Perineal massage in labour and prevention of perineal trauma: randomised controlled trial

The effectiveness of interventions in the prevention of perineal trauma in parturients: A systematic review with meta-analysis

AIM

To investigate the effectiveness of interventions to prevent the occurrence of perineal trauma in parturients.

METHODS

A bibliographic search was carried out in Cochrane Library, MEDLINE via PUBMED, LILACS via Virtual Health Library (VHL), Embase, Scopus, CINAHL, Scielo, Web of Science, and PEDro databases. Randomized clinical trials evaluating the effects of any intervention to prevent perineal trauma during pregnancy and/or childbirth were included. There were no temporal or language restrictions. The risk of bias assessment was performed using the Revised Cochrane Risk-of-bias Tool for Randomized Trials.

RESULTS

Fifty studies, with a total of 17,221 participants, were included in this meta-analysis. No intervention during childbirth was effective for the prevention of perineal trauma (RR = 1.07, 95% CI [0.98.1.18], p < 0.01, I² = 83%) when compared to no intervention. However, a lower risk of perineal laceration was verified with techniques performed during pregnancy, when compared to no intervention (RR = 0.81, 95% CI [0.71, 0.93], p = 0.05, I² = 47%). Among them, highlight the effects of perineal massage in preventing lacerations (RR = 0.69, 95% CI [0.54, 0.87], p < 0.01) when compared to no intervention.

CONCLUSIONS

The techniques performed during pregnancy, especially perineal massage, are associated with a lower risk of perineal laceration.

Effects of perineal massage during childbirth on maternal and neonatal outcomes in primiparous women: A systematic review and meta-analysis

BACKGROUND

Perineal massage during childbirth has been recommended as an effective measure to prevent perineal injury. However, the overall effects of perineal massage during childbirth on maternal and neonatal outcomes in primiparous women remain inconclusive. Particularly, the effects of perineal massage begun during different stages of labor need to be further investigated.

OBJECTIVES

To comprehensively review the effects of perineal massage during childbirth on primiparous health outcomes, including perineal-related outcomes, duration of labor, hemorrhage and postpartum perineal pain, and neonatal outcomes, including Apgar scores and neonatal complications, and to further explore the effects of perineal massage begun during different stages of labor.

DESIGN

A systematic review and meta-analysis following the Cochrane Handbook guidelines and PRISMA2020.

METHODS

A systematic search strategy was developed following the three-phase search approach, and the literature search was conducted in electronic databases and clinical trial registers from inception to 7th January 2022. Study selection and data extraction were completed independently by two researchers. The updated Cochrane risk of bias 2.0 tool for randomized trials was chosen to evaluate the quality of included studies. Data analyses were conducted using the Revman5.4 software, and subgroup analyses were performed based on the different start times of perineal massage. Furthermore, the certainty of body of evidence for each outcome was assessed utilizing the GRADEpro online tool.

RESULTS

Seventeen randomized controlled trials involving 3248 primiparous women were included in the review. The pooled results of meta-analyses indicated that perineal massage begun during the second stage of labor significantly increased the occurrence of intact perineum (RR = 2.78, 95 % CI: [1.52, 5.05], P < 0.001), reduced the rate of second- and third-degree perineal lacerations (P < 0.05), and decreased the incidence of episiotomy (RR = 0.63, 95 % CI: [0.50, 0.79], P < 0.001), while perineal massage during the first stage of labor effectively shortened the duration of the first and second stages of labor (P < 0.05). The available evidence also suggests the potential role of perineal massage on hemorrhage and long-term postpartum perineal pain (P < 0.05). However, the aggregated results failed to demonstrate the beneficial effects of perineal massage on neonatal outcomes (P > 0.05).

CONCLUSIONS

Perineal massage begun during the second stage of labor effectively improves the perineal-related outcomes in primiparous women, while perineal massage during the first stage of labor significantly shortens the duration of labor. High-quality studies exploring the standardized procedure for perineal massage and the short- and long-term effects of perineal massage are warranted.

REGISTRATION NUMBER

CRD42022302336 (PROSPERO).

The effect of sacral massage on meconium-stained amniotic fluid and the duration of fetal descent in labor: A randomized controlled trial

OBJECTIVE

The aim of this study was to investigate the effect of sacral massage on the presence of meconium-stained amniotic fluid and the duration of fetal descent during labor in pregnant women.

METHODS

A total of 220 nulliparous women with singleton low-risk pregnancies in the vertex position at term were recruited. Eligible women were randomly assigned to either massage group or a control group. The massages were performed with friction and tapotement protocol. The massage was applied for 10 min each time by a midwife who is also an expert in the field, at the onset of contractions during the intrapartum period, when cervical dilatation reached 10 cm. The Wong-Baker faces pain rating scale was evaluated.

RESULTS

No significant difference was found between the length of the first stage of labor and the total length of delivery (p = 0.097 and 0.434), respectively. There was a significant difference between the two groups in terms of perineal injuries. Perineal injury was lower in the massaged group (p = 0.005). There was a low percentage of meconium-stained amniotic fluid in the massaged group. The difference between the groups was statistically significant. The duration of fetal descent was shorter in the massaged group (p < 0.001). A significant difference was found in Wong-Baker FACES pain rating scale scores. Lower scores were detected in the massaged group (p < 0.001).

CONCLUSION

Sacral massage has beneficial effects on mothers and babies in obstetric practice. In addition, applying massage during labor plays a significant role in reducing the presence of meconium-stained amniotic fluid and the duration of fetal descent.

Perineal Massage for Prevention of Perineal Trauma and Episiotomy During Labor: A Systematic Review and Meta-Analysis

Objective: Vaginal births are associated with a certain degree of trauma to the genital tract, with significant short-term and long-term morbidity. Awareness of morbidity following perineal trauma has led to application of different interventions during the late first stage and second stage of labour to prevent severe perineal trauma. This includes techniques such as perineal massage, warm and cold compresses, and perineal management techniques. Objective of this meta-analysis is to evaluate the effect of perineal massage during the late first stage and second stage of labour on the rate of episiotomy and risk of perineal trauma. Materials and methods: Electronic databases (PubMed, Scopus, Cochrane Library and Science Direct) were searched from inception until August 2021. We included randomized controlled trials (RCTs) which compares perineal massage during labor (i.e., intervention group) with a control group in women with singleton gestation and cephalic presentation at ≥36 weeks. The primary outcome was severe perineal trauma and the rate of episiotomy. Meta-analysis was performed using the random-effects model of DerSimonian and Laird to produce summary treatment effects in terms of relative risk (RR) with 95% confidence interval (CI). Results: Ten trials including 4,088 women were analyzed. Women with perineal massage during labor had a significantly lower incidence of severe perineal trauma (RR: 0.52, 95% CI 0.29- 0.94) compared to the control group. The incidence of episiotomy was lower in the perineal massage group (RR: 0.71, 95% CI 0.52-0.98 p < 0.01) but was statistically insignificant (P>0.05). Conclusion: The finding of meta-analysis showed that perineal massage during labor could be effective in reducing the risk of severe perineal trauma, such as third- and fourth-degree spontaneous lacerations during labor.

Effect of Prenatal Perineal Massage on Postpartum Perineal Injury and Postpartum Complications: A Meta-Analysis

Background

The efficacy of perineal massage is controversial. The study was aimed at comparing the effects of perineal massage on perineal injury and complications.

Methods

PubMed, Embase, the Cochrane Library, and ISI Web of Science were searched for literature on the relationship between prenatal perineal massage and postpartum perineal injury and complications until April 2022. Indicators included postpartum perineal tears, perineotomy, postpartum perineal pain, natural labour, and postpartum incontinence. Finally, RevMan5.4 software was used to analyze the extracted data.

Results

A total of 6487 subjects in 16 studies were included, with 3211 who received perineal massage and 3276 did not. There was no significant difference in 1-2 degree perineal tearing between the intervention group and the control group (RR = 0.96, 95% CI [0.90, 1.03], P = 0.30), and there was no heterogeneity between studies (P = 0.62, I² = 0%), indicating publication bias. Compared with the control group, prenatal perineal massage significantly reduced the incidence of 3-4 degree perineal tears (RR = 0.56, 95% CI [0.47, 0.67], P < 0.00001), and there was no heterogeneity between studies (P = 0.16, I² = 30%), indicating publication bias. Compared with the control group, prenatal perineal massage reduced the risk of lateral perineal resection (RR = 0.87, 95% CI [0.80, 0.95], P = 0.001), and there was no heterogeneity between studies (P = 0.14, I² = 31%), and there was no publication bias. Compared with the control group, prenatal perineal massage reduced the risk of postpartum pain at 3 months (RR = 0.64, 95% CI [0.51, 0.81], P = 0.0002). There was no significant heterogeneity among studies (P = 0.23, I² = 31%).

Conclusion

Compared with no prenatal perineal massage, prenatal perineal massage can reduce the risk of perineal injury, the incidence of lateral perineal resection, and the incidence of long-term pain.

Perineal protection methods: knowledge and use

OBJECTIVE

To analyse the knowledge and use of perineal protection methods during the expulsive stage by health professionals involved in childbirth and whether they correspond to the World Health Organization's recommendations.

METHOD

This was a cross-sectional descriptive study aimed at health workers involved in births in Spain.

RESULTS

Fifty-seven professionals participated in the study: midwives (47%), gynaecologists (25%), nurse residents (14%) and resident physicians (14%) in obstetrics and gynaecology. The degree of knowledge and use of perineal protection methods differed according to the position held and was very limited among gynaecologists and resident physicians. The only method recognized by all positions was "hands on" (p = 0.05). "Hands off " (p = 0.002), "delayed pushing" (p = 0.0001) and "maternal posture" (p = 0.03) were only known to midwives and nurse residents. "Flexion technique" (p = 0.035) and "delayed pushing" (p = 0.011) were used effectively by midwives and nurse residents. "Episiotomy" was erroneously identified as a method to protect the perineum by gynaecologists and resident physicians (p = 0.003).

CONCLUSION

The degree of knowledge and use of perineal protection methods by health care professionals does not correspond to the recommendations of the World Health Organization.

Combined massage and warm compress to the perineum during active second stage of labor in nulliparas: A randomized trial

OBJECTIVE

To evaluate the combined effect of massage and warm compress to the perineum (MassComp) compared with standard "hands-off" in the second stage of labor.

METHODS

A randomized trial was conducted in a University hospital in Malaysia. Nulliparous women at term who were about to start pushing were randomized to massage during pushing and warm compress to the perineum in between pushes or to standard "hands-off" care. Primary outcome was suturing for perineal injury (episiotomy or tear).

RESULTS

A total of 156 participants were analyzed based on intention to treat. Perineal repair rates were 53/79 (67%) for MassComp versus 70/77 (91%) for control (relative risk [RR] 0.72, 95% confidence interval [CI] 0.61-0.98, number needed to treat for an additional beneficial outcome [NNT_b ] 5, 95% CI 2.83-8.62, P < 0.001). Of the secondary outcomes, participants' satisfaction with care (visual numerical rating scale 0-10; 8.3 ± 1.2 vs 7.8 ± 1.2, P = 0.014), major perineal injury (second degree or higher) rates 34/79 (43%) versus 51/77 (66%) (RR 0.72, 95% CI 0.58-0.97, NNT_b 5, 95% CI 2.61-12.56, P = 0.004), episiotomy rates 28/79 (37%) versus 40/77 (53%) (RR 0.72, 95% CI 0.52-0.98, NNT_b 8, 95% CI 3.63-36.46, P = 0.043), intervention to delivery intervals 29.5 ± 13.6 versus 27.9 ± 13.8 minutes (P = 0.472) and spontaneous vaginal delivery rates 63/79 (79.7%) versus 56/77 (72.7%) (RR 1.11, 95% CI 0.92-1.34, P = 0.306) for MassComp versus control, respectively.

CONCLUSION

Massage and warm compress during pushing decreased the perineal suturing, major perineal injury, and episiotomy rates and improved maternal satisfaction.

CLINICAL TRIAL REGISTRATION

https://doi.org/10.1186/ISRCTN42773879.

[Normal childbirth: physiologic labor support and medical procedures. Guidelines of the French National Authority for Health (HAS) with the collaboration of the French College of Gynaecologists and Obstetricians (CNGOF) and the French College of Midwives (CNSF) - Maternal postures during the second stage of labour, delivery techniques and perineal protection]

OBJECTIVE

To assess maternal postures during the second stage of labour on course of labour, mode of delivery and maternal and neonatal morbidity. To describe the different techniques of spontaneous vaginal delivery and their influence on maternal and neonatal morbidity. To describe the different perineal protection techniques.

METHOD

Systematic review of the literature through consultation of Medline, Cochrane databases and international recommendations.

RESULTS

There is no particular posture that has demonstrated its superiority (Level of Evidence (LE) 2). In case of no contraindication and permanent maternal and fetal monitoring, it is recommended to encourage women to adopt the postures they consider most comfortable during the second stage of labour (Consensus agreement). There is insufficient evidence in the literature to recommend a technique for fetal head and shoulders delivery. There is not enough data in the literature to recommend the use of Ritgen maneuver (grade B), perineal massage (gradeC) or hot compresses (Consensus agreement). The abdominal expression must be abandoned (grade B).

CONCLUSION

The second stage of labour is a crucial time in labour that can lead to significant maternal and neonatal morbidity. It is necessary to take the greatest possible care in the supervision and management of women, especially for the perineal protection. The influence of non-medicinal techniques on the course of the second stage of labour should be studied.

Factors Influencing Quality of Life during the First Trimester of Pregnancy: A Prospective Cohort Study

Introduction: Pregnancy, delivery and postpartum periods are associated with fast changes leading to decreased self-confidence, anxiety, stress or even maternal depression impairing their quality of life (QOL). Although considered important, QOL of women during pregnancy is poorly understood. The aim of our study was to assess factors influencing QOL during first trimester of pregnancy. The secondary goal of our study was to evaluate whether QOL during first trimester of pregnancy is associated with newborn weight. Materials and methods: A prospective cohort study was performed including pregnant women during the first trimester visit. Our questionnaire consisted of the SF-36 QOL questionnaire, Wexner fecal incontinence scale, and other additional information. The SF-36 questionnaire mental (MCS) and physical (PCS) health scores were used in order to evaluate QOL of women during first trimester of pregnancy. Two multiple logistic regression models were created in order to determine independent variables that influence the QOL. Results: 440 pregnant women were included in the study. The two main domains that were used in the study were MCS and PCS, their medians were 50.0 (25.0; 50.0) and 50.1 (39.4; 59.0) points respectively. From the two logistic regression models we determined several independent factors that influence QOL of women during the first trimester of pregnancy. Additionally, we determined that women who reported worse QOL tended to give birth to newborns large for their gestational age. Conclusions: We found several significant variables that influence QOL of women during the first trimester of pregnancy. We also found that that lower MCS and PCS scores during the first trimester are associated with newborns large for gestational age.

[Which interventions during labour to decrease the risk of perineal tears? CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]

OBJECTIVE

The objective of this review was to evaluate whether interventions performed during labour could influence the risk of perineal tears.

METHODS

A separate keyword search for each medical intervention during labor was performed by selecting only studies evaluating perineal consequences, particularly the risk of obstetrical anal sphincter injury (LOSA). Interventions during pregnancy and during fetal expulsion have been specifically addressed in other chapters of the recommendations.

RESULTS

Maternal mobilisation and postures during the first stage of labour have not been shown to reduce the risk of OASIS (LE3). No particular posture has demonstrated its superiority over any other during the second stage of labour for preventing obstetric perineal lesions including OASIS and postnatal incontinence (urinary or faecal) (LE2). There is no reason to recommend one maternal posture rather than another during the first and the second stages of labour for the purpose of reducing the risk of OASIS (Grade C). Women should be allowed to choose the position most comfortable for them during the first and second stages of labour (Professional consensus). Posterior cephalic positions present the greatest risks of perineal injury (LE2). Manual rotation of cephalic posterior positions to the anterior during the second stage of labour may make it possible to reduce the risk of operative vaginal delivery, although no reduction in the risk of perineal injuries or OASIS has been clearly demonstrated (LE3). For fetuses in posterior cephalic positions, no data justifies a preference for manual rotation at full dilation to diminish the risk of perineal injury (Professional consensus). Urinary catheterisation is recommended for women with epidural analgesia during labour when spontaneous micturition is not possible (Professional consensus). Although current data does not justify a preference for continuous or intermittent urinary catheterisation (LE2), intermittent catheterisation nonetheless appears preferable in this situation (Professional consensus). During the second stage phase, delayed pushing does not modify the risk of OASIS (LE1). It does, however, increase the chances of spontaneous delivery (LE1). It is thus recommended that, when maternal and fetal status allow it, the start of pushing should be delayed (Grade A). There is no evidence to support preferring one pushing technique rather than another to diminish the risk of OASIS (grade B). Performing an operative vaginal delivery for the sole purpose of reducing the duration of the second stage of labour may increase the risk of OASIS (LE3). Perineal massage or the application of warm compresses during the second stage of labour appear to reduce the risk of OASIS (LE2). However, we have not made a determination about their use in clinical practice.

Perineal massage during labor: a systematic review and meta-analysis of randomized controlled trials

Background: Different techniques have been analyzed to reduce the risk of perineal trauma during labor.Objective: To evaluate whether perineal massage techniques during vaginal delivery decreases the risk of perineal trauma.Search strategy: Electronic databases (Medline, Prospero, Scopus, ClinicalTrials.gov, Embase, ScienceDirect, the Cochrane Library, SciELO) were searched from their inception until February 2018. No restrictions for language or geographic location were applied.Selection criteria: We included all randomized controlled trials (RCTs) comparing the use of perineal massage during labor (i.e. intervention group) with a control group (i.e. no perineal massage) in women with singleton gestation and cephalic presentation at ≥36 weeks. Perineal massage was defined as massage of the posterior perineum by the clinician's fingers (with or without lubricant). Trials on perineal massage during antenatal care, before the onset of labor, or only in the early part of the first stage, were not included.Data collection and analysis: All analyses were done using an intention-to-treat approach. The primary outcome was severe perineal trauma, defined as third and fourth degree perineal lacerations. Meta-analysis was performed using the random-effects model of DerSimonian and Laird to produce summary treatment effects in terms of either a relative risk (RR) with 95% confidence interval (CI).Main results: Nine trials including 3374 women were analyzed. All studies included women with singleton pregnancy in cephalic presentation at ≥36 weeks undergoing spontaneous vaginal delivery. Perineal massage was usually done by a midwife in the second stage, during or between and during pushing time, with the index and middle fingers, using a water-soluble lubricant. Women randomized to receive perineal massage during labor had a significantly lower incidence of severe perineal trauma, compared to those who did not (RR 0.49, 95% CI 0.25-0.94). All the secondary outcomes were not significant, except for the incidence of intact perineum, which was significantly higher in the perineal massage group (RR 1.40, 95% 1.01-1.93), and for the incidence of episiotomy, which was significantly lower in the perineal massage group (RR 0.56, 95% CI 0.38-0.82).Conclusions: Perineal massage during labor is associated with significant lower risk of severe perineal trauma, such as third and fourth degree lacerations. Perineal massage was usually done by a midwife in the second stage, during or between and during pushing time, with the index and middle fingers, using a water-soluble lubricant.

The effect of perineal massage during the second stage of birth on nulliparous women perineal: A randomization clinical trial

Background

Childbirth and puerperium are of the most important periods in women's lives and can affect different aspects of their lives.

Objective

To determine the effect of perineal massage in the second stage of labor on perineal lacerations, episiotomy, and perineal pain in nulliparous women.

Methods

This randomization clinical trial was conducted at Be'sat Hospital in Sanandaj, Iran, from 2013 to 2014. A total of 195 nulliparous women were included in the study. The participants were selected through convenience sampling, and randomly assigned to two groups: intervention and control groups. The intervention group received 30-minute perineal massage during second stage of labor. Subsequently, we analyzed perineal laceration, episiotomy, and perineal pain among the two groups. All of them were taught about postpartum perineal pain and its severity, and the researcher followed them up 3 days, 10 days, and 3 months after childbirth by telephone. The data were analyzed using SPSS version 18. We used descriptive statistics and analytical statistics, including t test, Chi-square test, and Fisher's test.

Results

Frequency of episiotomy was 69.47% in the intervention group and 92.31% in the control group, and the difference was statistically significant (p<0.05). The results revealed 23.16% of first-degree perineal laceration and 2.11% of second-degree perineal laceration in the intervention group, and no vestibular laceration or third- and fourth-degree lacerations in the intervention group. However, there were 5.13% of vestibular laceration, 7.69% of first-degree laceration, 2.56% of second-degree laceration, and 1.05% of third-degree laceration (one woman) in the control group. Based on the results, the postpartum perineal pain was significantly different in both groups.

Conclusion

Regarding the results of this study and those of other studies, perineal massage during the second stage of labor can reduce the need to episiotomy, perineal injuries, and perineal pain.

Trial registration

The trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the Irct.ID: IRCT2013090314556N1.

Funding

This study received by financial support of Kurdistan University of Medical Sciences, Sanandaj, Iran.

Perineal techniques during the second stage of labour for reducing perineal trauma

BACKGROUND

Most vaginal births are associated with trauma to the genital tract. The morbidity associated with perineal trauma can be significant, especially when it comes to third- and fourth-degree tears. Different interventions including perineal massage, warm or cold compresses, and perineal management techniques have been used to prevent trauma. This is an update of a Cochrane review that was first published in 2011.

OBJECTIVES

To assess the effect of perineal techniques during the second stage of labour on the incidence and morbidity associated with perineal trauma.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (26 September 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Published and unpublished randomised and quasi-randomised controlled trials evaluating perineal techniques during the second stage of labour. Cross-over trials were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion, extracted data and evaluated methodological quality. We checked data for accuracy.

MAIN RESULTS

Twenty-two trials were eligible for inclusion (with 20 trials involving 15,181 women providing data). Overall, trials were at moderate to high risk of bias; none had adequate blinding, and most were unclear for both allocation concealment and incomplete outcome data. Interventions compared included the use of perineal massage, warm and cold compresses, and other perineal management techniques.Most studies did not report data on our secondary outcomes. We downgraded evidence for risk of bias, inconsistency, and imprecision for all comparisons. Hands off (or poised) compared to hands onHands on or hands off the perineum made no clear difference in incidence of intact perineum (average risk ratio (RR) 1.03, 95% confidence interval (CI) 0.95 to 1.12, two studies, Tau² 0.00, I² 37%, 6547 women; moderate-quality evidence), first-degree perineal tears (average RR 1.32, 95% CI 0.99 to 1.77, two studies, 700 women; low-quality evidence), second-degree tears (average RR 0.77, 95% CI 0.47 to 1.28, two studies, 700 women; low-quality evidence), or third- or fourth-degree tears (average RR 0.68, 95% CI 0.21 to 2.26, five studies, Tau² 0.92, I² 72%, 7317 women; very low-quality evidence). Substantial heterogeneity for third- or fourth-degree tears means these data should be interpreted with caution. Episiotomy was more frequent in the hands-on group (average RR 0.58, 95% CI 0.43 to 0.79, Tau² 0.07, I² 74%, four studies, 7247 women; low-quality evidence), but there was considerable heterogeneity between the four included studies.There were no data for perineal trauma requiring suturing. Warm compresses versus control (hands off or no warm compress)A warm compress did not have any clear effect on the incidence of intact perineum (average RR 1.02, 95% CI 0.85 to 1.21; 1799 women; four studies; moderate-quality evidence), perineal trauma requiring suturing (average RR 1.14, 95% CI 0.79 to 1.66; 76 women; one study; very low-quality evidence), second-degree tears (average RR 0.95, 95% CI 0.58 to 1.56; 274 women; two studies; very low-quality evidence), or episiotomy (average RR 0.86, 95% CI 0.60 to 1.23; 1799 women; four studies; low-quality evidence). It is uncertain whether warm compress increases or reduces the incidence of first-degree tears (average RR 1.19, 95% CI 0.38 to 3.79; 274 women; two studies; I² 88%; very low-quality evidence).Fewer third- or fourth-degree perineal tears were reported in the warm-compress group (average RR 0.46, 95% CI 0.27 to 0.79; 1799 women; four studies; moderate-quality evidence). Massage versus control (hands off or routine care)The incidence of intact perineum was increased in the perineal-massage group (average RR 1.74, 95% CI 1.11 to 2.73, six studies, 2618 women; I² 83% low-quality evidence) but there was substantial heterogeneity between studies). This group experienced fewer third- or fourth-degree tears (average RR 0.49, 95% CI 0.25 to 0.94, five studies, 2477 women; moderate-quality evidence).There were no clear differences between groups for perineal trauma requiring suturing (average RR 1.10, 95% CI 0.75 to 1.61, one study, 76 women; very low-quality evidence), first-degree tears (average RR 1.55, 95% CI 0.79 to 3.05, five studies, Tau² 0.47, I² 85%, 537 women; very low-quality evidence), or second-degree tears (average RR 1.08, 95% CI 0.55 to 2.12, five studies, Tau² 0.32, I² 62%, 537 women; very low-quality evidence). Perineal massage may reduce episiotomy although there was considerable uncertainty around the effect estimate (average RR 0.55, 95% CI 0.29 to 1.03, seven studies, Tau² 0.43, I² 92%, 2684 women; very low-quality evidence). Heterogeneity was high for first-degree tear, second-degree tear and for episiotomy - these data should be interpreted with caution. Ritgen's manoeuvre versus standard careOne study (66 women) found that women receiving Ritgen's manoeuvre were less likely to have a first-degree tear (RR 0.32, 95% CI 0.14 to 0.69; very low-quality evidence), more likely to have a second-degree tear (RR 3.25, 95% CI 1.73 to 6.09; very low-quality evidence), and neither more nor less likely to have an intact perineum (RR 0.17, 95% CI 0.02 to 1.31; very low-quality evidence). One larger study reported that Ritgen's manoeuvre did not have an effect on incidence of third- or fourth-degree tears (RR 1.24, 95% CI 0.78 to 1.96,1423 women; low-quality evidence). Episiotomy was not clearly different between groups (RR 0.81, 95% CI 0.63 to 1.03, two studies, 1489 women; low-quality evidence). Other comparisonsThe delivery of posterior versus anterior shoulder first, use of a perineal protection device, different oils/wax, and cold compresses did not show any effects on perineal outcomes. Only one study contributed to each of these comparisons, so data were insufficient to draw conclusions.

AUTHORS' CONCLUSIONS

Moderate-quality evidence suggests that warm compresses, and massage, may reduce third- and fourth-degree tears but the impact of these techniques on other outcomes was unclear or inconsistent. Poor-quality evidence suggests hands-off techniques may reduce episiotomy, but this technique had no clear impact on other outcomes. There were insufficient data to show whether other perineal techniques result in improved outcomes.Further research could be performed evaluating perineal techniques, warm compresses and massage, and how different types of oil used during massage affect women and their babies. It is important for any future research to collect information on women's views.

The Effect of Warm Compress Bistage Intervention on the Rate of Episiotomy, Perineal Trauma, and Postpartum Pain Intensity in Primiparous Women with Delayed Valsalva Maneuver Referring to the Selected Hospitals of Shiraz University of Medical Sciences in 2012-2013

BACKGROUND

Genital trauma during vaginal delivery may result from episiotomy, spontaneous perineal tears (perineum, vagina), or both. In 2012, this study aimed to investigate the effect of warm compress bistage intervention on the rate of episiotomy, perineal trauma, and postpartum pain intensity in the primiparous woman with delayed Valsalva maneuver.

METHODS

In this randomized clinical trial, which was performed in hospitals in Shiraz, Iran, in 2012-2013, 150 women were randomly divided into 2 groups: 1 intervention and 1 control. The intervention group received warm compress bistage intervention at 7-cm and 10-cm dilatation and zero position during the first and second stages of labor for 15 to 20 minutes, whereas the control group received the hospitals' routine care. After delivery, the prevalence of episiotomy; intact perineum; location, degree, and length of rupture; and postpartum pain intensity were assessed in the 2 groups. Following that, the data were analyzed with SPSS statistical software (version 16) using χ test, t test, and odds ratio.

RESULTS

The results revealed a significant difference between the intervention and control groups regarding the frequency of intact perinea (27% vs 6.7%) and the frequency of episiotomy (45% vs 90.70%). In addition, the frequency of the location of rupture (P = .019), mean length of episiotomy incision (P = .02), and mean intensity of pain the day after delivery (P < .001) were significantly lower in the intervention group compared with the control group. However, the rate of ruptures was higher in the intervention group.

CONCLUSIONS

Warm compress bistage intervention was effective in reducing episiotomies and the mean length of episiotomy incision, reducing pain after delivery, and increasing the rate of intact perinea. However, the rate of ruptures slightly increased in the intervention group compared with the control group.

Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition, and Repair

OBJECTIVE

To review the evidence relating to obstetrical anal sphincter injuries (OASIS) with respect to diagnosis, repair techniques and outcomes. To formulate recommendations as to patient counselling regarding route of delivery for subsequent pregnancy after OASIS.

OPTIONS

Obstetrical care providers caring for women with OASIS have the option of repairing the anal sphincter using end-to-end or overlapping techniques. They may also be involved in counselling women with prior OASIS regarding the route of delivery for future pregnancies.

OUTCOMES

The outcome measured is anal continence following primary OASIS repair and after subsequent childbirth.

EVIDENCE

Published literature was retrieved through searches of Medline, EMBASE, and The Cochrane Library in May 2011 using appropriate controlled vocabulary (e.g., anal canal, obstetrics, obstetric labour complication, pregnancy complication, treatment outcome, surgery, quality of life) and key words (obstetrical anal sphincter injur*, anus sphincter, anus injury, delivery, obstetrical care, surgery, suturing method, overlap, end-to-end, feces incontinence). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to September 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

BENEFITS, HARMS, AND COSTS

Benefits from implementation of these guidelines include: improved diagnosis of OASIS, optimal functional outcomes following repair, and evidence-based counselling of women for future childbirth.

Comparison of the Effect of Dry Cupping Therapy and Acupressure at BL23 Point on Intensity of Postpartum Perineal Pain Based on the Short Form of McGill Pain Questionnaire

BACKGROUND

Perineal pain is a major morbidity in the first few days after delivery. This study aimed to investigate the effect of dry cupping therapy and acupressure at BL23 point on the intensity of postpartum perineal pain based on the short-form of McGill pain questionnaire (SMPQ).

METHODS

The present clinical trial was conducted on 150 subjects in 3 groups of 50 cases. After at least 4-8 hr of delivery, cupping therapy was performed for 15-20 min up to 3 times a week (once a day) and acupressure was performed for 15-20 min based on clockwise model. The short-form of McGill pain questionnaire was completed both before and after the intervention. The SPSS statistical software was used to analyze the data using repeated measures ANOVA. Besides, p<0.05 was considered statistically significant.

RESULTS

In the cupping therapy group, mean of the perineal pain intensity reduced from 37.5±6.8 before the intervention to 11.1±6.1, 6.9±4.7, and 3.8±3.6 immediately, 24 hr, and 2 weeks after the intervention, respectively. The results of study showed that the differences between the intervention and control groups were statistically significant (p<0.01). Mean difference of the perineal pain intensity in the acupressure group reached from 35.6±8.1 before the intervention to 10.4±5.5 two weeks after the intervention, so the variation between intervention and control groups was statistically significant.

CONCLUSION

The study findings showed that cupping therapy and acupressure reduced perineal pain. Therefore, they may be considered as effective treatments for reducing pain intensity of allowing delivery.

The impact of obstetric gel on the second stage of labor and perineal integrity: a randomized controlled trial

OBJECTIVE

Dianatal® is a bioadhesive gliding film which reduces the opposing force to vaginal childbirth. We aimed to investigate the safety, applicability, and impact of Dianatal® obstetric gel on second stage of labor and perineal integrity.

METHODS

Low-risk singleton pregnancies at term were prospectively enrolled. Eligible women were randomly assigned to either labor management without using obstetric gel, or labor management using intermittent application of obstetric gel into the birth canal during vaginal examinations, starting at active phase of labor (≥4 cm dilation). The primary measured outcome was the length of second stage of labor.

RESULTS

Overall, 200 cases were analyzed. Demographic, obstetrical, and labor characteristics were similar between the groups. Neither adverse events nor maternal or neonatal side effects were observed. The mean lengths of the active and second stages of labor were comparable between the obstetric gel-treated and the control groups (157 versus 219 min and 48 versus 56 min, respectively). None of the women had grade III/IV perineal tears. Maternal and neonatal outcomes were not negatively influenced by using obstetric gel. No difference was found after sub-group analysis for spontaneous vaginal delivery.

CONCLUSION

Dianatal® obstetric gel is safe in terms of maternal or neonatal use. Albeit a trend toward shorter labor stages using Dianatal® obstetric gel, no significant differences were noted among the groups. In order to further investigate the influence of the obstetric gel on labor stage interval, perineal integrity and maternal and neonatal outcomes, larger randomized clinical trials are needed to be carried out.

[Impact of pelvic floor muscle training on prevention of perineal pain and dyspareunia in postpartum]

OBJECTIVE

Assessing the impact of perineal rehabilitation and massage on perineal pain and dyspareunia in the postpartum period, between 15days and 12months after delivery.

METHODS

We conducted an exhaustive review of the literature concerning pelvic floor rehabilitation in the postpartum between 1987 and May 2015, grading data by levels of evidence (LOE) according to the methodology recommendations for clinical guidelines.

RESULTS

Pelvic floor rehabilitation in the postpartum is not associated with a decreased prevalence of perineal pain and dyspareunia at 1year (LOE3). The practice of digital perineal massage during the third trimester of pregnancy is not associated with decreased prevalence at 3-month postpartum of perineal pain or dyspareunia (RR=0.64; 95% CI [0.39-1.08] and RR=0.96; 95% CI [0.84-1.08], respectively), except for women who have delivered vaginally (RR=0.45; 95% CI [0,24-0.87]) (LOE2). The practice of digital perineal massage or application of warm packs in the second stage of labor does not reduce perineal pain (RR=0.93; 95% CI [0.66-1.32]) or dyspareunia (RR=0.99; 95% CI [0.74-1.34]) at 3-month postpartum (LOE2).

CONCLUSION

There is no evidence of long-term benefit of perineal rehabilitation and perineal massage on perineal pain and dyspareunia in the year following childbirth. Further studies are needed to accurately assess the impact of therapeutic strategies proposed in France.

Effect of perineal self-acupressure on constipation: a randomized controlled trial

BACKGROUND

The efficacy of perineal self-acupressure in treating constipation is uncertain.

OBJECTIVE

We aimed to evaluate whether perineal self-acupressure would improve patient reports of quality of life and bowel function at 4 weeks after training.

DESIGN

A randomized, parallel group trial was conducted.

SETTING

The study took place at the UCLA Department of Medicine.

PATIENTS

One hundred adult patients who met Rome III criteria for functional constipation participated.

INTERVENTION

The control group received information about standard constipation treatment options, while the treatment group received training in perineal self-acupressure plus standard treatment options.

MEASUREMENTS

Primary outcome was the Patient Assessment of Constipation Quality of Life (PAC-QOL). Secondary outcomes included patient assessments of bowel function (as measured by a modified Bowel Function Index (BFI)), and health and well-being (as measured by the SF-12v2).

RESULTS

The mean PAC-QOL was improved by 0.76 in the treatment group and by 0.17 in the control group (treatment-effect difference, 0.59 [95 % CI, 0.37 to 0.81]; p < 0.01). The mean modified BFI was improved by 18.1 in the treatment group and by 4.2 in the control group (treatment-effect difference, 13.8 [95 % CI, 5.1 to 22.5]; p < 0.01). The mean SF-12v2 Physical Component Score was improved by 2.69 in the treatment group and reduced by 0.36 in the control group (treatment-effect difference, 3.05, [95 % CI, 0.85 to 5.25]; p < 0.01); and the mean SF-12v2 Mental Component Score was improved by 3.12 in the treatment group and improved by 0.30 in the control group (treatment-effect difference, 2.82, [95 % CI, -0.10 to 5.74]; p < 0.07).

LIMITATION

The trial was not blinded.

CONCLUSION

Among patients with constipation, perineal self-acupressure improves self-reported assessments of quality of life, bowel function, and health and well-being relative to providing standard constipation treatment options alone.

Searching for Medical Substances Safe for Mother and Child, Facilitating the Delivery of Pain Management and Decreasing Exhaustion--Evaluation of Obstetric Gel by Pregnant Women

The aim of the present study was to determine whether applying obstetric gel, a noninvasive method of pain management that is safe both for the mother and the child, during labor influences delivery satisfaction by facilitating pain management and decreasing exhaustion. Forty-seven primiparous women were included in the study: 23 on whom during the delivery gel was used and 24 whose delivery proceeded without the use of a gel (control group). The following research tools were used for the evaluation of satisfaction with the course of the delivery: Visual Analogue Scale (VAS), self-authorship survey, and the State-Trait Anxiety Inventory. There were no significant differences in intensification of pain in the first and second periods of delivery, exhaustion after delivery and intensification of pain in the second period of delivery, and increased anxiety between the study group and the control group. Our results suggest that application of obstetric gel during the first and second period of delivery does not significantly influence women's satisfaction with the course of delivery.

Antibiotic prophylaxis for third- and fourth-degree perineal tear during vaginal birth

BACKGROUND

One to eight per cent of women suffer third-degree perineal tear (anal sphincter injury) and fourth-degree perineal tear (rectal mucosa injury) during vaginal birth, and these tears are more common after forceps delivery (28%) and midline episiotomies. Third- and fourth-degree tears can become contaminated with bacteria from the rectum and this significantly increases in the chance of perineal wound infection. Prophylactic antibiotics might have a role in preventing this infection.

OBJECTIVES

To assess the effectiveness of antibiotic prophylaxis for reducing maternal morbidity and side effects in third- and fourth-degree perineal tear during vaginal birth.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2014) and the reference lists of retrieved articles.

SELECTION CRITERIA

Randomised controlled trials comparing outcomes of prophylactic antibiotics versus placebo or no antibiotics in third- and fourth-degree perineal tear during vaginal birth.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the trial reports for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

We identified and included one trial (147 women from a pre-planned sample size of 310 women) that compared the effect of prophylactic antibiotic (single-dose, second-generation cephalosporin - cefotetan or cefoxitin, 1 g intravenously) on postpartum perineal wound complications in third- or fourth-degree perineal tears compared with placebo. Perineal wound complications (wound disruption and purulent discharge) at the two-week postpartum check up were 8.20% and 24.10% in the treatment and the control groups respectively (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.12 to 0.96). However, the high failed-appointment rate may limit the generalisability of the results. The overall risk of bias was low except for incomplete outcome data. The quality of the evidence using GRADE was moderate for infection rate at two weeks' postpartum, and low for infection rate at six weeks' postpartum.

AUTHORS' CONCLUSIONS

Although the data suggest that prophylactic antibiotics help to prevent perineal wound complications following third- or fourth-degree perineal tear, loss to follow-up was very high. The results should be interpreted with caution as they are based on one small trial.

Antenatal perineal massage for reducing perineal trauma

BACKGROUND

Perineal trauma following vaginal birth can be associated with significant short-term and long-term morbidity. Antenatal perineal massage has been proposed as one method of decreasing the incidence of perineal trauma.

OBJECTIVES

To assess the effect of antenatal digital perineal massage on the incidence of perineal trauma at birth and subsequent morbidity.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (22 October 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2012, Issue 10), PubMed (1966 to October 2012), EMBASE (1980 to October 2012) and reference lists of relevant articles.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials evaluating any described method of antenatal digital perineal massage undertaken for at least the last four weeks of pregnancy.

DATA COLLECTION AND ANALYSIS

Both review authors independently applied the selection criteria, extracted data from the included studies and assessed study quality. We contacted study authors for additional information.

MAIN RESULTS

We included four trials (2497 women) comparing digital perineal massage with control. All were of good quality. Antenatal digital perineal massage was associated with an overall reduction in the incidence of trauma requiring suturing (four trials, 2480 women, risk ratio (RR) 0.91 (95% confidence interval (CI) 0.86 to 0.96), number needed to treat to benefit (NNTB) 15 (10 to 36)) and women practicing perineal massage were less likely to have an episiotomy (four trials, 2480 women, RR 0.84 (95% CI 0.74 to 0.95), NNTB 21 (12 to 75)). These findings were significant for women without previous vaginal birth only. No differences were seen in the incidence of first- or second-degree perineal tears or third-/fourth-degree perineal trauma. Only women who have previously birthed vaginally reported a statistically significant reduction in the incidence of pain at three months postpartum (one trial, 376 women, RR 0.45 (95% CI 0.24 to 0.87) NNTB 13 (7 to 60)). No significant differences were observed in the incidence of instrumental deliveries, sexual satisfaction, or incontinence of urine, faeces or flatus for any women who practised perineal massage compared with those who did not massage.

AUTHORS' CONCLUSIONS

Antenatal digital perineal massage reduces the likelihood of perineal trauma (mainly episiotomies) and the reporting of ongoing perineal pain, and is generally well accepted by women. As such, women should be made aware of the likely benefit of perineal massage and provided with information on how to massage.

Can we find the perfect oil to protect the perineum? A randomized-controlled double-blind trial

OBJECTIVE

To determine whether perineal massage during the second stage of labor using oil enriched with vitamins, increases the chances of delivering with an intact perineum as compared to perineal massage using pure liquid wax.

METHOD

A prospective, randomized, double-blind study was conducted. Women were assigned to liquid wax (jojoba oil) versus purified formula of almond and olive oil, enriched with vitamin B1, B2, B6, E and fatty acids. The caregivers used the oils during the second stage of labor.

RESULTS

A total of 164 women undergoing vaginal delivery were recruited. No significant differences regarding perineal lacerations, number of sutures and length of suturing were noted between the two groups. Likewise, while analyzing separately nulliparous and multiparous women, no significant differences were noted. Controlling for birth weight >4000 g, using the Mantel-Haenszel technique, no association was noted between perineal lacerations and the type of oil used (weighted OR = 0.9, 95% CI 0.3-2.4; p = 0.818).

CONCLUSION

The type of the oil used during the second stage of labor for prevention of perineal tears has no effect on the integrity of the perineum. Accordingly, it seems that there is no perfect oil.

The effects of perineal management techniques on labor complications

BACKGROUND

Many women suffer from perineal trauma during the normal vaginal delivery. Perineal trauma is mainly associated with pain and complications after the childbirth. Perineal management techniques can play a significant role in perineal trauma reduction. This study aimed to compare the effects of perineal management techniques (hands-off technique, Ritgen maneuver and perineal massage using a lubricant during delivery) on the labor complications.

MATERIALS AND METHODS

This quasi-experimental clinical trial was conducted on 99 primiparous women who referred to Daran Hospital, Isfahan, Iran for normal vaginal delivery in 2009. The subjects were selected using a convenient method and randomly assigned to three groups of Ritgen maneuver, hands-off technique and perineal massage with lubricant. A questionnaire was used to determine the demographic characteristics of the participants and complications after birth. The short form of McGill Pain Questionnaire and the visual analogue scale for pain were also employed. The incidence and degree of perineal tears were evaluated immediately after delivery. Moreover, the incidence and severity of perineal pain were assessed 24 hours and also 6 weeks after delivery.

FINDINGS

In the Ritgen maneuver group, the frequency of tears, the relative frequency of tear degrees, the severity of perineal pain 24 hours after delivery and the frequency of pain and perineal pain severity 6 weeks after delivery were significantly different from the other two methods.

CONCLUSIONS

Hands-off technique during parturition of the neonate's head was associated with fewer complications after delivery. It was even better than perineal massage during the parturition.

Perineal techniques during the second stage of labour for reducing perineal trauma

BACKGROUND

Most vaginal births are associated with some form of trauma to the genital tract. The morbidity associated with perineal trauma is significant, especially when it comes to third- and fourth-degree tears. Different perineal techniques and interventions are being used to prevent perineal trauma. These interventions include perineal massage, warm compresses and perineal management techniques.

OBJECTIVES

The objective of this review was to assess the effect of perineal techniques during the second stage of labour on the incidence of perineal trauma.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 May 2011), the Cochrane Central Register of ControlledTrials (The Cochrane Library 2011, Issue 2 of 4), MEDLINE (January 1966 to 20 May 2011) and CINAHL (January 1983 to 20 May 2011).

SELECTION CRITERIA

Published and unpublished randomised and quasi-randomised controlled trials evaluating any described perineal techniques during the second stage.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trails for inclusion, extracted data and evaluated methodological quality. Data were checked for accuracy.

MAIN RESULTS

We included eight trials involving 11,651 randomised women. There was a significant effect of warm compresses on reduction of third- and fourth-degree tears (risk ratio (RR) 0.48, 95% confidence interval (CI) 0.28 to 0.84 (two studies, 1525 women)). There was also a significant effect towards favouring massage versus hands off to reduce third- and fourth-degree tears (RR 0.52, 95% CI 0.29 to 0.94 (two studies, 2147 women)). Hands off (or poised) versus hand on showed no effect on third- and fourth-degree tears, but we observed a significant effect of hands off on reduced rate of episiotomy (RR 0.69, 95% CI 0.50 to 0.96 (two studies, 6547 women)).

AUTHORS' CONCLUSIONS

The use of warm compresses on the perineum is associated with a decreased occurrence of perineal trauma. The procedure has shown to be acceptable to women and midwives. This procedure may therefore be offered to women.

Reducing perineal trauma through perineal massage with vaseline in second stage of labor

PURPOSE

Maintaining an intact perineum is a highly regarded aim in delivery procedures today. Since perineal massage is a common practice during delivery, the present study aims to investigate the effect of perineal massage with Vaseline on perineal trauma (rate of episiotomy procedures and perineal tears).

METHOD

Ninety primiparous women (aged between 18 and 30 years with gestational age of 38-42 weeks) were selected sequentially in Tehran in 2009. Once participants' characteristics were registered, they were randomly assigned to the intervention (perineal massage with Vaseline) or control groups. In the massage group, perineal massage was performed in the second stage of delivery once the genitalia were treated with sterilized Vaseline. The perineum was examined after the delivery in terms of episiotomy or tear and its severity degree.

RESULTS

The two groups were homogeneous in terms of demographic data, weight gain during pregnancy, gestational age, abortion history and fetal weight. The second stage of delivery was significantly shorter in the massage group than the control group and the massage group had significantly more intact perineum (P = 0.004). In addition, lower episiotomy and higher first- and second-degree perineal tears were seen in the massage group in comparison with the control one (P < 0.001). Neither of the groups suffered from third- and fourth-degree tears.

CONCLUSION

The findings showed that the perineal massage with Vaseline in the second stage of labor increases perineal integrity and decreases perineal traumas (episiotomy and tears). So, it seems that the perineal massage could be an effective way to preserve an intact perineum in labor.

Antibiotic prophylaxis for third- and fourth-degree perineal tear during vaginal birth

BACKGROUND

One to eight per cent of women suffer third-degree perineal tear (anal sphincter injury) and fourth-degree perineal tear (rectal mucosa injury) during vaginal birth, and these tears are more common after forceps delivery (28%) and midline episiotomies. Third- and fourth-degree tears can become contaminated with bacteria from the rectum and this significantly increases in the chance of perineal wound infection. Prophylactic antibiotics might have a role in preventing this infection.

OBJECTIVES

To assess the effectiveness of antibiotic prophylaxis for reducing maternal morbidity and side effects in third- and fourth-degree perineal tear during vaginal birth.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2010) and the reference lists of retrieved articles.

SELECTION CRITERIA

Randomised controlled trials comparing outcomes of prophylactic antibiotics versus placebo or no antibiotics in third- and fourth-degree perineal tear during vaginal birth.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the reports and extracted data.

MAIN RESULTS

We identified and included one trial (147 participants) that compared the effect of prophylactic antibiotic (single-dose, second generation cephalosporin, intravenously) on postpartum perineal wound complications in third- or fourth-degree perineal tears. Perineal wound complications (wound disruption and purulent discharge) at the two-week postpartum check up were 8.20% and 24.10% in the treatment and the control groups respectively (risk ratio 0.34, 95% confidence interval 0.12 to 0.96).

AUTHORS' CONCLUSIONS

Although the data suggest that prophylactic antibiotics help to prevent perineal wound complications following third- or fourth-degree perineal tear, loss to follow-up was very high. The results should be interpreted with caution as they are based on one small trial.

Perinatal urinary and fecal incontinence: suffering in silence

This article focuses on the prevention, identification, and management of urinary and fecal incontinence in the perinatal period. Both urinary and fecal incontinence are common concerns affecting women throughout pregnancy, intrapartum, and postpartum. These are the problems that are not approached by healthcare providers during the initial antepartal assessment, nor are they fully investigated after delivery. Many women hesitate to disclose this information. Women tend to consider this to be a minor discomfort of pregnancy and a consequence resulting from childbirth in the postpartum period. Intervention strategies and nursing care components in the perinatal period will be presented.

Prospective randomised multicentre trial with the birth trainer EPI-NO for the prevention of perineal trauma

BACKGROUND

In several non-randomised trials training with EPI-NO increased the rate of intact perineum and decreased episiotomy rates, shortened the second stage of labour and lowered use of pain killers.

AIMS

To verify the preliminary results with EPI-NO in a prospective randomised trial.

METHODS

Randomised, single-blind multicentre trial in four university hospitals in Germany including 276 primigravidae.

RESULTS

After training with EPI-NO we observed a significant increase in the incidence of intact perineum (37.4% vs 25.7%; P = 0.05) and a tendency towards lower episiotomy rates (41.9% vs 50.5%; P = 0.11). We found no significant differences between the two groups regarding incidence of perineal tears, duration of second stage of labour, use of pain relief and rate of vaginal infection.

CONCLUSIONS

Training with EPI-NO increases significantly the likelihood of having an intact perineum and reduces the episiotomy rate.

Evidence-based labor and delivery management

Our objective was to provide evidence-based guidance for management decisions during labor and delivery. We performed MEDLINE, PubMed, and COCHRANE searches with the terms labor, delivery, pregnancy, randomized trials, plus each management aspect of labor and delivery (eg, early admission). Each management step of labor and delivery was reviewed separately. Evidence-based good quality data favor hospital births, delayed admission, support by doula, training birth assistants in developing countries, and upright position in the second stage. Home-like births, enema, shaving, routine vaginal irrigation, early amniotomy, "hands-on" method, fundal pressure, and episiotomy can be associated with complications without sufficient benefits and should probably be avoided. We conclude that labor and delivery interventions supported by good quality data as just described should be routinely performed. All aspects with lower data quality should be researched with adequately powered and designed trials.

The use of liquid petroleum jelly in the prevention of perineal lacerations during birth

Most of vaginal births are accompanied by lacerations in the genital tract. This was a randomized study carried out in a Birth Center located in São Paulo city to evaluate the efficacy of liquid petroleum jelly in reducing perineal laceration. The sample was composed of 38 nulliparous women per group (experimental and control). In the experimental group was used 30 ml of the petroleum jelly in the perineal region during the expulsive period. The parturient were allowed to push spontaneously during the delivery and remained in the left side position. The frequency of perineal laceration was similar in both groups (experimental 63.2% versus control 60.5%). The posterior perineum region presented the highest frequency of trauma (53.2%). Of the total cases of perineal trauma, 72.3% were first-degree lacerations. The use of liquid petroleum jelly of perineal protection does not reduce the frequency neither the degree of lacerations in childbirth.

Obstetric gel shortens second stage of labor and prevents perineal trauma in nulliparous women: a randomized controlled trial on labor facilitation

OBJECTIVE

To determine whether the obstetric gel shortens the second stage of labor and exerts a protective effect on the perineum.

METHOD

A total of 251 nulliparous women with singleton low-risk pregnancies in vertex position at term were recruited. A total of 228 eligible women were randomly assigned to Group A, without obstetric gel use, or to Group B, obstetric gel use, i.e., intermittent application into the birth canal during vaginal examinations, starting at the early first stage of labor (prior to 4 cm dilation) and ending with delivery.

RESULTS

A total of 183 cases were analyzed. For vaginal deliveries without interventions, such as C-section, vaginal operative procedure or Kristeller maneuver, obstetric gel use significantly shortened the second stage of labor by 26 min (30%) (P=0.026), and significantly reduced perineal tears (P=0.024). First stage of labor and total labor duration were also shortened, but not significantly. Results did not show a significant change in secondary outcome parameters, such as intervention rates or maternal and newborn outcomes. No side effects were observed with obstetric gel use.

CONCLUSION

Systematic vaginal application of obstetric gel showed a significant reduction in the second stage of labor and a significant increase in perineal integrity. Future studies should further investigate the effect on intervention rates and maternal and neonatal outcome parameters.

[What are the risk factors of anal incontinence after vaginal delivery?]

Fecal incontinence is one of the most feared complications of vaginal delivery. It may be the consequence of sphincter tears, of pudendal neuropathy, or of a combination of the two. Fecal incontinence occurs immediately following 13-54% of vaginal deliveries but its persistence in the mid and long term is poorly known. The incidence of perineal tear with anal sphincteric defect varies from 1-9% and the incidence of unrecognized sphincter injury may be as high as 18-35%. Half the women who undergo primary anal sphincter repair have short or long term continence problems. Pudendal neuropathy is caused by nerve stretch during pushing in the second stage of labor and descent of the fetal head; it may occur even with the first delivery. Risk factors for sphincter injury and pudendal neuropathy include forceps delivery, large neonatal size, and prolonged second stage of labor. The risk of fecal incontinence must be considered even during the first pregnancy. Routine episiotomy does not prevent sphincter injury and may even predispose to it. Pudendal neuropathy following delivery may lead to delayed fecal incontinence abetted by postmenopausal hormonal deficiency and tissue senescence. The possible benefit of early episiotomy for women at high risk of sphincter injury must be evaluated by prospective studies.

Perineal outcomes and maternal comfort related to the application of perineal warm packs in the second stage of labor: a randomized controlled trial

BACKGROUND

Perineal warm packs are widely used during childbirth in the belief that they reduce perineal trauma and increase comfort during late second stage of labor. The aim of this study was to determine the effects of applying warm packs to the perineum on perineal trauma and maternal comfort during the late second stage of labor.

METHODS

A randomized controlled trial was undertaken. In the late second stage of labor, nulliparous women (n = 717) giving birth were randomly allocated to have warm packs (n = 360) applied to their perineum or to receive standard care (n = 357). Standard care was defined as any second-stage practice carried out by midwives that did not include the application of warm packs to the perineum. Analysis was on an intention-to-treat basis, and the primary outcome measures were requirement for perineal suturing and maternal comfort.

RESULTS

The difference in the number of women who required suturing after birth was not significant. Women in the warm pack group had significantly fewer third- and fourth-degree tears and they had significantly lower perineal pain scores when giving birth and on "day 1" and "day 2" after the birth compared with the standard care group. At 3 months, they were significantly less likely to have urinary incontinence compared with women in the standard care group.

CONCLUSIONS

The application of perineal warm packs in late second stage does not reduce the likelihood of nulliparous women requiring perineal suturing but significantly reduces third- and fourth-degree lacerations, pain during the birth and on days 1 and 2, and urinary incontinence. This simple, inexpensive practice should be incorporated into second stage labor care.

'Soothing the ring of fire': Australian women's and midwives' experiences of using perineal warm packs in the second stage of labour

OBJECTIVE

to determine women's and midwives' experiences of using perineal warm packs in the second stage of labour.

DESIGN

as part of a randomised controlled trial (Warm Pack Trial), women and midwives were asked to complete questionnaires about the effects of the warm packs on pain, perineal trauma, comfort, feelings of control, satisfaction and intentions for use during future births.

SETTING

two hospitals in Sydney, Australia.

PARTICIPANTS

a randomised controlled trial was undertaken. In the late second stage of labour, nulliparous women (n=717) giving birth were randomly allocated to having warm packs (n=360) applied to their perineum or standard care (n=357). Standard care was defined as any second stage practice carried out by midwives that did not include the application of warm packs to the perineum. Three hundred and two nulliparous women randomised to receive warm packs (84%) received the treatment. Questionnaires were completed by 266 (88%) women who received warm packs, and 270 (89%) midwives who applied warm packs to these women.

INTERVENTION

warm, moist packs were applied to the perineum in the late second stage of labour.

FINDINGS

warm packs were highly acceptable to both women and midwives as a means of relieving pain during the late second stage of labour. Almost the same number of women (79.7%) and midwives (80.4%) felt that the warm packs reduced perineal pain during the birth. Both midwives and women were positive about using warm packs in the future. The majority of women (85.7%) said that they would like to use perineal warm packs again for their next birth and would recommend them to friends (86.1%). Likewise, 91% of midwives were positive about using the warm packs, with 92.6% considering using them in the future as part of routine care in the second stage of labour.

KEY CONCLUSIONS

responses to questionnaires, eliciting experiences of women and midwives involved in the Warm Pack Trial, demonstrated that the practice of applying perineal warm packs in the late second stage of labour was highly acceptable and effective in helping to relieve perineal pain and increase comfort.

IMPLICATIONS FOR PRACTICE

perineal warm packs should be incorporated into second stage pain relief options available to women during childbirth.