Effect of perineal massage on the rate of episiotomy and perineal tearing

Development of aids to relieve vulvodynia during the postpartum period

Postpartum women live with a low quality of life due to pain caused by episiotomy and perineal laceration. In particular, they endure pain when sitting for long periods of time to breastfeed. The purpose of this study is to develop a sitting aid to alleviate postpartum vulvodynia. This study was conducted in the following four phases from July 2017 to May 2019. They are: material selection and molding, cleaning and disinfection testing, pressure distribution measurement testing, and trial testing by postpartum women. The main material was a 100% polypropylene object with a three-dimensional reticular fiber spring structure and fiber density of 3.8 kg/m2. As a result, a sitting aid that withstands washing and disinfection well in the medical field and is breathable. It had moderate resilience and elasticity and reduced pressure on the seating surface for women weighing approximately 45 kg and 55 kg, but we were skeptical about its use for women weighing more than that. The completed sitting aid is noninvasively effective in improving the quality of life of many postpartum women, but the density and thickness of the main material should be reexamined to meet the needs of women in a wider weight range. In addition, a self-administered questionnaire survey of trial users revealed that some women did not experience relief from vulvodynia even after using the sitting aid. Such women also had physical problems such as discomfort in the lower back, difficulty breastfeeding, and difficulty standing up. For women with multiple physical problems, individual causes should be addressed.

The Effect of Virtual Glasses Application on Pain and Anxiety During Episiotomy Repair: Randomized Controlled Trial

BACKGROUND

In the literature, the efficacy of virtual glasses on acute pain and anxiety has been investigated, and no study has been found on its effect on pain and anxiety during episiotomy repair.

AIMS

To determine the efficacy of virtual glasses application in pain and anxiety during episiotomy repair.

DESIGN

Randomized controlled trial design was used.

PARTICIPANTS

The study included 120 women who were primiparous and pregnant: 40 in the control group and 80 in the experimental groups (virtual glasses and skin to skin contact).

METHODS

Data were collected using Descriptive Information Form, the Visual Analog Scale (VAS), and the State Anxiety Inventory. In experimental groups, virtual glasses and skin to skin contact were applied during episio tomy repair by the researcher, and they were not applied to the control group. The VAS and State Anxiety Inventory were used to assess pain and anxiety in all groups before and after application. In the statistical analysis of the data, the SPSS 23.0 packa ge program was used. In all tests, p < .005 wa s considered statistically significant.

RESULTS

Immediately post intervention, the women in the experimental groups had significantly decreased anxiety and pain during episiotomy repair. Comparing three methods, the virtual glasses significantly reduced anxiety and pain after application (p < .05).

CONCLUSIONS

Virtual glasses are more effective than skin to skin contact and control methods in decreasing pain and reducing anxiety during episiotomy repair. Additionally, virtual glasses may reduce the need for pharmacological medication due to this reduction in pain and anxiety during episiotomy repair.

Antenatal perineal massage - risk of perineal injuries, pain, urinary incontinence and dyspereunia - a systematic review

BACKGROUND

Natural childbirth is associated with the risk of damage to the perineum - a tears or a episiotomy. Adequate preparation of the woman for childbirth is essential to minimize the occurrence of perinatal injuries.

AIM

The aim of the review is to assess and analyze the impact of APM (antental perineal massage) on perinatal perineal injuries and the development of pelvic pain and other complications in postpartum women, such as dyspareunia, urinary (UI), gas (GI), and fecal incontinence (FI).

METHODS

PubMed, Web of Science, Scopus and Embase were searched. Three authors independently searched databases and selected articles for inclusion and exclusion criteria. Next one author did Risk of Bias 2 and ROBINS 1 analyze.

FINDINGS

Of 711 articles, 18 publications were left for the review. All 18 studies examined the risk of perineal injuries (tearing and episiotomy), 7 pain in postpartum period, 6 postpartum urinary, gas/fecal incontinence and 2 described dyspareunia. Most authors described APM from 34 weeks of pregnancy until delivery. There were different techniques and times for doing APM procedures.

DISCUSSION

APM has many benefits for women during labor and the postpartum period (e.g. lower rate of perineal injuries and pain). However, it can be observed that individual publications differ from each other in the time of massage, the period and frequency of its performance, the form of obtaining instruction and control of patients. These components may affect the results obtained.

CONCLUSION

APM can protects the perineum from injuries during labor. It also reduces risk of fecal and gas incontinence in postpartum period.

Perineal massage and warm compresses - Randomised controlled trial for reduce perineal trauma during labor

OBJECTIVE

The aim of this study is to evaluate the effect of perineal massage and warm compresses technique on the perineum integrity during second stage of labor.

DESIGN AND SETTING

A single-center, prospective, randomized controlled trial was conducted between March 1st, 2019, and December 31st, 2020, at Hospital of Braga.

PARTICIPANTS

Women with 18 years or older, between 37 weeks and 41 weeks pregnant, in whom a vaginal birth of a fetus in the cephalic presentation was planned were recruited. Eight hundred forty-eight women were randomly assigned (Perineal massage and warm compresses group, n = 424 and control group, n = 424), and 800 women, both perineal massage and warm compresses group (n = 400) and control group (n = 400) were included in the strict per protocol analysis.

INTERVENTION

In the perineal massage and warm compresses group, women received perineal massage and warm compresses and in the control group, women received hands-on technique.

RESULTS

The incidence of intact perineum was significantly higher in the perineal massage and warm compresses group [perineal massage and warm compresses group: 47% vs control group: 26.3%; OR 2.53, 95% CI 1.86-3.45, p<0.001], whereas second-degree tears and episiotomy rate were significantly lower in this group [perineal massage and warm compresses group: 7.2% vs control group: 12.3%; OR 1.96, 95% CI 1.17-3.29, p = 0.010 and perineal massage and warm compresses group: 9.5% vs control group: 28.5%; OR 3.478, 95% CI 2.236-5.409, p<0.001, respectively]. Also, obstetric anal sphincter injury with and without episiotomy and second-degree tears with episiotomy were significantly lower in the perineal massage and warm compresses group [perineal massage and warm compresses group: 0.5% vs control group: 2.3%; OR 5.404, 95% CI 1.077-27.126, p = 0.040 and perineal massage and warm compresses group: 0.3% vs control group: 1.8%; OR 9.253, 95% CI 1.083-79.015, p = 0.042, respectively].

CONCLUSIONS

The perineal massage and warm compresses technique increased the incidence of intact perineum and reduced the incidence of second-degree tear, episiotomy and obstetric anal sphincter injury.

IMPLICATIONS FOR PRACTICE

Perineal massage and warm compresses technique is feasible, inexpensive and reproductible. Therefore, this technique should be taught and trained to midwives students and midwives team. Thus, women should have this information and have the option to decide whether they want to receive the perineal massage and warm compresses technique in the second stage of labor.

Efficacy of perineal massage during the second stage of labor for the prevention of perineal injury: A systematic review and meta-analysis

BACKGROUND

Numerous interventions to reduce perineal trauma during childbirth have been studied in recent years, including perineal massage.

OBJECTIVE

To determine the efficacy of perineal massage during the second stage of labor to prevent perineal damage.

SEARCH STRATEGY

Systematic search in PubMed, Pedro, Scopus, Web of Science, ScienceDirect, BioMed, SpringerLink, EBSCOhost, CINAHL, and MEDLINE with the terms Massage, Second labor stage, Obstetric delivery, and Parturition.

SELECTION CRITERIA

The articles must have been published in the last 10 years; the perineal massage was administered to the study sample; and the experimental design consisted of randomized controlled trial.

DATA COLLECTION AND ANALYSIS

Tables were used to describe both the studies' characteristics and the extracted data. The PEDro and Jadad scales were used to assess the quality of studies.

MAIN RESULTS

Of the 1172 total results identified, nine were selected. Seven studies were included in the meta-analysis and indicated a statistically significant decreased number of episiotomies in perineal massage.

CONCLUSIONS

Massage during the second stage of labor appears to be effective in preventing episiotomies and reducing the duration of the second stage of labor. However, it does not appear to be effective in reducing the incidence and severity of perineal tears.

The effectiveness of interventions in the prevention of perineal trauma in parturients: A systematic review with meta-analysis

AIM

To investigate the effectiveness of interventions to prevent the occurrence of perineal trauma in parturients.

METHODS

A bibliographic search was carried out in Cochrane Library, MEDLINE via PUBMED, LILACS via Virtual Health Library (VHL), Embase, Scopus, CINAHL, Scielo, Web of Science, and PEDro databases. Randomized clinical trials evaluating the effects of any intervention to prevent perineal trauma during pregnancy and/or childbirth were included. There were no temporal or language restrictions. The risk of bias assessment was performed using the Revised Cochrane Risk-of-bias Tool for Randomized Trials.

RESULTS

Fifty studies, with a total of 17,221 participants, were included in this meta-analysis. No intervention during childbirth was effective for the prevention of perineal trauma (RR = 1.07, 95% CI [0.98.1.18], p < 0.01, I² = 83%) when compared to no intervention. However, a lower risk of perineal laceration was verified with techniques performed during pregnancy, when compared to no intervention (RR = 0.81, 95% CI [0.71, 0.93], p = 0.05, I² = 47%). Among them, highlight the effects of perineal massage in preventing lacerations (RR = 0.69, 95% CI [0.54, 0.87], p < 0.01) when compared to no intervention.

CONCLUSIONS

The techniques performed during pregnancy, especially perineal massage, are associated with a lower risk of perineal laceration.

Effects of perineal massage during childbirth on maternal and neonatal outcomes in primiparous women: A systematic review and meta-analysis

BACKGROUND

Perineal massage during childbirth has been recommended as an effective measure to prevent perineal injury. However, the overall effects of perineal massage during childbirth on maternal and neonatal outcomes in primiparous women remain inconclusive. Particularly, the effects of perineal massage begun during different stages of labor need to be further investigated.

OBJECTIVES

To comprehensively review the effects of perineal massage during childbirth on primiparous health outcomes, including perineal-related outcomes, duration of labor, hemorrhage and postpartum perineal pain, and neonatal outcomes, including Apgar scores and neonatal complications, and to further explore the effects of perineal massage begun during different stages of labor.

DESIGN

A systematic review and meta-analysis following the Cochrane Handbook guidelines and PRISMA2020.

METHODS

A systematic search strategy was developed following the three-phase search approach, and the literature search was conducted in electronic databases and clinical trial registers from inception to 7th January 2022. Study selection and data extraction were completed independently by two researchers. The updated Cochrane risk of bias 2.0 tool for randomized trials was chosen to evaluate the quality of included studies. Data analyses were conducted using the Revman5.4 software, and subgroup analyses were performed based on the different start times of perineal massage. Furthermore, the certainty of body of evidence for each outcome was assessed utilizing the GRADEpro online tool.

RESULTS

Seventeen randomized controlled trials involving 3248 primiparous women were included in the review. The pooled results of meta-analyses indicated that perineal massage begun during the second stage of labor significantly increased the occurrence of intact perineum (RR = 2.78, 95 % CI: [1.52, 5.05], P < 0.001), reduced the rate of second- and third-degree perineal lacerations (P < 0.05), and decreased the incidence of episiotomy (RR = 0.63, 95 % CI: [0.50, 0.79], P < 0.001), while perineal massage during the first stage of labor effectively shortened the duration of the first and second stages of labor (P < 0.05). The available evidence also suggests the potential role of perineal massage on hemorrhage and long-term postpartum perineal pain (P < 0.05). However, the aggregated results failed to demonstrate the beneficial effects of perineal massage on neonatal outcomes (P > 0.05).

CONCLUSIONS

Perineal massage begun during the second stage of labor effectively improves the perineal-related outcomes in primiparous women, while perineal massage during the first stage of labor significantly shortens the duration of labor. High-quality studies exploring the standardized procedure for perineal massage and the short- and long-term effects of perineal massage are warranted.

REGISTRATION NUMBER

CRD42022302336 (PROSPERO).

Perineal Massage during Pregnancy for the Prevention of Postpartum Urinary Incontinence: Controlled Clinical Trial

Background and objectives: Urinary incontinence is any involuntary loss of urine. It may result in anxiety, depression, low self-esteem and social isolation. Perineal massage has spread as a prophylactic technique for treating complications during labor. Acknowledged effects of perineal massage are reduction of incidence and severity of perineal tear and use of equipment directly related to the intrapartum perineal trauma. The aim of this study was to determine the effectiveness of massage in urinary incontinence prevention and identification of possible differences in its form of application (self-massage or by a physiotherapist), with the previous assumption that it is effective and that there are differences between the different forms of application. Materials and Methods: A controlled clinical trial with a sample of 81 pregnant women was conducted. The participants were divided into three groups: a group that received the massage applied by a specialized physiotherapist, another group that applied the massage to themselves, and a control group that only received ordinary obstetric care. Results: No differences were identified in the incidence or severity of urinary incontinence among the three groups. The severity of the incontinence was only affected by the body mass index and the weight of the baby at the time of delivery. Conclusions: A relationship between perineal massage interventions and development of urinary incontinence has not been observed.

Aspects of Pelvic Floor Protection in Spontaneous Delivery - a Review

The necessity of increasingly addressing aspects of pelvic floor protection, i.e., prevention of the most frequent female pelvic floor disorders, such as urinary incontinence, faecal incontinence and pelvic organ prolapse, is the result of the steadily improving understanding of the association of pregnancy and delivery with the prevalence of these disorders. About a quarter of all women experience one or more such symptoms during their life. Apart from age and weight, pregnancies and births play an important part. While initial discussion of pelvic floor protection often focused very rapidly on the mode of delivery and elective caesarean section as a possible protective intervention, it has become apparent in the last few decades how varied and wide-ranging the options are that can be used to protect against pelvic floor disorders. The mode of delivery as such is "only" one element among numerous other considerations and has diminished markedly in importance. Interprofessionality and interdisciplinarity undoubtedly represent an important development as resulting recommendations must always be incorporated in an overall context that considers mother and child at the same time. Considering the pelvic floor only certainly does not make sense. This review article will analyze in greater detail important pre-, intra- and postpartum aspects that in their entirety can provide insight into the various aspects of pelvic floor protection. The authors regard the following article as an additional basis for discussion on achieving a sustained reduction in the incidence and prevalence of female pelvic floor disorders.

Prevalence of Perineal Tear Peripartum after Two Antepartum Perineal Massage Techniques: A Non-Randomised Controlled Trial

Perineal massage increases elasticity of myofascial perineal tissue and decreases the burning and perineal pain during labour, thus optimising child birth, although an application protocol has not been standardised yet. The objective of this study is to determine the efficiency of massage in perineal tear prevention and identification of possible differences in massage application. Total of 90 pregnant participants were divided into three groups: perineal massage and EPI-NO^® device group, applied by an expert physiotherapist, self-massage group, where women were instructed to apply perineal massage in domestic household, and a control group, which received ordinary obstetric attention. Results: The results showed significant differences among the control group and the two perineal massage groups in perineal postpartum pain. Correlations in perineal postpartum pain, labour duration and the baby's weight were not statistically significant. Lithotomy posture was significantly less prevalent in the massage group than in the other two; this variable is known to have a direct effect on episiotomy incidence and could act as a causal covariate of the different incidence of episiotomy in the groups. Perineal massage reduces postpartum perineal pain, prevalence and severity of perineal tear during delivery.

Can pelvic floor muscle training prevent perineal laceration? A systematic review and meta-analysis

BACKGROUND

Pelvic floor muscle training (PFMT) is reportedly able to reduce risk factors for perineal trauma. However, the effects of these exercises on perineal injuries are unclear.

OBJECTIVE

To investigate the effectiveness of PFMT in the prevention of perineal laceration.

SEARCH STRATEGY

Searches were conducted in PubMed/Medline, LILACS, Scopus, Cochrane Library, Web of Science, and CINAHL. For search strategies, we combined the terms PFMT, tear, laceration, perineum, and delivery.

SELECTION CRITERIA

We included randomized controlled trials that evaluated the effectiveness of PFMT for the prevention of perineal laceration during vaginal delivery. There were no period or language limitations.

DATA COLLECTION AND ANALYSIS

We conducted data extraction and synthesis. We performed a quality appraisal, a qualitative synthesis, and for meta-analysis we used the Software R.

MAIN RESULTS

Nine studies were included. In most studies, PFMT was performed daily, with a wide range of the number of contractions and sustainability. Prevalence of perineal laceration had a wide range and information on laceration degree was limited. Meta-analysis showed that PFMT was not effective to prevent perineal laceration.

CONCLUSION

Pelvic floor muscle training does not prevent perineal laceration. Further studies are needed to investigate different protocols and interventions.

Non-pharmacological therapies applied in pregnancy and labor: an integrative review

OBJECTIVE

To identify non-pharmacological therapies applied during pregnancy and labor.

METHOD

Integrative review conducted in the databases: PubMed, ScieLO and PEDro, searching for articles from 2008 in English, Spanish and Portuguese. The descriptors used were: pregnancy, childbirth, physiotherapy, alternative and complementary medicine, alternative therapy, non-pharmacological therapy, biomechanical therapy.

RESULTS

Forty-one articles were analyzed and subdivided into ten categories of nonpharmacological therapies: massage, perineal massage, hot bath, supportive care, childbirth preparation group, breathing techniques, pelvic floor exercises, transcutaneous electrostimulation, Swiss ball and spontaneous pushing. Six articles (60%) showed a positive outcome for reduction of pain in labor and all of them had a positive outcome for different variables of labor, such as reduction of time, anxiety and pelvic floor laceration rates.

CONCLUSION

The use of non-pharmacological therapies was efficient to reduce the effects of labor and childbirth, such as pain, duration of labor, anxiety, laceration and episiotomy.

The effect of music and skin contact with the newborn on pain and anxiety during episiotomy repair in primiparous women: A double-blind randomized controlled study

OBJECTIVE

To show that music medicine and skin contact with the newborns can reduce pain and anxiety during episiotomy repair.

DESIGN

Double-blind randomized controlled trial SETTING: The study was conducted between April and July 2020 at the private Medipol Nisa Hospital.

PARTICIPANTS

A total of 150 primiparous pregnant women over 20 years of age who underwent vaginal delivery with episiotomy INTERVENTIONS: Participants were randomized into the music medicine, skin contact with the newborn, and control groups (with no treatment). After episiotomy repair (with the designated treatment or no treatment), the State Trait Anxiety Inventory and Visual Analog Scale were used to assess anxiety and pain, respectively.

MAIN OUTCOME MEASURES

Pain and anxiety experienced after episiotomy repair in the treatment and control groups.

RESULTS

Women in both treatment groups (music medicine and skin-to-skin contact) had significantly lower anxiety and pain levels than those in the control group. In particular, music medicine significantly reduced pain in comparison to skin contact with the newborn (VAS 2 3.92 ± 1.46 vs. 5.42 ± 1.73, respectively, VAS 3 2.64 ± 1.63 vs. 5.14 ± 1.77, respectively, VAS 4 1.38 ± 1.46 vs. 4.14 ± 2.04, respectively, p < 0.05). Thus, music medicine is more effective than skin-to-skin contact in reducing the pain experienced during episiotomy repair, but both treatments were equally effective in reducing anxiety (35.30 ± 6.47 vs. 36.82 ± 9.71 vs. 49.22 ± 16.95, respectively, p < 0.05).

CONCLUSION

Both of these nonpharmacological treatments can be used along with analgesics and anxiolytics for the treatment of pain and anxiety during episiotomy repair.

Practices of midwives working in delivery rooms for protection of perineum during intrapartum period and their feedback on these applications

INTRODUCTION AND HYPOTHESIS

Perineal traumas occurring during labor are undesirable for both the midwives and the woman. Midwives and obstetricians could use different techniques to protect the perineum.

PURPOSE

The aim of this study was to determine the practices of midwives working in the delivery room to protect the perineum during the second stage of labor.

METHODS

This is a prospective observational study regarding practices of midwifes for protection of perineum during intrapartum period. The study was conducted with a total of 20 midwives in a maternity unit of an training and research hospital. The data were collected through the forms prepared by the researchers.

FINDINGS

The average age of the midwives was 34 ± 8.77. The majority of midwives (n: 17, 85%) believed that the need for practices to protect the perineum during labor; 40% of them used perineal protection (hands on) technique to protect perineum and they preferred to perform routine episiotomy in all primiparas.

RESULTS AND CONCLUSIONS

As a result of the study, it was observed that evidence-based practices was not applied sufficiently enough by the midwives although they were knowledgeable and believed that they are beneficial. Studies are needed for the obstacles to these practices to be identified and removed.

The effect of antenatal pelvic floor muscle exercises on labour and birth outcomes: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

The current data on the effectiveness of antenatal pelvic floor muscle exercises (PFME) on childbirth outcomes are limited. Therefore, in this study the effect of antenatal PFMEs on labour and birth outcomes was assessed by undertaking a meta-analysis.

METHODS

Databases were systematically searched from 1988 until June 2019. Randomised controlled trials (RCTs) and quasi-experimental studies were included. The methodological quality of studies was assessed using Cochrane Collaboration tools. The outcomes of interest were: duration of first and second stage of labour, episiotomy and perineal outcomes, mode of birth (spontaneous vaginal birth, instrumental birth and caesarean section) and fetal presentation. The mean difference (MD) and risk ratio RR) with the corresponding 95% confidence intervals (CIs) were calculated to assess the association between PFME and the childbirth outcomes.

RESULTS

A total of 16 articles were included (n = 2,829 women). PFME shortened the duration of the second stage of labour (MD: -20.90, 95%, CI: -31.82 to -9.97, I²: 0%, p = 0.0002) and for primigravid women (MD: -21.02, 95% CI: -32.10 to -9.94, I²: 0%, p = 0.0002). PFME also reduced severe perineal lacerations (RR 0.57, 95% CI: 0.38 to 0.84, I²: 30%, p = 0.005). No significant difference was seen in normal vaginal birth, caesarean section, instrumental birth and episiotomy rate. Most of the studies carried a moderate to high risk of bias.

CONCLUSION

Antenatal PFME may be effective at shortening the second stage of labour and reducing severe perineal trauma. These findings need to be interpreted considering the included studies' risk of bias. More high-quality RCTs are needed.

Episiotomy: history, present and future - a review

Childbirth has always carried traumatic stress to the woman's body. To deliver with less perineal trauma, obstetricians have used episiotomies. Episiotomy is still a common practice despite the controversy regarding its use. Weighing the risks and benefits, the scientific literature supports its selective use. With the worldwide trend to reduce the rate of episiotomy, several techniques have been proposed to achieve that. However, further research is still needed to prove their efficacy. This review will shed light on the historical background of episiotomy, its different techniques, indications, and the future of its practice.

Effect of Perineal Massage with Ostrich Oil on the Episiotomy and Lacerations in Nulliparous Women: A Randomized Controlled Clinical Trial

BACKGROUND

Perineal lacerations resulting from vaginal delivery may cause short and long complications, which lead to some problems in women after the delivery. Ostrich oil is safe for use in skincare and beauty products. The aim of this study was to examine the effect of perineal massage with Ostrich oil on the episiotomy and lacerations in nulliparous women.

MATERIALS AND METHODS

This single-blind randomized controlled trial was conducted on 77 nulliparous women referred to Razi Hospital in Qazvin (Iran) from May to December 2018. After screening of potential participants, 80 out of 105 pregnant women were selected by convenience sampling and were assigned into the intervention and control groups by block randomization technique. In the intervention group, participants received a perineal massage with Ostrich oil in the active phase and the second stage of labor. The rates of episiotomy and perineal laceration were compared between the two groups. Data were analyzed using Chi-square, t-test and Mann-Whitney.

RESULTS

Perineal massage with Ostrich oil in the intervention group significantly decreased the rate of episiotomy compared to the control group (χ2 = 18.32, df = 1, p < 0.001). However, there was no statistically significant difference in perineal lacerations between the two groups.

CONCLUSIONS

The results revealed that perineal massage with Ostrich oil could be recommended as an effective, safe, and inexpensive method to improve the rate of episiotomy in vaginal delivery. Perineal massage can be performed by midwives in the first and second stages of labor.

Birth-Related Perineal Trauma in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis

Introduction Birth-related perineal trauma (BPT) is a common consequence of vaginal births. When poorly managed, BPT can result in increased morbidity and mortality due to infections, haemorrhage, and incontinence. This review aims to collect data on rates of BPT in low- and middle-income countries (LMICs), through a systematic review and meta-analysis. Methods The following databases were searched: Medline, Embase, Latin American and Caribbean Health Sciences Literature (LILACs), and the World Health Organization (WHO) regional databases, from 2004 to 2016. Cross-sectional data on the proportion of vaginal births that resulted in episiotomy, second degree tears or obstetric anal sphincter injuries (OASI) were extracted from studies carried out in LMICs by two independent reviewers. Estimates were meta-analysed using a random effects model; results were presented by type of BPT, parity, and mode of birth. Results Of the 1182 citations reviewed, 74 studies providing data on 334,054 births in 41 countries were included. Five studies reported outcomes of births in the community. In LMICs, the overall rates of BPT were 46% (95% CI 36–55%), 24% (95% CI 17–32%), and 1.4% (95% CI 1.2–1.7%) for episiotomies, second degree tears, and OASI, respectively. Studies were highly heterogeneous with respect to study design and population. The overall reporting quality was inadequate. Discussion Compared to high-income settings, episiotomy rates are high in LMIC medical facilities. There is an urgent need to improve reporting of BPT in LMICs particularly with regards to births taking in community settings.

FIGO Statement: Restrictive use rather than routine use of episiotomy

International standards for clinical staffing of delivery care in maternity units are currently lacking, with resulting gaps in provision leading to adverse outcomes and very poor experiences of care for women and families. While evidence‐informed modelling approaches have been proposed based on population characteristics and estimated rates of complications, their application and outcomes in low‐resource settings have not been reported. Here, FIGO's Safe Motherhood and Newborn Health Committee proposes indicative standards for labor wards as a starting point for policy and program development. These standards consider the volume of deliveries, the case mix, and the need to match clinical care requirements with an appropriate mix of professional skills among midwifery and obstetric staff. The role of Shift Leader in busy labor wards is emphasized. Application of the standards can help to assure women and their families of a safe but also positive birthing experience. FIGO calls for investment by partners to test these clinically‐informed recommendations for delivery unit staffing at hospital and district level in low‐ and middle‐income country settings.

Systematic review of pelvic floor interventions during pregnancy

BACKGROUND

Pelvic floor interventions during pregnancy could reduce the impact of pregnancy and delivery on the pelvic floor.

OBJECTIVE

To determine the effects of pelvic floor interventions during pregnancy on childbirth-related and pelvic floor parameters.

SEARCH STRATEGY

PubMed, Embase, and LILACS were searched for reports published during between 1990 and 2016 in English, Spanish, or Portuguese. The search terms were "pregnancy," "pelvic floor muscle training," and related terms.

SELECTION CRITERIA

Randomized controlled trials with healthy pregnant women were included.

DATA COLLECTION AND ANALYSIS

Baseline and outcome data (childbirth-related parameters, pelvic floor symptoms) were compared for three interventions: EPI-NO (Tecsana, Munich, Germany) perineal dilator, pelvic floor muscle training, and perineal massage.

MAIN RESULTS

A total of 22 trials were included. Two of three papers assessing EPI-NO showed no benefit. The largest study investigating pelvic floor muscle training reported a significant reduction in the duration of the second stage of labor (P<0.01), and this intervention also reduced the incidence of urinary incontinence (evaluated in 10 trials). Two of six trials investigating perineal massage reported that a lower rate of perineal pain was associated with this intervention.

CONCLUSION

Pelvic floor muscle training and perineal massage improved childbirth-related parameters and pelvic floor symptoms, whereas EPI-NO showed no benefit.

Perineal massage during labor: a systematic review and meta-analysis of randomized controlled trials

Background: Different techniques have been analyzed to reduce the risk of perineal trauma during labor.Objective: To evaluate whether perineal massage techniques during vaginal delivery decreases the risk of perineal trauma.Search strategy: Electronic databases (Medline, Prospero, Scopus, ClinicalTrials.gov, Embase, ScienceDirect, the Cochrane Library, SciELO) were searched from their inception until February 2018. No restrictions for language or geographic location were applied.Selection criteria: We included all randomized controlled trials (RCTs) comparing the use of perineal massage during labor (i.e. intervention group) with a control group (i.e. no perineal massage) in women with singleton gestation and cephalic presentation at ≥36 weeks. Perineal massage was defined as massage of the posterior perineum by the clinician's fingers (with or without lubricant). Trials on perineal massage during antenatal care, before the onset of labor, or only in the early part of the first stage, were not included.Data collection and analysis: All analyses were done using an intention-to-treat approach. The primary outcome was severe perineal trauma, defined as third and fourth degree perineal lacerations. Meta-analysis was performed using the random-effects model of DerSimonian and Laird to produce summary treatment effects in terms of either a relative risk (RR) with 95% confidence interval (CI).Main results: Nine trials including 3374 women were analyzed. All studies included women with singleton pregnancy in cephalic presentation at ≥36 weeks undergoing spontaneous vaginal delivery. Perineal massage was usually done by a midwife in the second stage, during or between and during pushing time, with the index and middle fingers, using a water-soluble lubricant. Women randomized to receive perineal massage during labor had a significantly lower incidence of severe perineal trauma, compared to those who did not (RR 0.49, 95% CI 0.25-0.94). All the secondary outcomes were not significant, except for the incidence of intact perineum, which was significantly higher in the perineal massage group (RR 1.40, 95% 1.01-1.93), and for the incidence of episiotomy, which was significantly lower in the perineal massage group (RR 0.56, 95% CI 0.38-0.82).Conclusions: Perineal massage during labor is associated with significant lower risk of severe perineal trauma, such as third and fourth degree lacerations. Perineal massage was usually done by a midwife in the second stage, during or between and during pushing time, with the index and middle fingers, using a water-soluble lubricant.

Perineal techniques during the second stage of labour for reducing perineal trauma

BACKGROUND

Most vaginal births are associated with trauma to the genital tract. The morbidity associated with perineal trauma can be significant, especially when it comes to third- and fourth-degree tears. Different interventions including perineal massage, warm or cold compresses, and perineal management techniques have been used to prevent trauma. This is an update of a Cochrane review that was first published in 2011.

OBJECTIVES

To assess the effect of perineal techniques during the second stage of labour on the incidence and morbidity associated with perineal trauma.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (26 September 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Published and unpublished randomised and quasi-randomised controlled trials evaluating perineal techniques during the second stage of labour. Cross-over trials were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion, extracted data and evaluated methodological quality. We checked data for accuracy.

MAIN RESULTS

Twenty-two trials were eligible for inclusion (with 20 trials involving 15,181 women providing data). Overall, trials were at moderate to high risk of bias; none had adequate blinding, and most were unclear for both allocation concealment and incomplete outcome data. Interventions compared included the use of perineal massage, warm and cold compresses, and other perineal management techniques.Most studies did not report data on our secondary outcomes. We downgraded evidence for risk of bias, inconsistency, and imprecision for all comparisons. Hands off (or poised) compared to hands onHands on or hands off the perineum made no clear difference in incidence of intact perineum (average risk ratio (RR) 1.03, 95% confidence interval (CI) 0.95 to 1.12, two studies, Tau² 0.00, I² 37%, 6547 women; moderate-quality evidence), first-degree perineal tears (average RR 1.32, 95% CI 0.99 to 1.77, two studies, 700 women; low-quality evidence), second-degree tears (average RR 0.77, 95% CI 0.47 to 1.28, two studies, 700 women; low-quality evidence), or third- or fourth-degree tears (average RR 0.68, 95% CI 0.21 to 2.26, five studies, Tau² 0.92, I² 72%, 7317 women; very low-quality evidence). Substantial heterogeneity for third- or fourth-degree tears means these data should be interpreted with caution. Episiotomy was more frequent in the hands-on group (average RR 0.58, 95% CI 0.43 to 0.79, Tau² 0.07, I² 74%, four studies, 7247 women; low-quality evidence), but there was considerable heterogeneity between the four included studies.There were no data for perineal trauma requiring suturing. Warm compresses versus control (hands off or no warm compress)A warm compress did not have any clear effect on the incidence of intact perineum (average RR 1.02, 95% CI 0.85 to 1.21; 1799 women; four studies; moderate-quality evidence), perineal trauma requiring suturing (average RR 1.14, 95% CI 0.79 to 1.66; 76 women; one study; very low-quality evidence), second-degree tears (average RR 0.95, 95% CI 0.58 to 1.56; 274 women; two studies; very low-quality evidence), or episiotomy (average RR 0.86, 95% CI 0.60 to 1.23; 1799 women; four studies; low-quality evidence). It is uncertain whether warm compress increases or reduces the incidence of first-degree tears (average RR 1.19, 95% CI 0.38 to 3.79; 274 women; two studies; I² 88%; very low-quality evidence).Fewer third- or fourth-degree perineal tears were reported in the warm-compress group (average RR 0.46, 95% CI 0.27 to 0.79; 1799 women; four studies; moderate-quality evidence). Massage versus control (hands off or routine care)The incidence of intact perineum was increased in the perineal-massage group (average RR 1.74, 95% CI 1.11 to 2.73, six studies, 2618 women; I² 83% low-quality evidence) but there was substantial heterogeneity between studies). This group experienced fewer third- or fourth-degree tears (average RR 0.49, 95% CI 0.25 to 0.94, five studies, 2477 women; moderate-quality evidence).There were no clear differences between groups for perineal trauma requiring suturing (average RR 1.10, 95% CI 0.75 to 1.61, one study, 76 women; very low-quality evidence), first-degree tears (average RR 1.55, 95% CI 0.79 to 3.05, five studies, Tau² 0.47, I² 85%, 537 women; very low-quality evidence), or second-degree tears (average RR 1.08, 95% CI 0.55 to 2.12, five studies, Tau² 0.32, I² 62%, 537 women; very low-quality evidence). Perineal massage may reduce episiotomy although there was considerable uncertainty around the effect estimate (average RR 0.55, 95% CI 0.29 to 1.03, seven studies, Tau² 0.43, I² 92%, 2684 women; very low-quality evidence). Heterogeneity was high for first-degree tear, second-degree tear and for episiotomy - these data should be interpreted with caution. Ritgen's manoeuvre versus standard careOne study (66 women) found that women receiving Ritgen's manoeuvre were less likely to have a first-degree tear (RR 0.32, 95% CI 0.14 to 0.69; very low-quality evidence), more likely to have a second-degree tear (RR 3.25, 95% CI 1.73 to 6.09; very low-quality evidence), and neither more nor less likely to have an intact perineum (RR 0.17, 95% CI 0.02 to 1.31; very low-quality evidence). One larger study reported that Ritgen's manoeuvre did not have an effect on incidence of third- or fourth-degree tears (RR 1.24, 95% CI 0.78 to 1.96,1423 women; low-quality evidence). Episiotomy was not clearly different between groups (RR 0.81, 95% CI 0.63 to 1.03, two studies, 1489 women; low-quality evidence). Other comparisonsThe delivery of posterior versus anterior shoulder first, use of a perineal protection device, different oils/wax, and cold compresses did not show any effects on perineal outcomes. Only one study contributed to each of these comparisons, so data were insufficient to draw conclusions.

AUTHORS' CONCLUSIONS

Moderate-quality evidence suggests that warm compresses, and massage, may reduce third- and fourth-degree tears but the impact of these techniques on other outcomes was unclear or inconsistent. Poor-quality evidence suggests hands-off techniques may reduce episiotomy, but this technique had no clear impact on other outcomes. There were insufficient data to show whether other perineal techniques result in improved outcomes.Further research could be performed evaluating perineal techniques, warm compresses and massage, and how different types of oil used during massage affect women and their babies. It is important for any future research to collect information on women's views.