Manual perineal support at the time of childbirth: a systematic review and meta‐analysis

Abstract

Background Genital tract trauma is common with vaginal births and is associated with significant morbidity, particularly with obstetric anal sphincter injuries (OASIS). Debate continues regarding the effectiveness of perineal support during childbirth in reducing the risk of trauma.Objectives This review aimed to assess the effect of routine 'hands on'/manual perineal support (MPS) during childbirth, versus ad hoc/no perineal support ('hands off/poised'), on the risk and degree of perineal trauma.Search strategy This review is registered on PROSPERO (http:// www.crd.york.ac.uk/PROSPERO/display_record.asp? ID=CRD42014007058). We searched the CENTRAL, Embase, Medline, CINAHL, and OVIDs midwifery and infant care databases (from inception to December 2014).Selection criteria Published randomised controlled trials (RCTs) and non-randomised studies (NRSs) evaluating any 'hands on' perineal support technique during childbirth.Data collection and analysis Two reviewers independently assessed trials for inclusion, data extraction, and methodological quality. Discrepancies were resolved by discussion with a third reviewer.Main results We included five RCTs and seven NRSs in the review. Meta-analysis of RCTs did not demonstrate a statistically significant protective effect of MPS on the risk of OASIS (three studies, 6647 women; relative risk, RR 1.03; 95% confidence interval, 95% CI 0.32-3.36; statistical test for heterogeneity I 2 = 71%). Meta-analysis of NRSs showed a significant reduction in the risk of OASIS with MPS (three studies, 74 744 women; RR 0.45; 95% CI 0.40-0.50; I 2 = 32%).Conclusion Current evidence is insufficient to drive change in practice. An adequately powered randomised trial with an efficient design to evaluate the complex interventions adopted as part of MPS policies, ensuring controlled childbirth, is urgently needed.Keywords Obstetric anal sphincter injuries, parturition, perineal support, perineal trauma. IntroductionIt is reported that 85% of women having a vaginal birth sustain some degree of perineal trauma. 1 Perineal tears are defined as first degree when the perineal skin is involved, second degree when the tear involves perineal muscles and skin, third degree when the anal sphincter complex is involved, and fourth degree when the tear involves all of the above structures and the anal epithelium or rectal mucosa. 2,3 Third-and fourth-degree tears are collectively called obstetric anal sphincter injuries (OASIS). The overall rate of OASIS varies in reports (0.6-10.2%), 4-8 and is sometimes attributed to differences in definitions and clinical practices. 9 Perineal trauma is associated with considerable shortand long-term morbidity. The risk and severity of complications is proportional to the extent of the trauma. 10,11 Despite identification and repair, postpartum complications such as perineal pain and faecal incontinence have a higher prevalence following OASIS, [12][13][14][15][16] and are associated with www.bjog.org Systematic review major psychological, physical, and social problems....

Manual perineal protection: The know‐how and the know‐why

“…Nevertheless, it is important to recognize that most of the randomized controlled trials (RCTs) that have evaluated the topic do not provide details about the technique used for perineal support or measures taken to ensure its standardization. Indeed, this is one of the major shortfalls of such RCTs compared with non‐randomized observational studies . Moreover, there is evidence from biomechanical studies that the accuracy of the performance of the different maneuvers, dependent on the type of MPP technique, is essential for its effectiveness.…”

Severe perineal trauma among women undergoing vaginal birth after cesarean delivery: A population‐based cohort study

“…Raisanen et al 9 hypothesized that the increased severe perineal trauma risk is because of fetopelvic disproportion which also predisposes a primary cesarean delivery. 17 Episiotomy is the most commonly performed obstetric procedure and was traditionally thought to decrease the risk of major perineal trauma and pelvic floor dysfunction in later life. Hehir et al 10 reported that "a large number" of women with severe perineal trauma in a subsequent vaginal delivery had progressed to an advanced stage before delivering by primary cesarean section (n = 27/60).…”

Effects of an intervention program for reducing severe perineal trauma during the second stage of labor

“…7,8 Careful clinical assessments, taking in a wide spectrum in routine clinical work, are nonetheless a valuable addition to the evidence and can shift emphasis toward methods that strive to improve health outcomes. 7,8 Careful clinical assessments, taking in a wide spectrum in routine clinical work, are nonetheless a valuable addition to the evidence and can shift emphasis toward methods that strive to improve health outcomes.…”