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...
