Hands-on versus hands-off techniques for the prevention of perineal trauma during vaginal delivery: a systematic review and meta-analysis of randomized controlled trials

Pierce-Williams, Rebecca; Saccone, Gabriele; Berghella, Vincenzo

doi:10.1080/14767058.2019.1619686

Cited by 35 publications

(25 citation statements)

References 11 publications

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“…In fact, the lack of analyzing per protocol may partly explain that no difference was found in the risk of OASI in the RCTs between the hands-on versus hands-off techniques. Three recent meta-analyses on randomized trials [31][32][33] include five RCT's with data on OASI incidence [34][35][36][37][38]. When the intention-to-treat analyses in these trials are combined with defining the intervention in the hands-off arm as "hands-poised", the treatment that was actually provided in each case becomes obscured, insofar the 'hands-poised' method allows for using elements from the hands-on method.…”

Section: Discussionmentioning

confidence: 99%

Which elements were significant in reducing obstetric anal sphincter injury? A prospective follow-up study

Rasmussen

Yding

Andersen

et al. 2021

BMC Pregnancy Childbirth

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Background To examine which elements of an obstetric anal sphincter injury (OASI) care bundle were protective for OASI. Several interventional trials showed that application of a care bundle involving a hands-on approach to perineal protection may reduce the risk of OASI. Previously, we found that only the element “hand on the fetal head” in itself was protective, although the risk of a type 2 error was calculated to be 50%. Methods A prospective follow-up study in an obstetric department in Denmark with 3200 deliveries per year. We included a cohort of 10,383 women giving birth vaginally from gestational week 22 + 0 from 2016 through 2019. We documented on a person-level the five elements of the care bundle together with maternal and obstetrical characteristics. The elements were 1) communication, 2) visible perineum, 3) hand on fetal head, 4) perineal support and 5) certification. Regression analysis was used for analysis of associations. The primary outcome measure was OASI. Results The total rate of OASI in vaginally delivering women was 1.9%. The incidence was 3.2% in nulliparous women giving birth vaginally. The rate of cesarean section was 16.5% and for episiotomy 2.4%. The reduction in the incidence of OASI was sustained since 2013. Hand on the fetal head and perineal support both were protective factors for OASI. In case of a nulliparous woman with a neonate weighing 3500 g giving birth spontaneously, the relative risk (RR) for OASI was 0.50 (95% CI 0.49- 0.51) with use of hand on the fetal head together with perineal support against no use. Similarly, with a nulliparous woman giving birth to a neonate of 3500 g by vacuum extraction, the RR for OASI was 0.65 (95% CI 0.62-0.68) against no use. Conclusions Both hand on the fetal head and perineal support were associated with a reduced risk of OASI.

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Section: Discussionmentioning

confidence: 99%

Which elements were significant in reducing obstetric anal sphincter injury? A prospective follow-up study

Rasmussen

Yding

Andersen

et al. 2021

BMC Pregnancy Childbirth

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“…As highlighted above a Cochrane review [22] and a systematic review by Pierce-Williams et al [27] found that hands-on or hands-off the perineum showed no clear supporting evidence in the incidence of intact perineum, first degree perineal tears, second degree tears or fourth degree tears, with episiotomy being performed more frequently in the hands-on group. These reviews were inconsistent regarding third degree tears.…”

Section: Discussionmentioning

confidence: 99%

“…The seventeen included publications dated from 2008 to 2019. The majority of the studies were systematic reviews (n = 6, of which 3 were Cochrane reviews) [22][23][24][25][26][27], randomised controlled trials (n = 6) [28][29][30][31][32][33], one cohort studies with prospective data collection [34], two surveys [35,36] and two qualitative focus group studies [37,38].…”

Section: Plos Onementioning

confidence: 99%

“…Table 1 shows the risk of bias in randomised controlled trials [28][29][30][31][32][33]. Most studies were of low or moderate quality, only the systematic reviews were of high quality [22][23][24][25][26][27]. The cohort study was assessed by CASP as good quality [34], both surveys were assessed as being of moderate quality [35,36].…”

Section: Plos Onementioning

confidence: 99%

“…Hands-on technique during spontaneous vaginal delivery of singleton gestations resulted in similar incidence of several perineal traumas compared to a hands-off technique. However, the incidence of third-degree lacerations and of episiotomy increases with the hands-on technique [27].…”

Section: Themesmentioning

confidence: 99%

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How do midwives facilitate women to give birth during physiological second stage of labour? A systematic review

et al. 2020

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Both nationally and internationally, midwives' practices during the second stage of labour vary. A midwife's practice can be influenced by education and cultural practices but ultimately it should be informed by up-to-date scientific evidence. We conducted a systematic review of the literature to retrieve evidence that supports high quality intrapartum care during the second stage of labour. A systematic literature search was performed to September 2019 in collaboration with a medical information specialist. Bibliographic databases searched included: PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Maternity and Infant Care Database and The Cochrane Library, resulting in 6,382 references to be screened after duplicates were removed. Articles were then assessed for quality by two independent researchers and data extracted. 17 studies focusing on midwives' practices during physiological second stage of labour were included. Two studies surveyed midwives regarding their practice and one study utilising focus groups explored how midwives facilitate women's birthing positions, while another focus group study explored expert midwives' views of their practice of preserving an intact perineum during physiological birth. The remainder of the included studies were primarily intervention studies, highlighting aspects of midwifery practice during the second stage of labour. The empirical findings were synthesised into four main themes namely: birthing positions, nonpharmacological pain relief, pushing techniques and optimising perineal outcomes; the results were outlined and discussed. By implementing this evidence midwives may enable women during the second stage of labour to optimise physiological processes to give birth. There is, however, a dearth of evidence relating to midwives' practice, which provides a positive experience for women during the second stage of labour. Perhaps this is because not all midwives' practices during the second stage of labour are researched and documented. This systematic review provides a valuable insight of the empirical evidence relating to midwifery practice during the physiological second stage of labour, which can also inform

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

Dwan,

Fox,

Lutje

et al. 2024

Cochrane Database of Systematic Reviews

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Rationale Postpartum haemorrhage (PPH) is responsible for around 27% of global maternal deaths. Perineal tears are common in vaginal births and a significant contributor to excessive blood loss. A diversity of perineal techniques are utilised to prevent perineal trauma and reduce the incidence of PPH; however, they lack evidence‐based comparisons to understand their effects. Objectives To assess the effect of perineal techniques during the second stage of labour on the incidence of and morbidity associated with perineal trauma to prevent postpartum complications. Search methods We searched four databases and two trial registers up to 16 April 2024. We checked references, searched citations and contacted study authors to identify additional studies. Eligibility criteria We included randomised controlled trials (RCTs) of women in the second stage of labour who intended to give birth vaginally, comparing any perineal techniques with control or another perineal technique. We excluded studies that performed perineal techniques outside the second stage of labour. Outcomes Our critical outcomes were second‐, third‐ and fourth‐degree tears measured immediately after birth, and PPH ≥ 500 mL measured within 24 hours after birth. Risk of bias We used the Cochrane risk of bias 2 tool to assess bias in the included RCTs. Synthesis methods We synthesised results for each outcome within each comparison using meta‐analysis where possible. Where this was not possible due to the nature of the data, we synthesised results narratively. We used GRADE to assess the certainty of evidence for each outcome. Included studies We included a total of 17 studies with 13,695 participants. Synthesis of results Hands off (or poised) versus hands on Hands off (poised) may result in little to no difference in second‐degree tears (risk ratio (RR) 0.73, 95% confidence interval (CI) 0.32 to 1.64; 2 studies; low‐certainty evidence) and third‐ or fourth‐degree tears when data are combined (RR 1.27, 95% CI 0.81 to 1.99; 2 studies; low‐certainty evidence). The evidence is very uncertain about the effect of hands off (poised) on third‐degree tears and fourth‐degree tears when reported separately (RR 0.50, 95% CI 0.05 to 5.27; 1 study; very low‐certainty evidence and RR 3.00, 95% CI 0.13 to 71.22; 1 study; very low‐certainty evidence). Hands off (poised) may result in little to no difference in PPH ≥ 500 mL (RR 1.16, 95% CI 0.92 to 1.47; 1 study; low‐certainty evidence). Hands off (poised) probably results in little to no difference in breastfeeding two days after birth (RR 1.02, 95% CI 0.99 to 1.06; 1 study; moderate‐certainty evidence) and perineal pain (RR 0.98, 95% CI 0.94 to 1.01; 1 study; moderate‐certainty evidence). Vocalisation ve...

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Hands-on versus hands-off techniques for the prevention of perineal trauma during vaginal delivery: a systematic review and meta-analysis of randomized controlled trials

Cited by 35 publications

References 11 publications

Which elements were significant in reducing obstetric anal sphincter injury? A prospective follow-up study

Which elements were significant in reducing obstetric anal sphincter injury? A prospective follow-up study

How do midwives facilitate women to give birth during physiological second stage of labour? A systematic review

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

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