Discussion
bleeding, hyperemia, first-degree tears, pain, ecchymosis, oedema, trauma
HYPEREMIA, BLEEDING, OEDEMA, ECCHYMOSIS
The principal findings of this study were that the use of surgical glue for the perineal repair of first- and second-degree tears and episiotomy in all tissue planes (skin, mucosa, and muscle) proved to be as effective as the standard suture method. It showed less pain, shorter procedure time, and a similar healing process.The strengths of the present study were the design of a clinical, controlled, and randomised trial, in which the researchers rigorously followed all the eligibility and inclusion criteria to minimise selection biases. Also, a surgical glue suitable for deep tissue layers, such as muscles, allowed it to be used in second-degree tears and episiotomy.In addition, the follow-up for a more extended period (up to 8 months) allowed the evaluation of the healing process until its complete resolution.Another strength was the development of the surgical glue application technique and training for the team that participated in the study, which will allow the future sharing of this method.There was a good acceptance among the women to participate in the research, which can be considered a strong study point. This finding surprised the researchers, as it was believed that, for being a new procedure, most women would not accept participating in the research out of fear, but this was not the case. On the contrary, some women allocated to the control group requested that the glue be used. However, the importance of randomisation in the types of perineal repair was explained by not allowing changing the method used.The weaknesses found in the current study were the extended data collection period due to the small number of deliveries per day at the research site and the high number of exclusions related to the indication of cesarean section or intact perineum.Due to the rapid polymerisation of the surgical glue, there was also difficulty in using surgical glue in the presence of heavy bleeding. In some cases, it was necessary to use more than one surgical glue ampoule (0.5 ml) to repair the tear, increasing the cost of the procedure. Another problem observed in the EG was the need for a new repair with surgical glue between 24 and 48 h after the initial procedure, which did not occur with the CG group. On the other hand, it was also observed that one glue unit could be used for more than one woman, depending on the degree and extent of the perineal tear.A significant limitation was the price of the products. The surgical glue had an excessive cost (R$ 350.00) compared to the suture thread (R$ 22.00) in this study. However, it is worth mentioning that some materials and medications were not used when performing the repair with surgical glue, such as anaesthetics for the procedure and using an analgesic schedule for perineal pain after delivery, and the shorter time spent by the health professional to perform it. Although there was an option of using more economical surgical glues for skin and mucosa repair, only the glue chosen in the research is registered at ANVISA with approval to be used in the innermost layer (muscle) of perineal trauma.The favourable results with surgical glue for repairing first- and second-degree tears concerning perineal pain agree with the results from other studies. A study in women with second-degree tears compared three skin closure methods (glue, suture, and non-suture) and showed that the lowest perineal pain intensity was with surgical glue. Assessed with a 100 mm visual analogue scale, the mean pain in the second postpartum week was 3.0 with glue, 5.0 with suture and 7.0 with no suture (A study with a sample of 135 women, aiming to compare the use of Histoacryl® glue with the Monosyb® suture thread to repair first-degree tears, was done. It showed that women repaired with surgical glue had less perineal pain intensity in all situations evaluated (at rest, when sitting, walking and urinating) than those with sutures in the first week after birth. Nevertheless, no difference in perineal pain was found at 30 days postpartum [As for the healing process, evaluated by the REEDA scale, the groups were similar regarding hyperemia, oedema, ecchymosis and discharge. The difference in edge coaptation was due to a lower score in the CG than in the EG, and it occurred mainly among women with second-degree tears up to 10 days after delivery. Other clinical trials that compared the use of glue to suture for perineal skin repair showed no significant difference in any of the items of the REEDA scale [Nonetheless, it is essential to point out that the coaptation of deeper tissue layers was not evaluated in these studies, which had different design than ours.The need to perform a new perineal repair procedure was also observed in a study conducted with 61 women where surgical glue was used to close the cutaneous episiotomy [Only the current study was the repair with surgical glue performed in all tissue layers affected (skin, mucosa and muscles), except for the anal sphincter muscles, as the women with third or fourth-grade tears were not included.As for the perineal repair time, in the EG, it was 6.1 min shorter than in the CG, corroborating the results of other studies [The results of this study related to less pain for women and a shorter procedure time are auspicious reasons for clinicians and policymakers to change the practice of perineal repair. Nevertheless, the excessive cost of surgical glue compared to suture thread can be an important limiting factor for its use in the delivery care practice, especially in health systems that face challenges due to the increased costs of materials and equipment, as well as in developing countries with few available resources.Therefore, future cost analysis research is suggested, comparing all materials, procedures involved, and time spent by the professional in performing the two types of perineal repair. It is also suggested that further studies be conducted with several types of glue available and application methods to find the materials and techniques that contribute to the best cost–benefit to women. In addition, another vital factor to be analysed is the woman's satisfaction with both types of perineal repair.