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Care of the Perineum

Issue Date: May 2008 Page 1

Care of the Perineum Practice Points

Antenatal perineal massage is an effective approach to increasing the chance of an intact perineum (Labrecque et al. 1999; Shipman et al. 1997) and in reducing instrumental deliveries (Shipman et al. 1997).

There is no evidence to support the practices of “ironing out” or massaging the perineum during birth (Enkin et al. 2000). Traditional practices such as flexion and extension of the head have been challenged (Myrfield et al. 1997).

Two methods of management of the perineum: “hands on” and “hands poised” have been compared (McCandlish et al. 1998). The only significant difference in outcome was more mild pain at ten days in the ”hands poised” group. Mayerhofer et al. (2002) confirmed McCandlish et al.’s findings of no statistical difference in overall perineal injury between the two groups but reported an increased rate of episiotomy and third degree tears in the “hands on” group. The findings of this study suggest that the “hands poised” method can effectively preserve the perineum. The use of either should therefore reflect both the midwife’s skill and the informed choice of the woman.

There is no evidence of short-term or long-term maternal benefit to support the use of liberal episiotomy (Carroli and Belizan 2004). Like any surgical procedure, episiotomy carries a number of risks (Enkin et al. 2000). Women report increased pain and discomfort after episiotomy that interferes with the experience of early motherhood (Kitzinger and Walters 1981). The practice should therefore be restricted mainly to fetal indications (Sleep 1990).

Episiotomy is strongly associated with a higher frequency of serious trauma (third and fourth degree lacerations) (Eason et al. 2000; Renfrew et al. 1998; Albers et al. 1999).

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Care of the Perineum

It is highly unlikely that women will not have sustained some trauma in the urogenital region following birth. An overall rate of 85% of women sustaining some degree of genital tract trauma has been reported by Albers et al, (2005). The highest rates of trauma have been observed in first births or operative vaginal deliveries and appear to increase with infant birth weight, maternal weight gain in pregnancy and fetal malpositions (Albers 2003 ). There is some evidence to suggest that the severity of the perineal injury is linked to the severity of perineal pain (Kenyon & Ford 2004).

There have been two useful randomised controlled trials investigating the effect of antenatal perineal massage. Labrecque et al. (1999), evaluating massage with sweet almond oil for 5-10 minutes daily from 34 weeks until birth, reported a significant increase in perineums remaining intact for women with first vaginal delivery, but not for women with a previous vaginal birth. A similar trial by Shipman et al. (1997) found a significant benefit of such massage in reducing second and third degree tears, episiotomies and instrumental deliveries. Analysis by mothers’ age showed a much larger benefit in those aged 30 and over. Labrecque et al. (2001) reported that the practice of massage was assessed positively by women.

Stamp et al.'s (2001) trial to determine the effects of perineal massage in the second stage of labour concluded that it did not increase the likelihood of an intact perineum or reduce the risk of pain, dyspareunia, or urinary and faecal problems, but was not harmful. The literature provides little detail of what constitutes good management at birth. McCandlish et al.’s (1998) trial, which involved 5,316 women, compared two methods of management. These were ”hands on”, in which the midwife’s hands put pressure on the baby’s head and support (“guard”) the perineum, lateral flexion then being used to facilitate delivery of the shoulders; and “hands poised”, in which the midwife keeps her hands poised, not touching the perineum or head and allowing spontaneous delivery of the shoulders. The results indicate more mild perineal pain at 10 days in the “hands poised” group. The only other statistically significant differences were in two secondary outcomes: the rate of episiotomy was lower in the ”hands poised” group, whereas manual removal of the placenta was more common. Mayerhofer et al.’s (2002) trial of 1, 076 women also compared “hands on” and “hands poised”. This study confirmed McCandlish et al.’s findings of no statistical difference in overall perineal injury between the two groups, but reported an increased rate of episiotomy and third degree tears in the “hands on” group. The findings of this study suggest that the “hands poised” method can effectively preserve the perineum. The use of either should therefore reflect both the midwife’s skill and the informed choice of the woman.

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There is no evidence to support the practices of “ironing out” or massaging the perineum during birth (Enkin et al. 2000). However, a recent national survey has reported that the practice of perineal massage during the 2nd stage of labour is being undertaken in 109 (52%) of maternity units in the UK (Sanders et al, 2005). This survey also reported that 70 (33%) of maternity units used hot packs and 44 (21%) used cold packs during the 2nd stage of labour in an attempt to reduce the severity of perineal injury and alleviate the associated burning sensation when a baby’s head is crowning. Very recently, a randomised controlled trial investigating perineal outcomes and maternal comfort with application of warm packs in 2nd stage of labour in nulliparous women reported that this practice does not reduce the need for suturing but found evidence that it reduced the risk of 3rd and 4th degree tears and some evidence that it reduced the severity of pain (Dahlen et al, 2007). No formal evaluation of the use of cold packs during the 2nd stage of labour has be reported.

The traditions of flexion and extension of the head have been challenged in a critical analysis of the scientific principles underpinning such practice (Myrfield et al. 1997). These authors suggest that such techniques may increase the risk of perineal trauma.

A Cochrane’s review evaluating firstly the risks and benefits of restrictive vs routine episiotomy and secondly the benefits or detrimental effects of the use of mediolateral vs midline episiotomy reported that there was a lower risk of posterior perineal trauma, need for suturing, healing complications at 7 days with restrictive use of episiotomy regardless of type of episiotomy incision. However, evidence to support either type of episiotomy incision (medio-lateral or midline was inconclusive). The researchers recommended a policy of restrictive use (Carroli & Belizan, 2004). Liberal use is unwarranted (Enkin et al. 2000) and probably harmful (Webb and Culhane 2002): the procedure, therefore, should be used mainly for fetal indications (Sleep 1990). Episiotomy is an example of an intervention which was introduced without accurate assessment and evaluation (Graham 1997) and without considering women’s views. The NCT study (Kitzinger and Walters 1981) of 1795 women, found that it caused pain at and following delivery, which could interfere with the initial relationship with her baby and her sexual activity. Systematic reviews (Eason et al. 2000; Renfrew et al. 1998;) have found that episiotomy is strongly associated with a higher frequency of serious trauma (third and fourth degree lacerations). A recent study reported that when nulliparous women have either a midline or medio-lateral episiotomy the perineal length maybe an indicator of the occurrence of severe perineal lacerations and suggest a critical value of 3 cm (Ayton et al. 2005). Further evidence is needed to support this claim.

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References

Albers LL, Sedler KD, Bedrick EJ, et al. (2005) Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: a randomiezed trial. Journal of Midwifery & Women’s Health. 50(5) 365-72. Back

Albers L (2003) Reducing genital tract trauma at birth launching a clinical trial in midwifery. Journal of Midwifery and Women’s Health 48: 105-110. Back

Ayton H, Tapisiz OL, Tuncay G, et al. (2005) Severe perineal lacerations in nulliparous women and episiotomy type. European Journal of Obstetrics & Gynecology. 121: 46-50. Back

Carroli G, Belizan J (2004) Episiotomy for vaginal birth (Cochrane Review): In: The Cochrane Library, Issue 1 Chichester, UK: John Wiley and Sons, Ltd. Back

Dahlen HG, Homer CSE, Cooke M, et al. (2007) Perineal outcomes and maternal comfort related to the application of perineal warm packs in the second stage of labor: a randomized controlled trial. Birth. 34:4 282-290. Back

Eason E, Labrecque M, Wells G, et al. (2000) Preventing perineal trauma during childbirth: a systematic review. Obstetrics and Gynecology 95: 464-471 Back

Enkin M, Keirse MJNC, Neilson J, et al. (2000) A guide to effective care in pregnancy and childbirth Oxford: Oxford University Press Back

Graham I (1997) Episiotomy: Challenging Obstetric Interventions Oxford: Blackwell Science Back

Kenyon S, Ford F (2004) How can we improve women’s post-birth perineal health. MIDIRS Midwifery Digest. 14(1) 7-12. Back

Kitzinger S, Walters R (1981) Some Women’s Experience of Episiotomy London: National Childbirth Trust Back

Labrecque M, Eason E, Marcoux S (2001) Women’s views on the practice of prenatal perineal massage. British Journal of Obstetrics and Gynaecology 108:499-504 Back

Labrecque M, Eason E, Marcoux S. Lemieux F, Pinault J, Feldman P, Lapperiere L (1999) Randomized controlled trial of prevention of perineal trauma by perineal massage during pregnancy. American Journal of Obstetrics and Gynecology 180 (3 pt 1): 593-600 Back

Mayerhofer K, Bodner-Adler B, Bodner K et al. (2002) Traditional Care of the Perineum During Birth. A prospective, Randomised Multicentre Study of 1,076 women. The Journal of Reproductive Medicine 47: 477-82 Back

McCandlish R, Bowler U, van Asten H, Berridge G, Winter C, Sames L, Garcia J, Renfrew M, Elbourne E (1998) A randomised controlled trial of care of the perineum during second stage of normal labour. British Journal of Obstetrics and Gynaecology 105: 1262-1272 Back

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)

This updated guideline was authored by Jane Munro Research Midwife and Mervi Jokinen Practice and Standards Development Adviser RCM with contributions on specific guidelines from Dr Mary Steen, Community Midwifery, Leeds Teaching Hospitals NHS Trust.

We wish to thank following peer reviewers for their contribution:Belinda Ackerman Consultant Midwife Guy’s & St Thomas’ NHS Foundation TrustTracey Cooper Consultant Midwife Worcestershire Acute Hospitals NHS TrustDr Marianne Mead Reader in Midwifery and Associate Research LeaderHealth and Human Sciences Research Institute, University of Hertfordshire

The development and ratification of this guideline has been under the auspices of the Professional Policy Committee of the RCM Council and the final version remains their responsibility.

Review date: 01/06/11 ©RCM Trust

Myrfield K, Brook C, Creedy D (1997) Reducing perineal trauma: implications of flexion and extension of the fetal head during birth. Midwifery 13: 197-201 Back

Renfrew MJ, Hannah W, Albers L, Floyd E (1998) Practices that Minimize Trauma to the Genital Tract in Childbirth: A Systematic Review of the Literature. Birth 25: 143-60 Back

Sanders J, Peters TJ, Campbell R (2005) Techniques to reduce perineal pain during spontaneous vaginal delivery and perineal suturing: a UK survey of midwifery practice. Midwifery. 21: 154-160. Back

Shipman M, Boniface D, Tefft M, Mcloghry F (1997) Antenatal perineal massage and subsequent perineal outcomes: a randomised controlled trial. British Journal of Obstetrics and Gynaecology 104: 787-791 Back

Stamp G, Kruzins G, Crowther C (2001) Perineal massage in labour and prevention of perineal trauma: a randomised controlled trial. British Medical Journal 322 : 1277-80 Back

Sleep J (1990) Spontaneous delivery in Alexander J, Levy V, Roch S (eds) Intrapartum Care A research-based approach. Hampshire and London: Macmillan Education Back

Webb D, Culhane J (2002) Hospital Variation in Episiotomy Use and the Risk of Perineal Trauma During Childbirth. Birth 29: 132-136 Back

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Appendix ASources

Four bibliographic sources (Medline, CINAHL, MIDIRS and the Cochrane Library) were searched in order to identify the published literature. As this document is an update of research previously carried out, the publication time period was restricted to 2004 to January 2008

Search Terms

Separate search strategies were developed for each section of the review. Initial search terms for each discrete area were identified by the authors. For each search, a combination of MeSH and keyword (free text) terms was used

Journals hand-searched by the authors (2004) were as follows:

Birth

British Journal of Midwifery

Midwifery

Practising Midwife

Evidence-based Midwfery

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