art © science wound care focus Perineal tears and episiotomy Date of acceptance: August 7 2007 Gould D (2007) Perineal tears and episiotomy. Nursing Standard. 21, 52, 41-46. Summary Perineal wounds are common and occur spontaneously du labour, An episiotomy is sometimes performed in an attempt to reduce perineal trauma, although there is limited evidence about its success. This article discusses the debate surrounding perineal repair and provides information on the indications for episiotomy nd the classification of teas, Author Dinah Gould is professor of applied health, School af Canmunity and Health Sciences City University, London. Email:d.gould@cityaciik Keywords Episiotomy; Perineal care; Perineal tear These keywords are based onthe subject headings from the British Nursing Index. This article has been subject to double-blind review. For author and research article guidelines vst the Nursing Standard home page at wwwwanuursing-standard.co.uk. Fr reiated articles vist our antne archive and search using the keywords PERINEAL WOUNDS commonly oceurin ‘women during labour (Albers a! 2005}. A.cross-sectional survey of 101 randomly selected NiStrustsin the UK in the mid-1990s revealed thar 83% of low risk primigravidae experienced some form of perineal trauma (Williamsetal 1998). Many women also experience labial tears, sgrazesor vulval varicosities which are painful {Steen 2007). Perineal wounds sustained during childbirch ean eause acute painand distress {Wenderlein and Merkle 1983, Verspyck eta! 2006). The intensity ofthe pain varies from mild to severe (Kertle 2001, Steen 2007) and appears toberelated to theextent of injury (Kenyon and Ford 2004), Interventions used during labour for delivery and pain reliofthavare thought to increase the risk of perineal injury and pain include {MacArthur and MacArthur 2004): » Instrumental delivery. » Epidural anaesthesia. » Episioromy. Majorthemes in the literature include assessment of perineal trauma, theneed for episioromy, suturing ‘methods and materialsand treatment of the NURSING STANDARD perineumin the postpartum period, but there are ‘many gapsin the lterarureand the evidence base ‘underpinning care(Calvertand Fleming 2000}, Classification of perineal wounds Perineal wounds oceur spontancously during labour orare surgically induced by performing episiotomy. Perineal earsareclasstied according tothe severity ofthe woundand the numberof tissue layers involved (Box 1). The common in primigravidac because the perineum ismore likely to berigid, bur they can occur with later births (Haneatty 2003), Most spontancously ‘occurring perineal tearsareclasifed as second degree tears (Steen 2007). The meidence of third and fourth degree tearsisestimated tobe 0.6- 9.0% (Davis eal 2003}. Although numbersare smal, these cases are clinically significant because ‘ofthe distress they cause (Steen 2007), The assessment and classification of injury isanimportantaspect of the eoutine care women ecziveassoon asthe baby is born (Steen and Cooper 1997) The purposeisto identify trauma requiringintervention, stop bleeding take rmeasuresto promote healing tothe taumatised sues, The National stitute for Healthand Clinical Excellence (NICE} (2006) recommendsthat every postpartum woman should beasked about perineal pain ateach profesional ‘contact Inthe period immediately aerchildbireh womenaremostlikelyoreceivecare froma midwife ora health visitor However,the length of time required for healingcan vary according the ‘extent of trauma, bile perception of pains highly individual (MeCandlsh 2001). Thus women may ‘continu toexperience pain and discomfort beyond theearly postpartum period (Hartmann er al2005), Any nurse ormidwifeconsultedby a new mother should ask about persistent perineal painandbe atleto identify the extent of injury, the progress of nitaltract Jrestore function _ healingand suggest strategies for pain relie. Episiotomy Anepisiotomy isa perineal incision madeduring childbieth by a doctor ora midhwife to help complere the second stage of labour, ostensibly to improve september 5 vol 21 no 52: 2007 41art C science wound care focus Fst degroe Second degree the anal sphincter Third degree Fourth deoree Definitions of spontaneous tears Injury to the perinoum involving the (external and anal sphincter) and the anal epithelia. Indications for episiotomy > To prevent perineal fearing or excessive stretching of the musles during the second stage of Ibow Perineal tering sss easy to contra than ‘deliberate surgical incision and may involve te anal sphincter. Excessive stretching is thought to predispose to genitourinary prolapse i ater if fetal and maternal outcomes American College of Obstetriciansand Gynecologists (ACOG) 2006}. ‘Theelinica indicationsare shown in Box 2. Immediate henefitsare reported toinclude reduced risksof perineal trauma and tearing, bleeding, infection and wound dehiscence (ACOG 2006). However ifepisiotomy isperformed too late, tearing ofthe vagina and deep perineal muscles may occuranyway:Iitisattempted too carly there isarisk of heavy bleeding (Hanratty 2003). Those arguingin favour of episiotomy believe rhatit realacesthe incidence of pelvic floordysfunction and genitourinary prolapse, sexual dysfunetion and incontinence, bur these longer-term benefits havealsobeen questioned (ACOG 2006). Episioromy was first described by a Seotish rmidwife in the 1740s but was nor widely used until the middle of the 20th century (Thacker and Banta 1983), Ithassince become a common procedure ‘worldwide (Kettle and Johanson 1998} andi undertaken routinely ia many centres (ACOG 20065). Inthe UK episiotomy rates vary from 26% 1067% ofall mothers depending on the centre, with an overall incidence of 40% (Williams etal 1998}. Thiseflectsthe lack of professional Injury to the sen ony Injury to the perineum, involving perineal muscles but not involving Injury tote perineum involving the anal sphincter complex: 3a less than 50%6 of extemal anal sphincter torn > 3 more than 50% af the exteral anal sphincter tom, > 3c internal anal sphincter tom, 31 sphincter complex ya alge of Dstt and Gynacesogts 2004) To protect the fetus fit is premature ori its being repeately forced against an unyielding perineum that is obstructing delivery. > To prevent damage during face or breach presentation of the fetus or during instrumental delivery. 42 september 5 : vol 21 no 52: 2007 ‘consensusabout when itis considered necessary, itsbenefitsand the associated riskso women (Hartmannet al 2005, ACOG 2006), Thelikelihood of undergoing episiotomy increases with the length of the second stage of labour ierespective of whether delivery is instrumental (Williamset al 1998). Episiotomy has generated much debate and marry studies have been designed to evaluate whetherit improves maternal outcomes. Much of our currenrknowiedge comes from the results of individual tials, burthrough systematic literature reviews summarising the results of ‘many studies, often with pooled analysis oftheir collective data. The technique used to perform episiotomy influencesthe extent of trauma, blood loss an healing (Steen and Cooper 1997, Steen 2007) Surgical technique \ number of diferent techniquesare used to undertake episioromy (Verspyck etal 2006). The incision, performed witha scalpel or surgical scissors, can be made in mediolateral position or along the midline of the perineum (Figuce 1). Right mediolateral episiotomies are most often performed in the UK because they resulrina shorter wound (Roxine Adler eta 2001). The midline of the perineum is, lessvaseular. Thusan incision madein thisarea should result in less bleeding, bruising, inflammation and oedema and should, therefore, beless painful. However, perineal earsare more likely to occur after midline episiotomy {Buppasiri etal 2005). poorly sited incision will increase scarring, which causes discomfort by friction against elothing (Wenderlein and Merkle 1983}. Many women report pain when the incisionismade and whenitis sutured, despite local anaesthesia (Wenderlein and Merkle 1983) The evidence froma major systematicreview derived from all studies published in the English language from 1950.0 2004 indicated that three monthsafter delivery large aumbersof women continued to report pain irrespective of the technique used (Hartmann ef al 2005}. Moreover severity of perines not reduced when episiotomy was performed and there was noevidenee thatone technique was berter than another Wound healing This takes place in overlapping stages and is influenced by the amount of tissue that has been lost (Box 3).In eases of minimal trauma spontaneous healingis possible by first intention, Healing by firstintention is also possible when a lean incision ismade bya sealpelor surgical scissors, but with thismore extensive trauma sutures are frequently used 10 promote healing by holding the wound edges together (Vuolo 2006). Scar formation isreduced ‘when wounds heal by primary intention, Perineal vwoundsare usually surured to speed tissue repair, NURSING STANDARDminimise infection and restore normal function (Fleming e¢ al 2003), However, there is some debateabout whether ornot perineal tears and «episiotomy wounds should be sutured because of theadditional trauma and because the suture material asa foreign body inereasesthe risk of infection, especially inan area where bacterial ‘countsare high Johnson 1988). Gordon etal (1998) explored pain and healing ‘when suturing wasnotattempred in 1,780 women undergoing episiotomy after frst or second degree perineal tears following spontaneous or straightforward instrumental delivery. Women ‘were allocated ether toa control geoup, which seccived sutures, ortoa treatment group, which, dlidnor. They were assessed by midiwiteand completed a questionnaire 24 hoursaftr delivery and againat48 hours, tendaysand three months postpartum. There were no differences in reports ‘of pain, incidence of wound breakdownand need forre-suturing between the two groups. However, three months ates, women who had not received sutures reported significant ess perineal pain and were less likely to report dyspareunia. These findings contrast with a more recent but much smaller prospectivecohort study in five macernity nits which followed up282 women who had second-degree perineal tears. Women who did nor receive sutures reported more urinary frequency tendayslaterand were more likely toseek medical help for perineal problemsaiter 12 months (Metcalfe etal 2006). ‘Thefindingsof these two studiesare difficult tocompare because their populations were dissimilar—one sample contained women with firstand second degree tearsand the other «examined second degree rears only. Tissue damage ollowingepisiotomy is generally greater than for women who have first or second degree tears. The trial reported by Gordon et al(1998) combined women who had and had not experienced instrumental delivery, which is thought to contribute to perineal trauma and pain (MacArthur and MacArthur 200). controlled trial by Fleminger al(2003) indicated that, although suturing does not reduce pain among, primigravidaesix weeks postpartum following, non-instrumental delivery with first or second degree tears, healing i significantly better Method of wound closure Episiosomy wounds and third or fourth degree perineal tears are repaired in three layers using absorbable sutures (Hanratty 2003), This involvesclosing: » The vaginal s > The underlying muscle with interrupted » The perineal skin with either a continuous oF incerrupted sutures NURSING STANDARD Locations commonly used for episiotomy wounds (@) Mean tine) The stages of wound healing » Proliferative phase: inflammation, formation of new collagen fibres angiogenesis and epitheiaisation to cover the raw wound surface, » Maturation ofthe wound, | ever 3962) Iiperineal woundsor episiotomiesarenot sutured, they heal by secondlary intention. Scar tissue replaces the tissue lost through trauma, Healing takes place mainly by contraction brought about by specialised cells the granulation issue called myofibroblasts. Epithelialisation over the wound surface islessimportantthan in woundsable to repairby primaryintention (Leaper 1995). When healing takes place by secondary intention, tissue ‘epaircanbe prolonged. Iris more likely result in scarring through repeated episodesof inflammationagcompanied by over granulation. Numerous research studies and systematic reviewshave been undertaken to establish which sururing rechniquesand macerialsare less likely tocause painand discomfort. Non-absorbable surures, suchas polypropylene, are generally considered unsuitable for perineal wounds because they need to be removed, increasing pain and trauma (Bryant 1992). However,even when absorbable sutures, such as polyglycolic acid are used to close perineal wounds, some ofthe suture material may haveto be removed manually and. thereisno evidence to suggest that absorbable synthetic sutures produce better outcomes for women (Verspyeck et al 2006). ‘Thetechniqueof suturinghas received ‘considerable esearch attention. A systematic review of four studies nvolvinga total of 1,864 womencompared interrupted suturesand continuous subcuticular sutures. Ten days later september 5 : vol 21 no 52: 2007 43 (b) Mediolateralart & science wound care focus the typeofsuturingwasnorassociated with levels of reported pain, amount ofanalgesia consumed, incidence of wound dehiscence orneed for re-sururing, However, the useof continuous sutures was associated with lessneed for manual removal ofemaining suture maverial that had noc been absorbed (Kettleand Johanson 1998}. Irrespective ofthe typeof suture material or the chosen technique. icisimportantto avo fastening, sutures too tightly because thiswillincrease ‘oedema and ischaemia in the surroundingtissues. Infection Theskin isthe body’smajorbarrier againstinvading pathogens: when itismo longer inact, infection hecomesa major risk (Winter 1962). Thisis the rationale for applying wound dressings to ovelude the damaged tissues until they are inact (Winter 1962). Dressingsa impractical and difficult to secure in the perineal area, where the need for scrupulous cleanlinessis important because of heavy bacterial contamination, However, Brennan et al(1986)~ ‘writing about other types of wounds frequently covered in potentially pathos “organisms~poines out thatthe that they interfere with healing under normal circumstances. The risk of infection is higher for fourth degree perineal tears, probably because bacterial contamination from the rectumis, _greater and! because of the greater degree of trauma (Buppasriet al 2005) Although prophylactic antibiotics are thought tobe importantin preventinginection in cases of severe perineal trauma and are often prescribed, conelusive research findings to evaluate their effectiveness are not yet available Buppasiri etal 2005), Women should be encouraged to ‘undertake stringent perineal hygiene to help recluce the risk of contamination fromthe rectum tothe wound (Enkin eta! 2000). They should be encouraged to wipe from the symphysis puis (the from) towards the anus (the back}. The area should be washed with warm water and patted dryafter bathing, voiding and bowel movements. ‘When clean padsare applied, care should be taken roavoid touchingthe central area, which will be in contact with the wound, Pads should be changed at leastevery three hours. Wound dehiscence Thisis reported to be relatively common after episiotomy and severe perineal tear (Ramin et a 1992), bur theres ite information about its incidenee. Infection is ‘thought tobe the most important risk factor, but other contributory factorshave nor been identified (Ramin ef af 1992). Where wound breakdown is superficial, conservative rreatment ‘without additional suturing has been isno evidence 44 september 5 vol 21 no 52 2007 recommended, but more extensive damage extendingto the anal sphineter or reetum will need surgical closure (ACOG 2006). Factors influencing healing and infection Instrumentation and! length of second stage labour are thought to increase the need for episiotomy: Hower often earto some degree, Poor healingand the risk of infection are influenced by intrinsic and extrinsicrisk factors (Box 4). Intrinsic rs factors ace those chat cannot easily be modified. Theyincluce factors such as maternal ageand ‘whether the woman has. condition which affeets general health, for example, diabetes. In recent yearsithas become apparent that inherited coagulation defects are quite common (Kadirezal 1998), Women affected are likely to have had menorrhagia before pregnancy and will heat increased risk of heavy bleedingafter the baby is born. Although itis not always possible to influence intrinsic risk factors, strategiesean bye put in place to optimise healing and reduce infection risks. Efforrsshould be madeto control conditions, uchasdiabetesand tocontain haemorrhage. Extrinsic risk factors can be modified by women and health professionals. Women can be advised on diet during pregnancy and postpartum to avoid anaemia and to promote healing by including sufficient calories, protein and vitamins. Excess weight gain during pregnancy should be avoided because obesity is associated with poor maternal outcomes (Cedergren 2004), Dietary fibres important 0 prevent constipation which could place undue tension on the healing tissue or sutures. Women whosmokeshould be encouraged togive up because of he known association between smokingand poor healing (Silverstein 1992} young, low-risk women Postpartum care There area number of aspects to be considered in the postpartum care of patients who have undergonean episiotomy. Each patient will have » Anaemia > Chronic conltions for example diabetes > Haematoma » Infection » Mechanical stress onthe wound » Presence of foreign bois » Poor nutrition » Tiat sutures causing ischaemia NURSING STANDARDdifferentneeds and preferences regarding treatment and staf should liaise with patients to assess which is most effective foreach individual. Pain relief Perineal pain disruptsnormal activites, makes breastfeeding more difficult because the woman cannot adopta comfortable position andaffects bowel funetionand sexual vity (MoCandlish 2001), Yet despite the number of women whoexperienee it, providing adequate relief continues tobe achallenge. The best approach is to combine systemic and localised strategies (Steen et.al 2006). Oral analgesia There has been litle evaluation oftheeffectiveness of analgesia provided for perineal traumaandl episiotomy (Verspyck etal 2006). Steen et al(2006) recommend paracetamol. However codeine derivative combined with paracetamol (Tylex®) ismore effectv Inutcosteine ean eause constipation, which is likely to add to postpartum discomfort (Steenand Marchant 2007). Dextropropoxyphene with paracetamol (co-proxamol) avoidsthe problem of constipation (Steenand Marchant 2007). Non-steroidal ant inflammatory drugsmay contribute ro bruising and inflammation sothey may not be the best choice of analgesic for women with perineal pain (Steen eta! 2006), Local pain relief Over the years various remedies References ‘Albers L, Sadler KO, Bice Es, “ea D Peralta P (2005), Midifery care messes in he second stage of abr an redction of arta act vous itl ome ral ara of Moher an Yemen's Heth. 50, ds: Ring Marge Mosby, t Lous MD Bump RC, Norton PA (995) Epulogy and mata ist ae Gnecloy Cas oft 5.5372 ‘America 25,4, 723746, ‘american Collegeof ‘Obstetricians and Gynecologists SUPBEST FLumbiganan (2008) COS Pacts Eueta Ho, 7 Epsilon Cll maagerent ‘nites for obtetrin ineolagsts. Obstetrics ana Gjrecloy 107 4 957-962 Bodner-Aaer 8 Bodner K. Kalder A et af 2001 os actors for hrd-dgre pers ears vagina eter, wit a anal of eviscony types Jour of Reprectie Medicine. 46.8 agin ith (Cote Revi Wiley art Sons, Caches Calvert Flaming V (2000) iin postr a: review of esearch pertning evince in chasing men, dat of dca 752730, ers, 322, 07-45, Batley CS, Kennedy CM, Cederaren Mt 200%) ate Nygard IE 2005) Pete Yor mb best an the sk symtoms and ifestye factors in __ahers pregnancy outco. der cme our of omens Health 1,2, 128136, 2.210224, Bryant R199) Acwe and Olver pei oe dysfinction. Obstet “hinkhanvop 4 Thinkhamrop B (200) Attic pela for Fourth perineal tear ving The Coca ira Ive 4 Je tts and Geog. 1, have been suggested to help relieve perineal pain, including salt added co bath water, aromatherapy oils and witch hazel. Takinga bath can be ‘comforting, but theres no evidence that adding salt, antiseptic (Sleep and Grant 1988) or applyingoils reduces pain (Daleand Cornwell 1994). Iced sitz baths, once widely recommended, are no longer popular because women dislike sttingin very cold water. [ee packsand cooling gel packsare now more widely used. They can provide relief, bur che effects appear tobe short-lived (Steen etal 2006). They probably achieve theireffects by cooling the superficial issues, numbing the nerve endings and reducing theeffeets of inflammation. They donot compromise healing (Steen eta! 2006). ‘Women prefer gel packs because they are conformable and therefore havea cushioning effect. Cooling maternity gel padseffectively reduce oedema, bruisingand pain (Steen e¢al 2000). Ice paekscan have sharp edges which are nfortable to siton (Steen and Marchant 2007}. Some women get relief by sittingon special cushions. Longer-termpelvic floor dysfunction Genital prolapse and incontinence are common, though Frequently unrecognised conditionsthathave major implications for women’s quality of life (Bumpand Norton 1998). Urinary and faecal Hanratty KP (2003) ose Mastrote Chel Livogstone, Davis K Kumar 0, StantonSt, ‘Thala R Fes M, Bland J (2008) Syptams an aa Feinbug 7 sphincter merholayfo'080 Hartman K, Viswanathan ery of Ma epi hee Teas. Palen Gals Me Bish our of Surgery 90,2, 15733599 DeLaney JO (2005) Tei enidani of ple Roe dsfnctin achievable qa for rove prevention and tester. Arico durot of Obstet rs ‘mecovoay. 192, 5, 1881895, Enda M Kelese M Nelson J etal (2000) A Gace to Effective ‘ae in Pega ant Cth, Thr edtion Oxford Uverty Press Ono Le KO (2005) Outcomes of routine pion: a systematic review rat ofthe Americ Mysco) Asoc, 293 2n2ve Jonson A 1968) Te cleansing ttc, sing Tames (Cnet Nursing Sent) 84,6, 9.10 Kadir RA, Economides DL, Sahin CA, Owens D, Lee €A (1998) Frequency of erie isdn serra women vith mmenornaoa, Me nce. 351, 90) 05,409, Kenyon 5, Ford F (2004) How ‘we mrve ween’ posttith ariel helt? MIDIRS iter Digest 101732 Kettle € (2001) Prins eae precnancy and chit Chia! Eadence 9, 972-982. ” . Fleming VE, Hagen 5, Niven (2008) Does pera suturing make 4 fleenc? The SUNS tral Brith shoul of Obstet ans Cynoecoay 10,7, 684-689 Gordon 8, MackrodtC, Ferm , Truesdale A Ayers , Grant A 11996) The Fc Chere Broman 85, Foster ME, Dale A Comal (1990) The lo Sty) Arann ection Kettle 6, Sanson RB (1998) eaper DU 9986) Aseptic octyl ekevig perineal of bwostoge postpartum perineal Confit ver interape! orandsheng ty scary sce flowing chibi) repaeleng he shi sired, sates fr prea eae Cocne ‘nt rf Hosts insrandanzed cl wil Jowmt—BetishJourat of bsttics and Rov, The octane Lita Ise Infection 8.3 268267 of Arce Nas 11. 88 NURSING STANDARD 196. Gynoeotay, 105, 4, 435-040, be Wey and Ss, Chics september 5: vol 21 no $2: 2007 45art & science wound care focus incontinence severely disrupt normal daily activities including ability to travel, work outside thehome and reduce women’scontibution to society and the economy (DeLanccy 2005). The subject istaboo,soxwomen often suffer silence andattribute cher sympeoms tothe combined effects of childbirth and ageing (Brad 2005). However, the results of large follow-up beliefs may beerroneousand that many women experi we perineal trauma respective of surgical intervention (ACOG 2006). Ikisdifficulrtoestablish the strength of the association between theextentof injury and later pelvic floor dysfunction, However, the available cevddence suggests that pelvie floor damage is proportional to theamount of trauma sustained and that episiocomy probably doesnot help to ‘Meta-analysis 'A Statistical technique used to combine the results of several studies into single calculation {Khan et af 2001), It involves taking the individual results from each study and calculating a single summary statistic (effect measure) for all the studies, Pooling data in meta-analysis is only worthwhile if each study has addressed the same outcome measure and tndertaken the same apprcach to measuring it, and also ifthe study populations andl samples are comparable Khan KS, tor Ret G, Glanville for ature research Fidrcr Bos Sowden A Wejjen (2001) eo 8 2, 00-08, Lundertating Stone Reviews of - National Institute fr Health and escorcl and Efectiveess cos ‘Natoma he (Gotan for Corin Oat or Canmssning Rees Sond «sition RD Repat Ho. 4. NHS (Genre fr Reis aed ‘semiation Ue of York, Leaper 91995) Anes a Posinatel Core Raine Postatd Car for Wor ond tr Bobs Gite NICE. Lond Ramin SM, Ramus RM, Little BB, Gistrap UC 3rd (1972) Ely pr of epsitony dehiscence associat ‘ith fction. Amncon Jaw of 273260 Steen I, cooper K (977A fer asessng pees trauma Jere af and Coe 6,9, 432-426, Steen M, Marchant P (2007) Icepcks ae colin el versus no ald trata free of perl po 2 ono alleviate damage (MeCandlish 2001), Hartmann etal (2005) could noestablish whether women undergoingepisioromy were at reduced risk of later faecal and urinary incontinence and impaired sexual dysfunction because none ofthe studies included in theirsystematic review had continued forlong enough to provide the required information. The meta-analysis(Box 5) of existing studies provides good evidence that mediolateral episiotomy ismore likely tobe associated with injury totheanal sphincter, but didnot dlemnonstrate whether this was relaced to future risk of pelvicfloordamageand incontinence |ACOG 2006), Longitudinal studies are required to provide his information, butare expensive to undertake and require commitment from both the research team and the women involved. Conclusion Although perineal wounds that oceur spontaneously duringlabour are common and frequently accompanied by interventions that have the potential ro increase pain and trauma, many aspects of care continue to be under rched. Despite numerous large-scale studies and meca-analysis, there site evidence to underpin interventions intended to reduce the risk of infection alleviate pain and avoid damage tothe pelvic floor, Further research needs to be undertaken toimprove short and longerterm maternal outcomes NS 38 6,322:338, VerspyckE, Sentihs Roman H, Sergent F, Marpeau (2096) Eston teshnques. uma! de Gynecoone Obstet et Boone leo Repradeton. 35,1 Sup Is401S51 Wolo Je (2006) Assessnnt ad amageret of sagen! want ‘hea practic. Maing Stand serio Msn Tis 92, cance SER M.S gD 20-52, 6-56 apt tlos07 {2000 evn psu jeden aM, Merle (935) Macarthur Ad Machethur © Berea trauma Toco rte carota conédy ptt vin {Royal calege of Obstetricians So aa nurs spay, SOM i cide, every, a Sty of 413 women th g ere srk ana Gynneotoits (2008) 14,8.308308 i. ‘i eects in a en eatin Spontaneaus compat ree ‘in delivery-a prospective e os ery Dovel Rope Cig hs 25 ‘Sten M, Copper Ky Marchant, nr. Geburshi rover $3 Cote sty Anerean seraleg Perel Rept GriffithsJones M, Walker 10. 625608 (tse and Gece 19.4 (2000) randomised contraed m9204 Silverstein P (1992 Sing nd Wits Fd V Florey C Mites ‘wean healing. American Journ of Magne 94 14,225.24, ‘Sleep 4 Grant A (1988) Es of ‘alt at Sab tah cpa sigan, Mrsing Tres, 22, 5557 ‘Steen M (2007 Feria tes and ‘isiotony: hw do wounds bea ‘rth Sora of Wi. 13,8. ‘Mecandish R200) Peis ‘wauma:povrtion ang treatment oor of Midefery and Woes ‘health 466, 396-401, Metcalfe A, Bick D, Toit, Willams A Halon V (2005) 4 prospective crt std of ei and orepaiofsacnt-ogroe ies rau ests an ses 46 september 5 : vol 21 no 52 2007 tel tocarpare te efetvnes of ieepeks and Epon th coin maternity gl pds at alvin strata prea ama, Midfry.10.1. 40-5, ‘Thacker 58, Banta HO (963) Bevis and sks of episotony: an intorpeetative revo oft Ents Iongiag trate, 1860-1080. (Obstet ee Gynecol Survey (4, Ogston SA 199) Esisctony il prints otk UK pregravde Joore! of Puc ath Mev 20,4, 422-427 Winter 60 (1962) Formation the Scab ad tho at of epithlzstion of supetial wounds the sin of the young dames pg Mature. 193, 293204 NURSING STANDARD