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Three Part Question

[Perineal techniques] can [prevent perineal tear] [in second stage of labour]?

Clinical Scenario

You are a midwife looking after a low risk primigravida in labour. How do you support her in preventing perineal tears of any grade?

Search Strategy

NICE Healthcare Databases Advanced Search. CIHNAL and MEDLINE.
PERINEAL TRAUMA; hands poised technique, per* Tear*, Theasurus Perineum, Birth Injuries
LIMIT to English language only, human studies

Search Outcome

Fifty-six articles were identified, six of them were systematic reviews and only one was a qualitative study.
Seven articles describing the use of tools, positions and techniques have been included in this review and the remaining forty were excluded as they failed to answer the question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Flynn et al. 1997 Canada	Pregnant women, second stage of labour no instrumental	Systematic review	Grade of perineal tear	Upright position should be avoided as they can cause perineal oedema.	This paper analyses all the different options. It highlights that labour management is mainly based on expert opinions and traditions.
Thies-Lagergren et al. 2011 Sweden	Singleton pregnancy at term BMI <30	Randomized control trial	The primary outcome measurement is the number of instrumental deliveries when a birthing stool is used. Secondary outcome	Birth stool did not reduce instrumental. It did not register any adverse perineal outcomes and it was revealed to be protective towards episiotomy	This study only focus on the use of birthing stool
BUMPES 2017 UK	Pregnant women 16 years or older, were > 37 weeks, nulliparous, singleton	Randomized control trial	The primary outcome was spontaneous vaginal birth.	There is no statistical difference between	It mainly focuses on use of epidural related to position during second stage of labour
Zhou F, et al 2014 China	Singleton pregnant women	Systematic review	Whether hyaluronidase	It has been registered a lower	The authors suggest that the result should be interpreted cautiously due to bias and confounding in the non-placebo controlled comparison.
Petrocnik P & Marshall 2015 UK	Singleton term pregnant women	Systematic review	Systematical review of all the literature that compares hands on and hands poised technique and the outcomes	Evidence would suggest that the hands-poised technique is a safe and recommended technique for perineal management and discussions of such a technique should be included in all midwifery education and training programmes.	In this study the evidence presented are not strong
AasheimV et al 2017 Norway	Pregnant women planning to have a spontaneous vaginal birth (after 36 weeks of pregnancy, singleton, cephalic presentation).	Systematic review	To assess the effect of perineal techniques during the second stage in reducing perineal trauma.	Warm compresses, and massage have a moderate quality evidence in reducing third and fourth degree tears. However is unclear if these techniques have an impact on other outcomes or other type of tears.	The data were insufficient and high risk of bias outcome data
Begley at al, 2018 Ireland & New Zealand	21 senior midwives with average experience of 15 years with a very high no suture rate	Qualitative	To explore the skills employed by experienced midwives in new Zealand and Ireland in preserving the perineum intact during spontaneous vaginal birth.	This study gives understanding of the techniques used by experienced midwives to prevent perineal trauma.	It is a small study but the findings are in correlation with other studies

Comment(s)

This literature research shows that there is no strong evidence with any of the perineal techniques used in clinic practice. It appears that midwives are using their clinical judgment to support women in second stage of labour. None of the techniques seems to be more effective than the others, also none of them can be considered harmful or responsible for greater incidence of perineal tears. In the only qualitative study one of the most successful techniques described by the midwives was breathing slowly and controlled the birth. No quantitative data are available on this topic. More research is needed in order to understand whether it is possible to prevent perineal lacerations in second stage of labour.

Clinical Bottom Line

Midwives should use their own clinical judgment and select the appropriate birth position or use of tools (e.g. birthing stool, warm compresses) on individual basis.

References

1. Flynn P, Franiek J, Janssen P, Hannah W J, Klein M C (1997) How can Second Stage management prevent perineal trauma? Canadian Family Physician 1997; 43:73-84.
2. Thies-Lagergren L, Kvist LJ, Christensson K, Hildingsson I No reduction in instrumental vaginal births and no increased risk for adverse perineal outcome in nulliparous women giving birth on a birth seat: results of a Swedish randomized controlled trial. BMC Pregnancy and Childbirth 2011; 11:22
3. The Epidural and Position Trial Collaborative Group Upright versus lying down position in second stage of labour in nulliparous women with low dose epidural: BUMPES randomised controlled trial. BMJ 359:j4471
4. Zhou F, Wang XD, Li J, Huang GQ, Gao BX Hyaluronidase for reducing perineal trauma Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD010441
5. Petrocick P, Marshall J Hands-on or hands-poised: what does the evidence say? The Practising Midwife 2015 18 (7) 10:12
6. AasheimV, Nilsen ABV, Reinar LM, Lukasse M Perineal techniques during the second stage of labour for reducing perineal trauma (Review) Cochrane Database of Systematic Reviews 2017, Issue 6. Art. No.: CD006672
7. Begley C, Guilliland K, Dixon L, Reilly M, Keegan C, McCann C, Smith V Qualitative exploration of techniques used by expert midwives to preserve the perineum intact. Elsevier ltd 2018