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Meta-Analysis
. 2017 Jun 13;6(6):CD006672.
doi: 10.1002/14651858.CD006672.pub3.

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

Vigdis Aasheim  1 , Anne Britt Vika Nilsen, Liv Merete Reinar, Mirjam Lukasse
Affiliations
Meta-Analysis

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

Vigdis Aasheim et al. Cochrane Database Syst Rev. .

Abstract

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Selection criteria: Published and unpublished randomised and quasi-randomised controlled trials evaluating perineal techniques during the second stage of labour.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.

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Conflict of interest statement

Vigdis Aasheim: none known.

Anne Britt Vika Nilsen: none known.

Liv Merete Reinar: has received royalties from the publisher Cappelen Damm in relation to a chapter written in a published textbook for midwives.

Mirjam Lukasse: none known.

Figures

1
1
Study flow diagram
2
2
Methodological quality summary: review authors' judgements about each methodological quality item for each included study
3
3
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies
1.1
1.1. Analysis
Comparison 1 Hands off (or poised) versus hands on, Outcome 1 Intact perineum.
1.2
1.2. Analysis
Comparison 1 Hands off (or poised) versus hands on, Outcome 2 1st degree tear.
1.3
1.3. Analysis
Comparison 1 Hands off (or poised) versus hands on, Outcome 3 2nd degree tear.
1.4
1.4. Analysis
Comparison 1 Hands off (or poised) versus hands on, Outcome 4 3rd or 4th degree tears.
1.5
1.5. Analysis
Comparison 1 Hands off (or poised) versus hands on, Outcome 5 Episiotomy.
1.6
1.6. Analysis
Comparison 1 Hands off (or poised) versus hands on, Outcome 6 3rd degree tear.
1.7
1.7. Analysis
Comparison 1 Hands off (or poised) versus hands on, Outcome 7 4th degree tear.
2.1
2.1. Analysis
Comparison 2 Warm compresses versus control (hands off or no warm compress), Outcome 1 Intact perineum.
2.2
2.2. Analysis
Comparison 2 Warm compresses versus control (hands off or no warm compress), Outcome 2 Perineal trauma not requiring suturing.
2.3
2.3. Analysis
Comparison 2 Warm compresses versus control (hands off or no warm compress), Outcome 3 Perineal trauma requiring suturing.
2.4
2.4. Analysis
Comparison 2 Warm compresses versus control (hands off or no warm compress), Outcome 4 1st degree tear.
2.5
2.5. Analysis
Comparison 2 Warm compresses versus control (hands off or no warm compress), Outcome 5 2nd degree tear.
2.6
2.6. Analysis
Comparison 2 Warm compresses versus control (hands off or no warm compress), Outcome 6 3rd or 4th degree tears.
2.7
2.7. Analysis
Comparison 2 Warm compresses versus control (hands off or no warm compress), Outcome 7 Episiotomy.
2.8
2.8. Analysis
Comparison 2 Warm compresses versus control (hands off or no warm compress), Outcome 8 3rd degree tears.
2.9
2.9. Analysis
Comparison 2 Warm compresses versus control (hands off or no warm compress), Outcome 9 4th degree tears.
3.1
3.1. Analysis
Comparison 3 Massage versus control (hands off or care as usual), Outcome 1 Intact perineum.
3.2
3.2. Analysis
Comparison 3 Massage versus control (hands off or care as usual), Outcome 2 Perineal trauma requiring suturing.
3.3
3.3. Analysis
Comparison 3 Massage versus control (hands off or care as usual), Outcome 3 1st degree perineal tear.
3.4
3.4. Analysis
Comparison 3 Massage versus control (hands off or care as usual), Outcome 4 2nd degree perineal tear.
3.5
3.5. Analysis
Comparison 3 Massage versus control (hands off or care as usual), Outcome 5 3rd or 4th degree tears.
3.6
3.6. Analysis
Comparison 3 Massage versus control (hands off or care as usual), Outcome 6 Episiotomy.
3.7
3.7. Analysis
Comparison 3 Massage versus control (hands off or care as usual), Outcome 7 3rd degree tear.
3.8
3.8. Analysis
Comparison 3 Massage versus control (hands off or care as usual), Outcome 8 4th degree tear.
4.1
4.1. Analysis
Comparison 4 Ritgen's manoeuvre versus standard care, Outcome 1 Intact perineum.
4.2
4.2. Analysis
Comparison 4 Ritgen's manoeuvre versus standard care, Outcome 2 1st degree tear.
4.3
4.3. Analysis
Comparison 4 Ritgen's manoeuvre versus standard care, Outcome 3 2nd degree tear.
4.4
4.4. Analysis
Comparison 4 Ritgen's manoeuvre versus standard care, Outcome 4 3rd or 4th degree tears.
4.5
4.5. Analysis
Comparison 4 Ritgen's manoeuvre versus standard care, Outcome 5 Episiotomy.
4.6
4.6. Analysis
Comparison 4 Ritgen's manoeuvre versus standard care, Outcome 6 3rd degree tears.
4.7
4.7. Analysis
Comparison 4 Ritgen's manoeuvre versus standard care, Outcome 7 4th degree tears.
5.1
5.1. Analysis
Comparison 5 Primary delivery of posterior versus anterior shoulder, Outcome 1 Perineal trauma requiring suturing.
5.2
5.2. Analysis
Comparison 5 Primary delivery of posterior versus anterior shoulder, Outcome 2 3rd or 4th degree tears.
6.1
6.1. Analysis
Comparison 6 Perineal protection device versus perineal support, Outcome 1 Intact perineum.
6.2
6.2. Analysis
Comparison 6 Perineal protection device versus perineal support, Outcome 2 1st and 2nd degree tears.
6.3
6.3. Analysis
Comparison 6 Perineal protection device versus perineal support, Outcome 3 3rd or 4th degree tears.
6.4
6.4. Analysis
Comparison 6 Perineal protection device versus perineal support, Outcome 4 Episiotomy.
6.5
6.5. Analysis
Comparison 6 Perineal protection device versus perineal support, Outcome 5 3rd degree tears.
6.6
6.6. Analysis
Comparison 6 Perineal protection device versus perineal support, Outcome 6 4th degree tears.
7.1
7.1. Analysis
Comparison 7 Enriched oil versus liquid wax, Outcome 1 1st degree tear.
7.2
7.2. Analysis
Comparison 7 Enriched oil versus liquid wax, Outcome 2 2nd degree tear.
7.3
7.3. Analysis
Comparison 7 Enriched oil versus liquid wax, Outcome 3 Episiotomy.
7.4
7.4. Analysis
Comparison 7 Enriched oil versus liquid wax, Outcome 4 3rd degree tears.
8.1
8.1. Analysis
Comparison 8 Cold compresses versus control, Outcome 1 1st degree tear.
8.2
8.2. Analysis
Comparison 8 Cold compresses versus control, Outcome 2 Episiotomy.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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Attarha 2009 {published data only}
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Dahlen 2007 {published data only}
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Geranmayeh 2012 {published data only}
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Harlev 2013 {published data only}
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McCandlish 1998 {published data only}
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Most 2008 {published and unpublished data}
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Musgrove 1997 {unpublished data only}
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Rezaei 2014 {published data only}
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Shirvani 2014a {published data only}
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Stamp 2001 {published data only}
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References to studies excluded from this review

Ashwal 2016 {published data only}
    1. Ashwal E, Aviram A, Wertheimer A, Krispin E, Kaplan B, Hiersch L. The impact of obstetric gel on the second stage of labor and perineal integrity: a randomized controlled trial. Journal of Maternal‐Fetal & Neonatal Medicine 2016;29(18):3024‐9. - PubMed
Barbieri 2013 {published data only}
    1. Barbieri M, Henrique AJ, Chors FM, Maia NL, Gabrielloni MC. Warm shower aspersion, perineal exercises with Swiss ball and pain in labor [Banho quente de aspersão, exercícios perineais com bola suíça e dor no trabalho de parto]. Acta Paulista de Enfermagem 2013;26(5):478‐84.
Behmanesh 2009 {published data only}
    1. Behmanesh F, Pasha H, Zeinalzadeh M. The effect of heat therapy on labor pain severity and delivery outcome in parturient women. Iranian Red Crescent Medical Journal 2009;11(2):188‐92.
Corton 2012 {published data only}
    1. Corton MM, Lankford JC, Ames R, McIntire DD, Alexander JM, Leveno KJ. A randomized trial of birthing with and without stirrups. American Journal of Obstetrics and Gynecology 2012;207(2):133.e1‐5. - PMC - PubMed
Demirel 2015 {published data only}
    1. Demirel G, Golbasi Z. Effect of perineal massage on the rate of episiotomy and perineal tearing. International Journal of Gynecology and Obstetrics 2015;131:183‐6. - PubMed
Hassaballa 2015 {published data only}
    1. Hassaballa M, Cohn M. The impact of dianatal in dysfunctional labour. International Journal of Gynecology and Obstetrics 2015;131:E221.
Karacam 2012 {published data only}
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Low 2013 {published data only}
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Schaub 2008 {published and unpublished data}
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References to studies awaiting assessment

Taavoni 2015 {published data only}
    1. Taavoni S, Abdolahian S, Haghani H. Effect of pelvic tilt by birth ball usage, sacrum‐perinea heat therapy and combination of them on active phase of physiologic labor. International Confederation of Midwives 30th Triennial Congress. Midwives: Improving Women’s Health; 2014 June 1‐4; Prague, Czech Republic. 2014:C169.
    1. Taavoni S, Abdolahian S, Neisani L, Haghani H. Three noninvasive interventions for physiologic labour pain management: use of birth ball, sacrum‐perinea heat therapy, and combined use of them during active phase. International Journal of Gynecology and Obstetrics 2015;131(Suppl 5):E217.
    1. Taavoni S, Abdolahian S, Neisani L, Hamid H. Labor pain management: effect of pelvic tilt by birth ball, sacrumperinea heat therapy, and combined use of them, a randomized controlled trial. European Psychiatry 2016;33S:S503.
Velev 2013 {published data only}
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References to ongoing studies

NCT02588508 {published data only}
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References to other published versions of this review

Aasheim 2011
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