Summary of the main findings for comparison 2
3.3 Second stage of labour
3.3.6 Techniques for preventing perineal trauma RECOMMENDATION 38
3. EVIDENCE AND RECOMMENDATIONS
3.3.6 Techniques for preventing perineal trauma
WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE
Birth trauma: The review did not include birth trauma as an outcome.
Values
Findings from a review of qualitative studies looking at what matters to women during intrapartum care (23) indicate that most women want a normal childbirth with good outcomes for mother and baby (high confidence in the evidence). Findings also suggest that women are aware of the unpredictability of labour and childbirth and are fearful of potentially traumatic events (including medical interventions and maternal and fetal morbidities) that can occur during the birthing process (high confidence in the evidence). It is therefore likely that women will value any technique that may limit perineal trauma, particularly if it is offered by kind, competent health care professionals who are sensitive to their needs (high confidence in the evidence).
Qualitative evidence also shows that, when interventions are being considered, women would like to be informed about the nature of the interventions and, where possible, given a choice (high confidence in the evidence) (23).
Additional considerations
Findings from a meta-synthesis of women’s
experiences of perineal trauma suggest that women may feel devalued, dismissed, depressed and have a sense of failure when their perineum is damaged following childbirth (164).
Resources
No review evidence was found.
Additional considerations
Perineal techniques are a low-cost intervention for which in-service training would be the main cost.
If perineal massage increases the proportion of women with an intact perineum after childbirth and
reduces third- and fourth-degree tears, it would logically be more cost-effective than usual care by reducing the costs associated with suturing supplies (e.g. suture materials, local anaesthetics, swabs) and health care professional time required to suture.
A 2002 study from Argentina reported an average provider cost saving of US$ 20.21 per birth with a change in episiotomy policy that led to fewer episiotomies being performed and a reduced need for suturing (165), which gives an indirect indication of possible cost savings that might occur per birth with reduced third- and fourth-degree tears and an increase in intact perineum.
Equity
No evidence on perineal techniques and equity was found.
Additional considerations
If health care professionals could contribute to preserving the integrity of the perineum in the second stage of labour through simple perineal techniques, women in LMICs might be more inclined to use facility-based birth services, which could have a positive impact on equity.
Acceptability
A qualitative systematic review of women’s experiences of labour and childbirth found no direct evidence relating to women’s views on perineal massage techniques (26). Indirect evidence from this review suggests that, in certain contexts, some women may appreciate techniques that limit perineal trauma, provided they are applied by kind and sensitive health care professionals (low confidence in the evidence). In other contexts, women may find these techniques painful, uncomfortable or embarrassing (very low confidence in the evidence).
The qualitative systematic review also found no direct evidence on health care professionals’ views Table 3.53 Main resource requirements of perineal massage
Resource Description
Staff Midwives/nurses/doctors
Training Pre-service and in-service training on how to perform this perineal technique Supplies Gloves: similar to usual care
Lubricant, e.g. petroleum jelly: optional Equipment and infrastructure None
Time Performed during the second stage so time is the same as for usual care Supervision and monitoring Same as for usual care
3. EVIDENCE AND RECOMMENDATIONS
on perineal techniques to prevent perineal trauma (26).
Additional considerations
In a Canadian survey of women’s views of prenatal perineal massage (n = 684), the authors found that women held positive views of the technique and would use it again in a subsequent pregnancy (166).
It is likely that women would appreciate any of the perineal techniques if there was evidence to suggest they might help or limit any of the potential long-term consequences of a damaged perineum (dyspareunia, sexual dysfunction, urinary or faecal incontinence).
Feasibility
A qualitative systematic review of women’s
experiences of labour and childbirth found no direct evidence relating to women’s views on perineal techniques (26). Indirect evidence from this review
would suggest that there are unlikely to be any concerns around feasibility.
The qualitative systematic review also found no direct evidence on health care professionals’
views relating to perineal techniques (26).
Indirect evidence would suggest that health care professionals in certain contexts may lack the training and/or experience to use some or all of the perineal techniques described (very low confidence in the evidence).
Additional considerations
In a small survey of 54 Australian midwives taking part in an RCT on perineal massage during labour (167), the author found that midwives did not always apply the intervention for a variety of reasons, including: (i) women found it uncomfortable; (ii) labour progressed too quickly; (iii) there was fetal distress; (iv) they didn’t have time and (v) they felt it was intrusive. After the trial, the number of midwives who felt the technique was “definitely beneficial” increased from 8 to 15.
Table 3.54 Summary of judgements: Perineal massage compared with usual care (no perineal massage) (comparison 1)
Desirable
effects –
Don’t know –
Varies –
Trivial –
Small ✓
Moderate –
Large Undesirable
effects –
Don’t know –
Varies –
Large –
Moderate –
Small ✓
Trivial Certainty of
the evidence –
No included studies
Very low✓ –
Low –
Moderate –
High
Values –
Important uncertainty or
variability
Possibly – important uncertainty or
variability
Probably no – important uncertainty or
variability
No important ✓ uncertainty or variability Balance of
effects –
Don’t know –
Varies –
Favours usual care
Probably – favours usual
care
Does not – favour perineal
massage or usual care
Probably – favours perineal massage
Favours ✓ perineal massage Resources
required –
Don’t know –
Varies –
Large costs –
Moderate costs
Negligible costs ✓ or savings
Moderate – savings
Large savings–
Certainty of evidence of required resources
No included – studies
Very low✓ –
Low –
Moderate –
High
Cost-effectiveness –
Don’t know –
Varies –
Favours usual care
Probably – favours usual
care
Does not – favour perineal
massage or usual care
Probably ✓ favours perineal massage
Favours – perineal massage
Equity –
Don’t know –
Varies –
Reduced –
Probably reduced
Probably no – impact
Probably ✓ increased
Increased–
Acceptability –
Don’t know –
Varies –
No –
Probably No ✓
Probably Yes –
Yes
Feasibility –
Don’t know –
Varies –
No –
Probably No ✓
Probably Yes –
Yes
WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE
Comparison 2: Warm perineal compress compared with control (“hands off” or usual care)
Four studies (1799 participants) from Australia, Iran, Spain and the USA contributed data to this comparison. In one study (717 participants), warm perineal compresses were provided as pads soaked in warm sterile water (heated to between 45°
and 59 °C) and applied during contractions once the baby’s head distended the perineum. The pad was re-soaked between contractions to maintain warmth. In another study (808 participants), warm compresses were applied continually, during and between contractions in the second stage. The warm compresses provided in the other two studies were not described in detail in the review.
Maternal outcomes
Perineal/vaginal trauma: High-certainty evidence suggests that warm compresses make little or no difference to having an intact perineum after giving birth (4 trials, 1799 women, RR 1.02, 95% CI 0.85–1.21). High-certainty evidence indicates that warm compresses reduce the incidence of third- or fourth-degree perineal tears (4 trials, 1799 women, RR 0.46, 95% CI 0.27–0.79). The absolute effect on third- or fourth-degree tears is estimated as 24 fewer per 1000 (from 9 to 33 fewer). Moderate-certainty evidence suggests that warm compresses probably make little or no difference to episiotomy (4 trial, 1799 women, RR 0.86, 95% CI 0.60–1.23).
Evidence on first- and second-degree tears and the need for perineal suturing is of very low certainty.
Long-term morbidity: The review found no evidence on long-term outcomes.
Birth experience: The review found no evidence on maternal satisfaction or other outcomes related to birth experience.
Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: The review found no evidence on Apgar scores less than 7 at 5 minutes.
Birth trauma: The review did not include birth trauma as an outcome.
Additional considerations
The review also included a separate analysis of cold compresses compared with a control group (1 study, 64 women) for which the resulting evidence was assessed as being largely very uncertain.
Values
Findings from a review of qualitative studies looking at what matters to women during intrapartum care indicate that most women want a normal childbirth with good outcomes for mother and baby (high confidence in the evidence) (23).
Findings also suggest that women are aware of the unpredictability of labour and childbirth and are fearful of potentially traumatic events (including medical interventions and maternal and fetal morbidities) that can occur during the birthing process (high confidence in the evidence). It is therefore likely that women will value any technique that may limit perineal trauma, particularly if it is offered by kind, competent health care professionals who are sensitive to their needs (high confidence in the evidence).
Qualitative evidence also shows that, when interventions are being considered, women would like to be informed about the nature of the interventions and, where possible, given a choice (high confidence in the evidence).
Additional considerations
Findings from a meta-synthesis of women’s
experiences of perineal trauma suggest that women may feel devalued, dismissed, depressed and have a sense of failure when their perineum is damaged following childbirth (164).
Resources
No review evidence was found.
Table 3.55 Main resource requirements of warm perineal compresses
Resource Description
Staff Midwives/nurses/doctors
Training Pre-service and in-service training on how to perform this perineal technique
Supplies Pads and warm water
Equipment and infrastructure Ready access to clean warm water
Time Performed during the second stage so time is the same as for usual care Supervision and monitoring Same as for usual care
3. EVIDENCE AND RECOMMENDATIONS
Additional considerations
Warm compresses are a low-cost intervention for which supplies of pads/packs and in-service training would be the main cost. However, sterile water was used in at least one of the included trials, and this would have additional cost implications.
Health care providers would need access to clean warm water, which may not be possible in some low-resource settings. As warm compresses reduce third- and fourth-degree tears, this practice should be more cost-effective than usual care, as costs associated with suturing supplies (e.g. suture materials, local anaesthetics, swabs) and health care professional time required to suture should be reduced.
A 2002 study from Argentina reported an average provider cost saving of US$ 20.21 per birth with a change in episiotomy policy that led to fewer episiotomies being performed and a reduced need for suturing (165), which gives an indirect indication of possible cost savings that might occur per birth with reduced third- and fourth-degree tears.
Equity
No evidence on perineal techniques and equity was found.
Additional considerations
If health care professionals could contribute to preserving the integrity of the perineum in the second stage of labour through simple perineal techniques, women in LMICs might be more inclined to use facility-based birth services, which could have a positive impact on equity.
Acceptability
A qualitative systematic review of women’s
experiences of labour and childbirth found no direct evidence relating to women’s views on perineal techniques (26). Indirect evidence from this review suggests that, in certain contexts, some women may
appreciate techniques that limit perineal trauma, provided they are applied by kind and sensitive health care professionals (low confidence in the evidence). In other contexts, women may find these techniques painful, uncomfortable or embarrassing (very low confidence in the evidence).
The qualitative systematic review also found no direct evidence relating to health care professionals’
views on perineal techniques to prevent perineal trauma (26).
Additional considerations
It is likely that women would appreciate any perineal techniques if there was evidence to suggest they might help or limit any of the potential long-term consequences of a damaged perineum (dyspareunia, sexual dysfunction, urinary or faecal incontinence).
Women might plausibly perceive warm compresses as less uncomfortable and embarrassing than perineal massage, but no evidence on this was found.
Feasibility
A qualitative systematic review of women’s
experiences of labour and childbirth found no direct evidence relating to women’s views on perineal techniques (26). Indirect evidence from this review would suggest that there are unlikely to be any concerns around feasibility.
The qualitative systematic review also found no direct evidence on health care professionals’ views relating to perineal techniques (26).
Additional considerations
Although it is a low-cost intervention, warm compresses might be less feasible to implement in settings where resources are limited, particularly if warm running tap water is not available in delivery rooms.
WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE
Table 3.56 Summary of judgements: Warm perineal compress compared with no warm compress (comparison 2)
Desirable
effects –
Don’t know –
Varies –
Trivial –
Small ✓
Moderate –
Large Undesirable
effects –
Don’t know –
Varies –
Large –
Moderate –
Small ✓
Trivial Certainty of
the evidence –
No included studies
✓
Very low –
Low –
Moderate –
High
Values –
Important uncertainty or
variability
Possibly – important uncertainty or
variability
Probably no – important uncertainty or
variability
No important ✓ uncertainty or
variability Balance of
effects –
Don’t know –
Varies –
Favours usual care
Probably – favours usual
care
Does not – favour warm
perineal compress or
usual care
Probably – favours warm
perineal compress
Favours warm ✓ perineal compress
Resources
required –
Don’t know –
Varies –
Large costs –
Moderate costs
Negligible ✓ costs or savings
Moderate – savings
Large savings–
Certainty of evidence of required resources
No included – studies
Very low✓ –
Low –
Moderate –
High
Cost-effectiveness –
Don’t know –
Varies –
Favours usual care
Probably – favours usual
care
Does not – favour warm
perineal compress or
usual care
Probably ✓ favours warm
perineal compress
Favours warm – perineal compress
Equity –
Don’t know –
Varies –
Reduced –
Probably reduced
Probably no – impact
✓ Probably increased
Increased–
Acceptability –
Don’t know –
Varies –
No –
Probably No ✓
Probably Yes –
Yes
Feasibility –
Don’t know –
Varies –
No –
Probably No ✓
Probably Yes –
Yes
Comparison 3: “Hands-off” compared with
“hands-on” perineum approach
Five studies (7317 participants) from Austria, Brazil, Iran and the United Kingdom contributed data to this comparison. The hands-off (or poised) approach was generally expectant and observational to the extent that light pressure could be applied to the baby’s head in case of rapid expulsion, with the plan not to touch the head or perineum otherwise, and to allow spontaneous birth of the shoulders. A hands-on approach (or guarding) involved the midwife supporting the anterior and posterior perineum with both hands to protect/guard the perineum and maintain flexion of, and control, the expulsion of the fetal head.
Maternal outcomes
Perineal/vaginal trauma: Moderate-certainty evidence suggests that use of the hands-off compared with the hands-on approach probably makes little or no difference to the likelihood of
having an intact perineum after giving birth (2 trials, 6547 women, RR 1.03, 95% CI 0.95–1.12).
Low-certainty evidence suggests that the hands-off approach may increase first-degree tears
compared with the hands-on approach (2 trials, 700 participants, RR 1.32, 95% CI 0.99–1.77), however, the estimate of effect includes the possibility of no difference. The absolute effect is estimated as 58 more per 1000 (from 2 fewer to 139 more). Evidence on third- and fourth-degree tears, second-degree tears and episiotomy is of very low certainty.
Long-term morbidity: The review found no evidence on long-term outcomes.
Birth experience: The review found no evidence on maternal satisfaction or other outcomes related to childbirth experience.
Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: The review found no evidence on Apgar scores less than 7 at 5 minutes.
3. EVIDENCE AND RECOMMENDATIONS
Birth trauma: The review did not include birth trauma as an outcome.
Values
Findings from a review of qualitative studies looking at what matters to women during intrapartum care (23) indicate that most women want a normal childbirth with good outcomes for mother and baby (high confidence in the evidence). Findings also suggest that women are aware of the unpredictability of labour and childbirth and are fearful of potentially traumatic events (including medical interventions and maternal and fetal morbidities) that can occur during the birthing process (high confidence in the evidence). It is therefore likely that women will value any technique that may limit perineal trauma, particularly if it is offered by kind, competent health care professionals who are sensitive to their needs (high confidence in the evidence).
Qualitative evidence also shows that, when interventions are being considered, women would like to be informed about the nature of the interventions and, where possible, given a choice (high confidence in the evidence).
Additional considerations
Findings from a meta-synthesis of women’s
experiences of perineal trauma suggest that women may feel devalued, dismissed and depressed and may have a sense of failure when their perineum is damaged following childbirth (164).
The quantitative evidence suggests that there may be little difference between these approaches;
however, the possibility of more first-degree tears with the hands-off approach might incline some women to prefer the hands-on approach.
Resources
No review evidence was found.
Additional considerations
Perineal techniques are low-cost interventions for which in-service training would be the main cost.
Although the evidence suggests that the hands-off approach might increase first-degree perineal tears, these do not usually require suturing and are not associated with other poor outcomes, therefore this may not have cost implications.
Equity
No evidence on perineal techniques and equity was found.
Additional considerations
If health care professionals could contribute to preserving the integrity of the perineum in the second stage of labour through simple perineal techniques, women in LMICs might be more inclined to use facility-based birth services, which could have a positive impact on equity. However, from the evidence on effects, it is not clear whether these perineal techniques reduce perineal trauma.
Acceptability
A qualitative systematic review of women’s
experiences of labour and childbirth found no direct evidence relating to women’s views on perineal techniques (26). Indirect evidence from this review suggests that, in certain contexts, some women may appreciate techniques that limit perineal trauma, provided they are applied by kind and sensitive health care professionals (low confidence in the evidence). In other contexts, women may find these techniques painful, uncomfortable or embarrassing (very low confidence in the evidence).
The qualitative systematic review also found no direct evidence on health care professionals’ views relating to perineal techniques to prevent perineal trauma (26).
Table 3.57 Main resource requirements of “hands-off” and “hands-on” perineal approaches
Resource Description
Staff Midwives/nurse/doctors
Training Pre-service and in-service training on how to perform these perineal techniques
Supplies Same as for usual care
Equipment None
Time Performed during the second stage so time is the same as for usual care Supervision and monitoring Same as for usual care
WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE
Additional considerations
It is likely that women would appreciate any of the perineal techniques if there was evidence to suggest they might help or limit any of the potential long-term consequences of a damaged perineum (dyspareunia, sexual dysfunction, urinary or faecal incontinence).
Feasibility
A qualitative systematic review of women’s
experiences of labour and childbirth found no direct evidence relating to women’s views on perineal
Table 3.58 Summary of judgements: “Hands-off” approach compared with “hands-on” approach (comparison 3)
Desirable
effects –
Don’t know –
Varies ✓
Trivial –
Small –
Moderate –
Large Undesirable
effects –
Don’t know –
Varies –
Large –
Moderate ✓
Small –
Trivial Certainty of
the evidence –
No included studies
Very low✓ –
Low –
Moderate –
High
Values –
Important uncertainty or
variability
Possibly – important uncertainty or
variability
Probably no ✓ important uncertainty or
variability
No important – uncertainty or
variability Balance of
effects –
Don’t know –
Varies –
Favours hands-on approach
Probably ✓ favours hands-on approach
Does not – favour
off or hands-on approach
Probably – favours hands-off approach
Favours – hands-off approach Resources
required –
Don’t know –
Varies –
Large costs –
Moderate costs
Negligible ✓ costs or savings
Moderate – savings
Large savings–
Certainty of evidence of required resources
No included ✓ studies
Very low– –
Low –
Moderate –
High
Cost-effectiveness –
Don’t know –
Varies –
Favours hands-on approach
Probably – favours hands-on approach
Does not ✓ favour
off or hands-on approach
Probably – favours hands-off approach
Favours – hands-off approach
Equity –
Don’t know –
Varies –
Reduced –
Probably reduced
Probably no ✓ impact
Probably – increased
Increased–
Acceptability –
Don’t know –
Varies –
No –
Probably No ✓
Probably Yes –
Yes
Feasibility –
Don’t know –
Varies –
No –
Probably No ✓
Probably Yes –
Yes
techniques (26). Indirect evidence from this review would suggest that there are unlikely to be any concerns around feasibility.
The qualitative systematic review also found no direct evidence on health care professionals’
views relating to perineal techniques (26).
Indirect evidence would suggest that health care professionals in certain contexts may lack the training and/or experience to use some or all of the perineal techniques described (very low confidence in the evidence).
3. EVIDENCE AND RECOMMENDATIONS
Comparison 4: Ritgen’s manoeuvre compared with usual practice (“hands-on” approach) Two studies (1489 participants) from Iran and Sweden contributed data to this comparison. A modified Ritgen’s manoeuvre was performed in the second stage of labour in the largest study (1423 participants). This involved “using one hand to pull the fetal chin from between the maternal anus and the coccyx, and the other (hand placed) on the fetal occiput to control speed of birth”. In this study, the manoeuvre was considered to be modified as it was used during a uterine contraction instead of between contractions. The “standard practice” arm comprised using one hand to support the perineum and the other hand to control the expulsion of the fetal head. Standard practice was also to perform selective episiotomy for certain indications not described in the review.
Maternal outcomes
Perineal/vaginal trauma: Low-certainty evidence suggests that Ritgen’s manoeuvre may have little or no impact on third- and fourth-degree perineal tears (1 trial, 1423 participants, RR 1.24, 95% CI 0.78–
1.96) and episiotomy (2 trials, 1489 participants, RR 0.81, 95% CI 0.63–1.03). The evidence on the likelihood of having an intact perineum and other perineal outcomes is of very low certainty.
Long-term morbidity: The review found no evidence on long-term outcomes.
Birth experience: The review found no evidence on maternal satisfaction or other outcomes related to birth experience.
Fetal and neonatal outcomes
Apgar scores: The review found no evidence on Apgar scores less than 7 at 5 minutes.
Birth trauma: The review did not include birth trauma as an outcome.
Additional considerations
The review also included a comparison of another type of guiding procedure: delivery of the posterior shoulder first compared with delivery of the anterior shoulder first; however, data for the review outcomes were limited and the resulting evidence was of very low certainty.
Values
Findings from a review of qualitative studies looking at what matters to women during intrapartum care indicate that most women want a normal childbirth with good outcomes for mother and baby (high confidence in the evidence) (23).
Findings also suggest that women are aware of the unpredictability of labour and childbirth and are fearful of potentially traumatic events (including medical interventions and maternal and fetal morbidities) that can occur during the birthing process (high confidence in the evidence). It is therefore likely that women will value any technique that may limit perineal trauma, particularly if it is offered by kind, competent health care professionals who are sensitive to their needs (high confidence in the evidence).
Qualitative evidence also shows that, when interventions are being considered, women would like to be informed about the nature of the interventions and, where possible, given a choice (high confidence in the evidence).
Resources
No review evidence was found.
Additional considerations
Perineal techniques are a low-cost intervention for which in-service training would be the main cost.
Equity
No evidence on perineal techniques and equity was found.
Table 3.59 Main resource requirements of Ritgen’s manoeuvre
Resource Description
Staff Midwives/nurses/doctors
Training Pre-service and in-service training on how to perform this perineal technique Supplies Similar to standard practice
Equipment None
Time Performed during the second stage so time is the same as for usual care Supervision and monitoring Probably more than with standard practice, to ensure adherence to technique
and to monitor potential adverse outcomes