ReviewPreventing perineal trauma during childbirth: a systematic review
Section snippets
Sources
We searched the medical literature for published reports in any language of randomized clinical trials (RCTs) of interventions with perineal trauma as an outcome, using MEDLINE (1966–1999) with the search terms childbirth or pregnancy or delivery, perineum, episiotomy, perineal massage, obstetric forceps, vacuum extraction, labor stage-second. MEDLINE searches restricted to specific study types (clinical trial, randomized controlled trial, prospective study) were insensitive and did not find
Study selection
Studies were included on the basis of random or quasirandom allocation of an intervention for perineal trauma and complete reporting of perineal outcomes, including lacerations and episiotomies. (Quasirandom includes allocation methods based on medical record numbers.) Exclusions were based on failure to report outcomes by intention to treat, or incomplete or internally inconsistent reporting of perineal outcomes. Final selection of studies and data extraction was by consensus of the first two
Results
Data from RCTs that evaluated similar interventions were combined to determine the weighted estimate of risk difference. The number needed to treat, ie, the number of women needed to receive (or avoid) an intervention to prevent one case of sutured perineal trauma or anal sphincter trauma was calculated. Each article was assigned a quality score using the (previously validated) Jadad 5-point score.7 Double-masking was not possible for any of the interventions, so 3 was the highest possible
Conclusion
In the last 20 years, reliable scientific observations have been made on a few aspects of birth care. Evidence from RCTs showed that avoiding episiotomy protected perineal integrity. Routine mediolateral episiotomy did not protect against anal sphincter trauma, and median episiotomy caused more anal sphincter tears. In women approaching their first vaginal births, perineal massage for a few weeks beforehand decreased the risk of perineal trauma. Operative delivery by forceps was associated with
References (59)
- et al.
Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation
Am J Obstet Gynecol
(1994) - et al.
Assessing the quality of reports of randomized clinical trialsIs blinding necessary?
Control Clin Trials
(1996) - et al.
Episiotomy and its role in the incidence of perineal lacerations in a maternity center and a tertiary hospital obstetric service
Am J Obstet Gynecol
(1989) - et al.
A randomized prospective trial of the obstetric forceps versus the M-cup vacuum extractor
Am J Obstet Gynecol
(1996) - et al.
Effect of perineal massage on the incidence of episiotomy and perineal laceration in a nurse-midwifery service
J Nurse Midwifery
(1986) - et al.
Perineal massage—Effect on the incidence of episiotomy and laceration in a nulliparous population
J Nurse Midwifery
(1987) - et al.
Randomized controlled trial of prevention of perineal trauma by perineal massage during pregnancy
Am J Obstet Gynecol
(1999) - et al.
An experiment of squatting birth
Eur J Obstet Gynecol Reprod Biol
(1989) - et al.
Randomised, controlled trial of squatting in the second stage of labour
Lancet
(1989) - et al.
A randomised trial to evaluate the use of a birth chair for delivery
Lancet
(1983)
Ueber sein Dammschutzverfahren. Monatschrift fur Geburtskunde u
Frauenkrankh
Obstetrics for nurses
Relaxation and management of the perineum during parturition
JAMA
The use of episiotomy in normal delivery
Midwives Chron
Putting research into practicePerineal management during delivery
Meta-analysis in clinical trials
Control Clin Trials
Is routine episiotomy necessary?
BMJ
West Berkshire perineal management trial
BMJ
Episiotomy and the perineumA random controlled trial
J Obstet Gynaecol
Routine vs. selective episiotomyA randomised controlled trial
Lancet
Episiotomy, elective or selectiveA report of a random allocation trial
J Obstet Gynaecol
The protection of the perineum in labour
Edinburgh Med J
Association between median episiotomy and severe perineal lacerations in primiparous women
Can Med Assoc J
Midline episiotomiesMore harm than good?
Obstet Gynecol
Factors associated with rectal injury in spontaneous deliveries
Obstet Gynecol
Benefits and risks of episiotomyAn interpretative review of the English language literature 1860–1980
Obstet Gynecol Surv
Shall we cut and reconstruct the perineum for every primipara?
Am J Obstet
A comparison between midline and mediolateral episiotomies
Br J Obstet Gynaecol
Cited by (181)
The prevention of perineal trauma during vaginal birth
2024, American Journal of Obstetrics and GynecologyLanguage barrier as a risk factor for obstetric anal sphincter injury – A case-control study
2021, Journal of Gynecology Obstetrics and Human ReproductionPostoperative management of postpartum perineal tears
2019, Wound MedicineIncidence and risk factors of third- and fourth-degree perineal tears in a single Italian scenario
2018, European Journal of Obstetrics and Gynecology and Reproductive Biology