year-old Para 1(1 alive) lady who had a vaginal delivery three years ago. Delivery was conducted in a maternity home supervised by unskilled birth attendant. She admitted having a genital laceration which was repaired using an improvised domestic sewing thread (possibly silk). However, there was no follow up visit for the removal of the silk. Since delivery, she has been treating recurrent vaginal discharge without success. She also has a history of dyspareunia which dates to her postpartum period. She subsequently presented to our fertility donor recruitment and screening for altruistic oocyte donation for her aunt who is being worked up for invitro fertilization and oocyte donor transfer. Her vaginal examination during evaluation revealed a black double-stranded thread knot at the lower posterior vaginal wall causing narrowing of the introitus. A vaginal swab was taken, and she was started on empirical treatment. She was then scheduled for vaginoplasty and removal of the threadlike material. Histology of the material removed at vaginoplasty revealed to be an undissolved silk material used for the perineal repair.
Figure 1 & 2: Silk suture knot in lower vaginal canal and silk suture being pulled out from the vagina epithelium respectivelty.
Figure 3 & 4: Double-stranded braided silk suture and separated strands of silk suture removed at episiotomy site respectively.
Discussion
Perineal trauma or injury which occurs during spontaneous or assisted vaginal delivery can occur spontaneously or iatrogenically where an episiotomy was made [1]. It is likely to be more extensive with nulliparous parturients than their multiparous counterparts [1]. It occurs in as much as in about 70% of vaginal deliveries in various degrees [1]. Most perineal injuries are first- or second-degree laceration often needing repair [1,2,5].
The immediate complications include bleeding, perineal pain, oedema, infection, hematoma, wound dehiscence, and wound extension to 3rd or 4th degree lacerations and perineal pain within the early few weeks post-partum [5]. The long term complications include the formation of scar tissue formation, wound infections, dyspareunia, delayed resumption of sexual intercourse and depression [2,5]. The consequence of perineal trauma juxtaposed on a new mother enmeshed with the demands of a newborn, the pressure of her new motherly role and the hormonal changes may ultimately interfere with a new mother’s ability to bond and care for her newborn [1,2]. The physical, emotional, and sexual dissatisfaction following wound complication can last for months after delivery [2].
Mitigating the consequence of perineal trauma would be a much important relieve to a new mother who has a lot to deal with. This can be achieved by having a skilled attendant to appropriately identify and repair different types of perineal trauma using the best suturing techniques and suture materials to minimize short- and long-term morbidity afterwards. Three major causes of post repair complications were: inexperienced or poor surgical skills, inappropriate repair technique and inappropriate suture choice [7].
The presence of an experienced surgeon with the knowledge of various types of perineal trauma and pelvic anatomy should be available especially where there are doubts as to the type and extent of trauma in order to achieve optimum outcome [8,9].
Absorbable suture materials have become the mainstay for perineal repair usually needing no return visit for removal in most cases except in a few and where it is broken down or delay in healing where a re-stitch may be appropriate.
Non-absorbable suture material as was used by an inexperience birth attendant in the case presented is not ideal for repair of perineal trauma and not recommended. The newer synthetic absorbable suture materials elicit less inflammatory tissue response than chromic catgut [5]. They cause less postpartum pain and providing a better wound healing irrespective of whether it is the standard synthetic or rapidly absorbable, braided or monofilament [1,2,5,6].[2].
Conclusions
Various degrees of perineal injury occur during vaginal births and more frequently and more extensive with nulliparous parturient with associated short and long-term morbidity in the background of dealing with the pressure of new motherly role and its challenges alongside the hormonal changes. The extent and severity of morbidity after perineal trauma is related to extent of trauma, suture technique, skill of surgeon, suture choice used and postoperative care. These variables should be the focus in order to prevent and minimize short- and long-term complications from obstetrical perineal trauma
Consent
As per international standards or university standards, patient(s) written consent has been collected and preserved by the author(s).
References
-
Kettle C, Dowswell T, Ismail KM. Absorbable suture materials for primary repair of episiotomy and second-degree tears. Cochrane Database Syst Rev. 2010 Jun 16;2010(6): CD000006.
Publisher | Google Scholor -
Schmidt PC, Fenner DE. Repair of episiotomy and obstetrical perineal lacerations (first-fourth). Am J Obstet Gynecol. 2024 mar;230(3S):S1005-S1013.
Publisher | Google Scholor -
Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 198: Prevention and management of obstetric lacerations at vaginal delivery. Obstet Gynecol 2018;132:e87–102.
Publisher | Google Scholor -
Smith LA, Price N, Simonite V, Burns EE. Incidence of and risk factors for perineal trauma: a prospective observational study. BMC Pregnancy Childbirth 2013;13:59.
Publisher | Google Scholor -
Bharathi A, Reddy DB, Kote GS. A prospective randomized comparative study of vicryl rapide versus chromic catgut for episiotomy repair. J Clin Diagn Res. 2013 Feb;7(2):326-30.
Publisher | Google Scholor -
Upton A, Roberts CL, Ryan M, Faulkner M, Raynes GC. A randomized trial, conducted by midwives of perineal repairs comparing a polygly¬colic suture material and chromic catgut. Midwifery. 2002;18:223-29.
Publisher | Google Scholor -
Cawich SO, Wright D, Kulkarni S, Rattray C, Bambury I, Christie L, Naraynsingh V. Severe perineal lacerations in obstetric practice: the effect of institutional practice guidelines on repair failures in a single centre. Int Sch Res Notices 2014;2014:131682.
Publisher | Google Scholor -
Harvey MA, Pierce M, Alter JE, Chou Q, Diamond P, Epp A, Geoffrion R, et al. Obstetrical anal sphincter injuries (OASIS): prevention, recognition, and repair. J Obstet Gynaecol Can 2015;37(12):1131–48.
Publisher | Google Scholor -
Zimmo K, Laine K, Vikanes Å, Fosse E, Zimmo M, Ali H, Thaker R, Sultan AH, Hassan S. Diagnosis and repair of perineal injuries: knowledge before and after expert training-a multicentre observational study among Palestinian physicians and midwives. BMJ Open 2017;7
Publisher | Google Scholor
Copyright: © 2025 Ayodeji Kayode Adefemi, this is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.