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

Vaginal births are often associated with some form of trauma to the genital tract, which can sometimes be associated with significant short- and long-term problems for the woman. It is especially the third- and fourth-degree tears, that affect the anal sphincter or mucosa, which can cause the most problems. Perineal trauma can occur spontaneously or result from a surgical incision of the perineum, called episiotomy. Different perineal techniques and interventions are being used to slow down the birth, and allow the perineum to stretch slowly to prevent perineal injury. Perineal massage, warm compresses and different perineal management techniques are widely used by midwives and birth attendants. 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. We included eight randomised trials (involving 11,651 women) conducted in hospital settings in six countries. The participants in the included studies were women with no medical complications who were expecting a vaginal birth. We conclude that there is sufficient evidence to support the use of warm compresses to prevent perineal tears. The procedure has been shown to be acceptable to both women and midwives. From the meta-analyses we found significant effect of the use of warm compresses compared with hands off or no warm compress on the incidence of third- and fourth-degree tears. We also found a reduction in third- and fourth-degree tears with massage of the perineum versus hands off; and of ‘hands off’ the perineum versus ‘hands on’ to reduce the rate of episiotomy. The studies in our systematic review have considerable clinical variation and the terms ‘hands on’, ‘hands off’, ‘standard care’ and ‘perineal support’ can mean different things and are not always defined sufficiently. The methodological quality of the included studied also varied.

The question of how to prevent the tears is complicated and involves many other factors in addition to the perineal techniques that are evaluated here, e.g. birth position, women’s tissue, speed of birth. More research is necessary in this field, to evaluate perineal techniques and also to answer the questions of determinants of perineal trauma

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.

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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 strategy: 

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)).