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Review article| Volume 283, P100-111, April 2023

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

Published:February 17, 2023DOI:https://doi.org/10.1016/j.ejogrb.2023.02.008

      Abstract

      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.

      Keywords

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      References

        • Monteiro J.C.D.S.
        • Pitangui A.C.R.
        • Sousa L.d.
        • Beleza A.C.S.
        • Nakano A.M.S.
        • Gomes F.A.
        Associação entre a analgesia epidural e o trauma perineal no parto vaginal.
        Esc Anna Nery. 2009; 13: 140-144
      1. Green-top Guideline R. The Management of Third- and Fourth-Degree Perineal Tears. Vol. 29, Royal College of Obstetricians & Gynaecologists. 2015.

      2. Abedzadeh-Kalahroudi M, Talebian A, Sadat Z, Mesdaghinia E. Perineal trauma: incidence and its risk factors. J Obstet Gynaecol (Lahore) [Internet]. 2019;39(2):206–11. Available from: 10.1080/01443615.2018.1476473.

        • Williams A.
        • Herron-Marx S.
        • Carolyn H.
        The prevalence of enduring postnatal perineal morbidity and its relationship to perineal trauma.
        Midwifery. 2007; 23: 392-403
        • Aquino C.I.
        • Guida M.
        • Saccone G.
        • Cruz Y.
        • Vitagliano A.
        • Zullo F.
        • et al.
        Perineal massage during labor: a systematic review and meta-analysis of randomized controlled trials.
        J Matern Neonatal Med. 2020; 33: 1051-1063
        • Abdelhakim A.M.
        • Eldesouky E.
        • Elmagd I.A.
        • Mohammed A.
        • Farag E.A.
        • Mohammed A.E.
        • et al.
        Antenatal perineal massage benefits in reducing perineal trauma and postpartum morbidities: a systematic review and meta-analysis of randomized controlled trials.
        Int Urogynecol J. 2020; 31: 1735-1745
        • Beckmann M.M.
        • Stock O.M.
        Antenatal perineal massage for reducing perineal trauma.
        Cochrane Database Syst Rev. 2013; 2013
        • Pierce-Williams R.A.M.
        • Saccone G.
        • Berghella V.
        Hands-on versus hands-off techniques for the prevention of perineal trauma during vaginal delivery: a systematic review and meta-analysis of randomized controlled trials.
        J Matern Neonatal Med. 2021; 34: 993-1001
        • Bulchandani S.
        • Watts E.
        • Sucharitha A.
        • Yates D.
        • Ismail K.M.
        Manual perineal support at the time of childbirth: A systematic review and meta-analysis.
        BJOG An Int J Obstet Gynaecol. 2015; 122: 1157-1165
        • Zhou F.
        • Wang X.D.
        • Li J.
        • Huang G.Q.
        • Gao B.X.
        Hyaluronidase for reducing perineal trauma.
        Cochrane Database Syst Rev. 2013; 2013
      3. Magoga G, Saccone G, Al-Kouatly HB, Dahlen G H, Thornton C, Akbarzadeh M, et al. Warm perineal compresses during the second stage of labor for reducing perineal trauma: A meta-analysis. Eur J Obstet Gynecol Reprod Biol [Internet]. 2019;240:93–8. Available from: 10.1016/j.ejogrb.2019.06.011.

        • Sobhgol S.S.
        • Smith C.A.
        • Dahlen H.G.
        The effect of antenatal pelvic floor muscle exercises on labour and birth outcomes: a systematic review and meta-analysis.
        Int Urogynecol J. 2020; 31: 2189-2203
        • Higgins J.P.T.
        • Thomas J.
        • Chandler J.
        • Cumpston M.
        • Li T.
        • Page M.J.
        • et al.
        Cochrane handbook for systematic reviews of interventions.
        Cochrane Handb Systemat Rev Intervent. 2019; : 1-694
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • Altman D.
        • Antes G.
        • et al.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        PLoS Med. 2009; 6
        • Agur W.
        • Steggles P.
        • Waterfield M.
        • Freeman R.
        Does antenatal pelvic floor muscle training affect the outcome of labour? A randomised controlled trial.
        Int Urogynecol J. 2008; 19: 85-88
        • Dias L.A.R.
        • Driusso P.
        • Aita D.L.C.C.
        • Quintana S.M.
        • Bø K.
        • Ferreira C.H.J.
        Effect of pelvic floor muscle training on labour and newborn outcomes: a randomized controlled trial.
        Braz J Phys Ther [Internet]. 2011; 15 (Available from): 487-493
        • Ghodsi Z.
        • Asltoghiri M.
        Effects of aerobic exercise training on maternal and neonatal outcome: A randomized controlled trial on pregnant women in Iran.
        J Pak Med Assoc. 2014; 64: 1053-1056
        • Rodríguez-Blanque R.
        • Sanchez-Garcia J.C.
        • Sanchez-Lopez A.M.
        • Expósito-Ruiz M.
        • Aguilar-Cordero M.J.
        Randomized clinical trial of an aquatic physical exercise program during pregnancy.
        JOGNN - J Obstet Gynecol Neonatal Nurs [Internet]. 2019; 48: 321-331https://doi.org/10.1016/j.jogn.2019.02.003
        • Mohamed H.-A.-E.-A.
        • Elngger N.S.
        Effect of Regular Perineal Massage during Last Month of Pregnancy on Perineal Outcomes.
        Zagazig Nurs J [Internet]. 2011; 7 (Available from:): 33-48
        • Labrecque M.
        • Eason E.
        • Marcoux S.
        • Lemieux F.
        • Pinault J.J.
        • Feldman P.
        • et al.
        Randomized controlled trial of prevention of perineal trauma by perineal massage during pregnancy.
        Am J Obstet Gynecol. 1999; 180: 593-600
      4. Ali HAE fttah. Effects of Prenatal Perineal Massage and Kegel Exercise on the Episiotomy Rate. IOSR J Nurs Heal Sci [Internet]. 2015;4(4):2320–1940. Available from: www.iosrjournals.org.

        • Dönmez S.
        • Kavlak O.
        Effects of prenatal perineal massage and kegel exercises on the integrity of postnatal perine.
        Health (Irvine Calif). 2015; 07: 495-505
        • Shipman M.K.
        • Boniface D.R.
        • Tefft M.E.
        • McCloghry F.
        Antenatal perineal massage and subsequent perineal outcomes: a randomised controlled trial.
        BJOG An Int J Obstet Gynaecol. 1997; 104: 787-791
        • Elsebeiy F.I.
        Comparison of the effects of prenatal perineal massage versus kegel exercise on labor outcome.
        IOSR J Nurs Heal Sci. 2018; 7 (Available from:): 43-53
        • Ugwu E.O.
        • Iferikigwe E.S.
        • Obi S.N.
        • Eleje G.U.
        • Ozumba B.C.
        Effectiveness of antenatal perineal massage in reducing perineal trauma and post-partum morbidities: A randomized controlled trial.
        J Obstet Gynaecol Res. 2018; 44: 1252-1258
        • Shahoei R.
        • Hashemi-Nasab L.
        • Gaderkhani G.
        • Zaheri F.
        • Shahoei F.
        The impact of perineal massage during pregnancy on perineal laceration during childbirth and postpartum: A randomized clinical trial study.
        Chronic Dis J [Internet]. 2018; 4 (Available from:): 13-20
        • Atan I.K.
        • Shek K.L.
        • Langer S.
        • Rojas R.G.
        • Caudwell-Hall J.
        • Daly J.O.
        • et al.
        Does the Epi-No® birth trainer prevent vaginal birth-related pelvic floor trauma? A multicentre prospective randomised controlled trial.
        BJOG An Int J Obstet Gynaecol. 2016; 123: 995-1003
        • Shek K.L.
        • Chantarasorn V.
        • Langer S.
        • Phipps H.
        • Dietz H.P.
        Does the Epi-No® Birth Trainer reduce levator trauma? A randomised controlled trial.
        Int Urogynecol J. 2011; 22: 1521-1528
        • Ruckhäberle E.
        • Jundt K.
        • Bäuerle M.
        • Brisch K.H.
        • Ulm K.
        • Dannecker C.
        • et al.
        Prospective randomized multicentre trial with the birth trainer EPI-NO for the prevention of perineal trauma.
        Obstetr Gynecol Surv. 2010; 65: 71-72
        • Geranmayeh M.
        • Habibabadi Z.R.
        • Fallahkish B.
        • Farahani M.A.
        • Khakbazan Z.
        • Mehran A.
        Reducing perineal trauma through perineal massage with vaseline in second stage of labor.
        Arch Gynecol Obstet. 2012; 285: 77-81
        • Albers L.L.
        • Sedler K.D.
        • Bedrick E.J.
        • Teaf D.
        • Peralta P.
        Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: a randomized trial.
        J Midwifery Women’s Heal. 2005; 50: 365-372
        • Shahoei R.
        • Zaheri F.
        • Hashemi Nasab L.
        • Ranaei F.
        The effect of perineal massage during the second stage of birth on nulliparous women perineal: a randomization clinical trial.
        Electron Physician. 2017; 9: 5588-5595
        • Romina S.
        • Ramezani F.
        • Falah N.
        • Mafi M.
        • Ranjkesh F.
        Effect of perineal massage with ostrich oil on the episiotomy and lacerations in nulliparous women: A randomized controlled clinical trial.
        Iran J Nurs Midwifery Res. 2020; 25: 134-138
        • Stamp G.
        • Kruzins G.
        • Crowther C.
        Perineal massage in labour and prevention of perineal trauma: Randomised controlled trial.
        Br Med J. 2001; 322: 1277-1280
        • Karaçam Z.
        • Ekmen H.
        • Çalişir H.
        The Use of Perineal Massage in the Second Stage of Labor and Follow-Up of Postpartum Perineal Outcomes.
        Health Care Women Int. 2012; 33: 697-718
        • Demirel G.
        • Golbasi Z.
        Effect of perineal massage on the rate of episiotomy and perineal tearing.
        Int J Gynecol Obstet [Internet]. 2015; 131 (Available from:): 183-186https://doi.org/10.1016/j.ijgo.2015.04.048
        • Gayiti M.R.Y.
        • Li X.Y.
        • Zulifeiya A.K.
        • Huan Y.
        • Zhao T.N.
        Comparison of the effects of water and traditional delivery on birthing women and newborns.
        Eur Rev Med Pharmacol Sci. 2015; 19: 1554-1558
        • Shibayama T.
        • Eto H.
        Reducing perineal trauma by application of warm packs in the second stage of labor: Histrical controlled trial.
        J Japan Acad Midwifery. 2015; 29: 293-302
        • Terré-Rull C.
        • Beneit-Montesinos J.V.
        • Gol-Gómez R.
        • Garriga-Comas N.
        • Ferrer-Comalat A.
        • Salgado-Poveda I.
        Aplicación de termoterapia en el periné durante el parto para reducir las lesiones que precisan sutura posparto.
        Enferm Clin [Internet]. 2014; 24 (Available from:): 241-247https://doi.org/10.1016/j.enfcli.2014.03.007
        • Dahlen H.G.
        • Homer C.S.E.
        • Cooke M.
        • Upton A.M.
        • Nunn R.
        • Brodrick B.
        Perineal outcomes and maternal comfort related to the application of perineal warm packs in the second stage of labor: A randomized controlled trial.
        Birth. 2007; 34: 282-290
        • Ohlsson G.
        • Buchhave P.
        • Leandersson U.
        • Nordström L.
        • Rydhström H.
        • Sjölin I.
        Warm tub bathing during labor: Maternal and neonatal effects.
        Acta Obstet Gynecol Scand. 2001; 80: 311-314
        • Ahmadi Z.
        • Torkzahrani S.
        • Roosta F.
        • Shakeri N.
        • Mhmoodi Z.
        Effect of breathing technique of blowing on the extent of damage to the perineum at the moment of delivery: a randomized clinical trial.
        Iran J Nurs Midwifery Res. 2017; 22: 62-66
        • Rezaei R.
        • Sussan S.
        • Huak C.Y.
        • Sharif N.H.
        A comparison of the “hands-off” and “hands-on” methods to reduce perineal lacerations: a randomised clinical trial.
        J Obstet Gynecol India. 2014; 64: 425-429
        • Foroughipour A.
        • Firuzeh F.
        • Ghahiri A.
        • Norbakhsh V.
        • Heidari T.
        The effect of perineal control with hands-on and hand-poised methods on perineal trauma and delivery outcome.
        J Res Med Sci. 2011; 16: 1040-1046
        • de Costa A.
        • SC da
        • Riesco. M.L.G.
        A comparison of “hands off” versus “hands on” techniques for decreasing perineal cacerations during birth.
        J Midwifery Women’s Heal. 2006; 51: 106-111
        • Koyucu R.G.
        • Demirci N.
        Effects of pushing techniques during the second stage of labor: A randomized controlled trial.
        Taiwan J Obstet Gynecol. 2017; 56: 606-612
        • Yildirim G.
        • Beji N.K.
        Effects of pushing techniques in birth on mother and fetus: a randomized study.
        Birth. 2008; 35: 25-30
        • Chatfield W.R.
        • Moir D.D.
        The effect of Hyaluronidase on the Perineum - a Controlled Trial of 200 Primigravid Patients in Labour.
        J Obs Gynaecol Br Commonw. 1966; 73: 670-671
        • Schaub A.F.
        • Litschgi M.
        • Hoesli I.
        • Holzgreve W.
        • Bleul U.
        • Geissbühler V.
        Obstetric gel shortens second stage of labor and prevents perineal trauma in nulliparous women: a randomized controlled trial on labor facilitation.
        J Perinat Med. 2008; 36: 129-135
        • Scarabotto L.B.
        • Riesco M.L.G.
        Use of Hyaluronidase to Prevent Perineal Trauma During Spontaneous Delivery: A Pilot Study.
        J Midwifery Women’s Heal. 2008; 53: 353-361
        • Araújo N.M.
        • de Oliveira S.M.J.V.
        The use of liquid petroleum jelly in the prevention of perineal lacerations during birth.
        Rev Lat Am Enfermagem. 2008; 16: 375-381
        • Nasir A.
        • Korejo R.
        • Noorani K.J.
        Child birth in squatting position.
        J Pak Med Assoc. 2007; 57: 19-22
        • Gupta J.K.
        • Brayshaw E.M.
        • Lilford R.J.
        An experiment of squatting birth.
        Eur J Obstet Gynecol Reprod Biol. 1989 Mar 1; 30: 217-220
        • Moraloglu O.
        • Kansu-Celik H.
        • Tasci Y.
        • Karakaya B.K.
        • Yilmaz Y.
        • Cakir E.
        • et al.
        The influence of different maternal pushing positions on birth outcomes at the second stage of labor in nulliparous women.
        J Matern Neonatal Med. 2017; 30 (Available from:): 245-249
        • Brément S.
        • Mossan S.
        • Belery A.
        • Racinet C.
        Accouchement en décubitus latéral. Essai clinique randomisé comparant les positions maternelles en décubitus latéral et en décubitus dorsal lors de la deuxième phase du travail.
        Gynecol Obstet Fertil. 2007; 35: 637-644
        • Stewart P.
        • Hillan E.
        • Calder A.
        A randomised trial to evaluate the use of a birth chair for delivery.
        Lancet [Internet]. 1983; 321 (Available from): 1296-1298
        • Bomfim-Hyppólito S.
        Influence of the position of the mother at delivery over some maternal and neonatal outcomes.
        in: International Journal of Gynecology and Obstetrics [Internet]. John Wiley and Sons Ltd, 1998: S67-S73 (Available from:)
        • Allahbadia G.N.
        • Vaidya P.R.
        Why Deliver in the Supine Position?.
        Aust New Zeal J Obstet Gynaecol. 1992; 32: 104-106
        • Gardosi J.
        • Hutson N.
        • B-Lynch
        • Randomised C.
        Controlled Trial of Squatting in the Second Stage of Labour.
        Lancet. 1989; 334: 74-77
        • Lin Y.C.
        • Gau M.L.
        • Kao G.H.
        • Lee H.C.
        Efficacy of an ergonomic ankle support aid for squatting position in improving pushing skills and birth outcomes during the second stage of labor: a randomized controlled trial.
        J Nurs Res [Internet]. 2018; 26 (Available from:): 376-384
        • Zhang H.
        • Huang S.
        • Guo X.
        • Zhao N.
        • Lu Y.
        • Chen M.
        • et al.
        A randomised controlled trial in comparing maternal and neonatal outcomes between hands-and-knees delivery position and supine position in China.
        Midwifery. 2017; 2015: 117-124https://doi.org/10.1016/j.midw.2017.03.022
        • Crowley P.
        • Elbourne D.
        • Ashurst H.
        • Garcia J.
        • Murphy D.
        • Duignan N.
        Delivery in an obstetric birth chair: a randomized controlled trial.
        Br J Obstet Gynaecol. 1991; 98: 667-674
        • Thies-Lagergren L.
        • Kvist L.J.
        • 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 Pregn Childbirth. 2011; 11: 1-9
        • de Jong P.R.
        • Johanson R.B.
        • Baxen P.
        • Adrians V.D.
        • Van der Westhuisen S.
        • Jones P.W.
        Randomised trial comparing the upright and supine positions for the second stage of labour.
        Br J Obstet Gynaecol. 1997; 104: 567-571
        • Gardosi J.
        • Sylvester S.
        • Lynch C.B.
        Alternative positions in the second stage of labour: a randomized controlled trial.
        Br J Obstet Gynaecol. 1989; 96: 1290-1296
        • Hillebrenner J.
        • Wagenpfeil S.
        • Schuchardt R.
        • Schelling M.
        • Schneider K.T.M.
        Erste klinische erfahrungen bei erstgebärenden mit einem neuartigen geburtstrainer Epi-no®.
        Z Geburtshilfe Neonatol. 2001; 205: 12-19
      5. Aceituno L, Segura MH, Ruiz E, Sánchez-Barroso MT, Acosta V, Delgado L, et al. Estrategia para disminuir la incidencia de patología grave del perine durante el parto. Clin Invest Ginecol Obstet [Internet]. 2011 Jan 1 [cited 2021 Oct 8];38(1):8–14. Available from: https://www.elsevier.es/es-revista-clinica-e-investigacion-ginecologia-obstetricia-7-articulo-estrategia-disminuir-incidencia-patologia-grave-S0210573X09002330.

        • Dieb A.S.
        • Shoab A.Y.
        • Nabil H.
        • Gabr A.
        • Abdallah A.A.
        • Shaban M.M.
        • et al.
        Perineal massage and training reduce perineal trauma in pregnant women older than 35 years: a randomized controlled trial.
        Int Urogynecol J. 2020; 31 (Available from:): 613-619
      6. Leon-Larios F, Corrales-Gutierrez I, Casado-Mejía R, Suarez-Serrano C. Influence of a pelvic floor training programme to prevent perineal trauma: A quasi-randomised controlled trial. Midwifery [Internet]. 2017 Jul 1 [cited 2021 Oct 8];50:72–7. Available from: https://pubmed.ncbi.nlm.nih.gov/28391147/.