PERINEAL CARE: LITERATURE REVIEW OF CARE MEASURES DURING LABOUR TO REDUCE THE RISK OF PERINEAL TRAUMA

The following was a literature review of care measures during labour to reduce the risk of perineal trauma, which was written in 2007 for my final piece as a student midwife. There were five research studies that were critiqued and these were:

1. Albers, L.L., Sedler, K.D., Bedrick, E.J., Teaf, D. and Peralta, P. (2006) Midwifery care measures in the second stage of labour and reduction of genital tract trauma at birth: a randomised trial. MIDIRS Midwifery Digest 16:2 p174-180.

2. Hastings-Tolsma, M., Vincent, D., Emeis, C., and Francisco, T. (2007) Getting through birth in one piece: protecting the perineum. MIDIRS Midwifery Digest 17:3 p383-388.

3. Eogan, M., Daly, L. and O’Herlihy, C (2006) The effect of regular antenatal perineal massage on postnatal pain and anal sphincter injury: A prospective observational study. Journal of Maternal, Foetal and Neonatal Medicine 19:4 p225-229

4. De Souza Caroci De Costa, A., and Gonzales Riesco, M.L. (2006) A comparison of hands-off versus hands-on techniques for decreasing perineal lacerations during birth. Journal of Midwifery and Women’s Health 51:2 p106-111

5. Gottvall, K., Allebeck, P. and Ekeus, C. (2007) Risk factors for anal sphincter tears: the importance of maternal position at birth. British Journal of Obstetrics and Gynaecology 114 p1266-1272.

Abstract

In the United Kingdom approximately 85% of the 750,000 women given birth each year suffer a perineal tear of some description. Perineal trauma can lead to short-term problems such as pain and bleeding, but it is the long-term problems such as dyspareunia and incontinence, affecting around 20% of women, which can impact a woman’s relationships, her ability to bond with her baby and her self-image.

It is important therefore that we as midwives examine the clinical measures which can help to prevent such trauma. While research is vital in reducing episiotomy rates, there is still a need for good quality randomized controlled trials to provide recommendations on practice.

Various risk factors have been identified relating to the issue of perineal trauma but specific care measures such as maternal positioning, directed pushing, perineal massage, and hands-off vs hands-on techniques have limited research to either support or refute their use in practice.

This analysis therefore aims to examine these issues further in an attempt to establish how we as midwives can reduce the incidence of perineal trauma and to identify the need for further research and change in policies.

Introduction

Perineal management is a vast issue within midwifery care and Wickham (2003) pointed out that such a term suggests that midwives need to manage a woman’s body rather than the woman deciding for herself how she would like to be cared for. Traditionally manual support during labour was frowned upon unless complications arose but since Louis XIV asked his mistress to deliver on her back so that he could observe, doctors have encouraged women to birth in this position as it provides a better view of the perineum. This move has drastically changed birthing outcomes and perceptions of women for years to come and paved the way for endless interventions (Wickham, 2003).

Perineal trauma rates have increased from 11% to over 65% of vaginal deliveries in the last 30 years (Albers et al, 2006; Hastings-Tolsma et al, 2007), with anal sphincter injury occurring in 3% of these deliveries, despite continuous improvements in midwifery practice (Eogan et al, 2006). While women wanting caesareans to maintain an intact perineum (Premkumar, 2005) have been helpful in reducing these statistics, there are no recommended evidence-based measures other than Sleep et als (1984) fundamental research, demonstrating the need for lowering the rates of episiotomies, which are thought to contribute to anal sphincter injuries (Albers et al, 2006; Hastings-Tolsma, 2007; Robertson, 2002). This research caused midwives to focus on care measures which may reduce perineal tears, thus reducing morbidity rates. Despite these measures, anal sphincter injury rates have increased from 1.7% to 6% in the last 20 years (Gottvall et al, 2007; Di Piazza et al, 2006), so one must question what is contributing to such a rise.

Conflicting practice brought about the HOOP trial (1998), which aimed to promote evidence-based care and question the common assumption that traditional hands-off care was inferior, causing midwives to realise that they were unsure of the effects of the care that they were giving (Bosomworth and Saltikov, 2006; McCandlish, 1999; McCandlish et al, 2003; Robertson, 2002; Wickham, 2003). Also disputed, is the question of directed versus spontaneous pushing during the second stage of labour. Research has associated neonatal morbidity with prolonged second stage (Bosomworth and Saltikov, 2006), causing professionals to advise directed pushing after early studies showed that this measure could shorten the length of the second stage, possibly at a cost to the perineum. Yet midwives continue to practice directed pushing because it is what they were taught rather than making an evidence-based decision (Robertson, 2002).

Perhaps professionals should consider possible measures that can improve perineal trauma rates, giving them a more prominent place in practice, such as perineal massage, shown to be practiced by 22% of women in a National Childbirth Trust survey (1993) (Gomme et al, 2003). Local trust policies are required to be updated regularly in order to make evidence-based recommendations on perineal management, and auditing ensures compliance with these policies so that trust trauma rates may be compared to national maternity statistics, introducing recommendations on categorisation of tears, which in turn ensures more appropriate management. RCOG guidelines emphasize that obstetricians as well as midwives need appropriate training in maintaining standards of care outlined in these policies. Both midwives and obstetricians encourage lithotomy positions, providing more access for intervention in today’s high-risk culture, and hence perineal care is a multi-professional issue (Gottvall et al, 2007).

When conducting a literature review one must establish the necessity for a study and its implications in practice. In today’s high-risk culture, intervention is the norm, so research is needed to prove that women can birth and heal without this intervention. Through reflection, professionals can use evidence to oppose this culture (Wickham, 2003). Severe perineal trauma can increase morbidity rates in women, with problems of bleeding and pain postpartum, and longer-term problems such as faecal incontinence, depression, and sexual dysfunction (Albers and Borders, 2007; Gottvall et al, 2007; Premkumar, 2005; Robertson, 2002), which can impact a mother’s ability to function, in turn affecting the newborn who is dependent on her, and the family unit as a whole. Reduced postnatal admissions, needs for medications, and suturing in those with intact perineums, and the financial implications of this, combined with maternal functioning, make the need for evidence-based perineal management a priority for professionals (Albers and Borders, 2007; Jackson, 2000; Robertson, 2002; Thakar and Sultan, 2005). It should be prioritised as some techniques, such as Valsalva pushing, have been suggested to cause reduced perfusion to the uterus, hypoxia in the foetus, and maternal fatigue, which increases the risk of instrumental delivery and consequently an increased risk of perineal trauma. Professionals need research to make informed decisions in maternity practice while addressing physical, social, and psychological maternal well-being (McCandlish et al, 2003; Robertson,2002).

Research will always have implications for practice, highlighting the need to question the midwife’s role. Wickham (2003), suggests that midwives’ practice is defined by what they are taught, and use of the term perineal care makes them feel compelled to manually assist, rather than trusting the ‘guiding’ mechanism of the labia and concentrating on factors such as positioning and building a relationship with the woman. Midwives must recognise interventions which could alter the risk of perineal trauma, and those which need further research in order to provide evidence-based care. Knowledge of risk factors in perineal trauma are also essential, for example, primiparity (Hastings- Tolsma et al, 2007; Gottvall et al, 2007). When research suggests, for example, using a ‘hands off’ approach, which tends to differ from midwifery training, midwives should question whether their management is physiologically necessary or simply a ritual (Wickham, 2003). Since perineal trauma is a complication in primiparous women, midwives should be aware of measures which reduce their risk and reduce the chance of recurring tears in subsequent deliveries (Albers et al, 2006), consequently reducing the need for postnatal treatments and appointments, and hopefully improving women’s quality of life. Since a woman’s instinct is to push involuntarily if left alone, maybe midwives should abandon the directed pushing and allow her to follow the signs her body gives her (Bosomworth and Saltikov, 2006). Obviously, in cases with epidurals where sensation is reduced, or where complications arise, directed pushing has been recommended for reducing the length of the stage, and therefore reducing risks to the foetus. In avoiding adverse outcomes, midwives can then promote vaginal delivery more easily (Bosomworth and Saltikov, 2006; Premkumar, 2005). It could be said that perineal trauma is a marker for patient safety and quality of care, in which more research is needed to provide evidence-based care (Brubaker et al, 2007), and midwives must ensure that they respect the trust that women place in them, to keep them and their babies safe (McCandlish et al, 1999).

The focus of this review will be on measures taken during second stage of labour, particularly hands off versus hands on management, birthing position, directed versus non directed pushing, perineal massage and delivery of foetal head during versus between contractions, which tend to be more due to cultural patterns rather than evidence-based practice. The HOOP trial (1998), which mad midwives question the issue of hands off versus hands on management, provided no significant evidence that one method was better than the other, but there were flaws to this study which could make one question its reliability (Brailey, 2003; McCandlish, 1998). The hands poised group would have a lower compliance rate because complications such as dystocia, would mean that hands on management became necessary. The only statistically significant result was reduced pain in the hands on group, but assessment of such complex issues may be inaccurate (Robertson, 2002). Also, the evidence was not applicable to individual women. Foetal malposition may increase the risk of tearing alongside other factors such as primiparity, maternal age etc (Bruce, 2003), but the common factors in research seem to be instrumental deliveries, episiotomy, foetal macrosomia, prolonged second stage and epidural use (Bruce, 2003; Edwards et al, 2006; Fitzgerald et al, 2007). Despite this knowledge, Albers et al (2006) identify gaps in the literature, in the lack of significant evidence recommending how to reduce perineal injury following spontaneous vaginal delivery, so techniques used in perineal protection should be used cautiously until clear evidence is provided (Caroci da Costa and Riescco, 2006). There is also little evidence to examine anal sphincter injury rates (Eogan et al, 2006).

The specific aim of this review is to highlight care measures during labour recommended to reduce perineal trauma and to determine which areas require further research, thus substantiating the value of midwifery interventions. The greatest challenge is to determine how useful results of research are to practice, so Rees’ (2003) framework for critical analysis of research has been used to gain a clearer picture of how reliable the five trials are.

Search Methods

Literature searches allow an overall picture of a topic to be developed prior to critical analysis of the research, allowing professionals to develop skills and answer questions relating to their practice (Burns and Grove, 2003).

A plan was made to search for relevant literature in databases using keywords. The main topic area is perineal care, but with many areas surrounding this broad topic, it was necessary to refine the search. A spider diagram was used to plan the search (Crookes and Davis, 2004).

Keywords such as ‘genital tract trauma’ and ‘perineal massage’ produced more relevant articles, which on closer inspection identified possible factors associated with perineal care, such as maternal position and Valsalva pushing. These keywords were entered into three databases to locate references: CINAHL, MEDLINE and MIDIRS. CINAHL and MEDLINE are two of the largest databases, but the index does not always recognise terms used for the subject, so may provide less references, hence the importance of refining the search using other related words (Crookes and Davis,2004). An article may be located under genital tract trauma, for example, so searching under perineal injury may not return the piece of research. The MIDIRS database allows for keyword searches, in addition to broad searches of a topic, before exploring subheadings such as maternal position or perineal massage (Rees, 2003).

Not all databases hold particular journals, so keyword searches were performed on journal websites, for example, British Journal of Midwifery, Practising Midwife and Birth, and their indexes were searched for anything relating to the chosen topic. Comparison of policies and guidelines to relevant research was important to see if practice was evidence-based. The searches included research from 1995 to 2007, on the basis of changing attitudes towards perineal care, and the HOOP trial, shortly after this time, which questioned hands on practice. Guidelines from the Royal College of Midwives (RCM), NICE and the Royal College of Obstetricians and Gynaecologists (RCOG) were also searched.

Research produced amounted to over 600 papers, although the abstracts showed many to be out of date, irrelevant or involving high risk participants rather than those undergoing normal vaginal delivery. These papers were excluded, and full text articles were sought for 14 of the studies to examine their relevance, credibility, design and sample, resulting in five being chosen for further analysis. Systematic reviews were not chosen, because while their aim is to suggest best practice, and they were usually randomised controlled trials which tend to be more reliable and less biased, those undertaking the review may not choose to use research if it adversely affects the result of the review (Rees, 2003), hence it was felt they could be misleading. The chosen papers cover a variety of aspects of the original topic and are carried out by different authors with contrasting views, who used a variety of study methods and settings, which is hoped to give an overall less biased view of perineal care. Qualitative research, was used for its broad aim, which would provide an overall view of factors contributing to perineal trauma, while quantitative research examined specific factors relating to perineal management.

This review aims to determine what is known about the topic, and through further analysis, highlight inconsistencies in practice and question the policies, thus improving practice and uncovering the need for further research (Rees, 2003).

Introduction to Critical Analysis

The five selected research papers will be critiqued using Rees’ framework (2003). Critical analysis involves examination of the quality of the research, by considering the credibility and validity of the work. The author must consider how the research can be used in practice and whether it will influence change in policies. Sources cited in the research should be written within five years prior to the study, but sometimes landmark studies, for example, the HOOP trial (1998), may be mentioned, which although they may be older, are still significant in their influence over clinical practice (Burns and Grove, 2003).

The most important questions are whether the research is reliable and valid, that is, that the data is accurate and not influenced by staff bias. Possibly peers may have double checked findings, or participants asked to do a ‘members check’ to confirm accounts are accurate. Also generalisability should be considered and whether the findings can be applied to other situations, as this could influence the importance of the research to practice (Rees, 2003).

Knowledge gained from asking such questions can be used to improve quality of care. Rees (2003) concentrates on three main questions, which will be the focus of this analysis: what does the research say? Can it be trusted? and how does it contribute to practice? These questions will be answered using Rees’ framework and looking at the purpose and method of the research, the findings and conclusions drawn, measures taken to reduce bias, and what evidence it provides to challenge current practice (Rees, 2003).

Research Study No.1

Albers, L.L, Sedler, K.D., Bedrick, E.J., Teaf, D. and Peralta, P. (2006) Midwifery Care Measures in the second Stage of Labour and reduction of Genital Tract Trauma at birth: a randomised trial. MIDIRS Midwifery Digest 16.2 p174-180.

Albers et al (2006) recognise that trauma is common, with associated long and short term problems, and since the only clear evidence concerns reduction of episiotomies (Sleep et al, 1984), they identify the need to know which care measures prevent trauma, in order to provide evidence based care, reducing the need for drugs and suturing postpartum. This randomised trial used correlation to associate use of compresses or massage with hands off technique. It was approved by two ethical committees and consent was informed and rechecked in labour. Checks were performed after a year to ensure no treatments were harmful, although one in eight women being massaged asked the midwife to stop, the reason being unclear.

Despite cultural differences between America and England (Wickham, 2007), this appears to be a well structured study, demonstrating reliability and validity. The design was appropriate to the aim of the research, but it was essential that any differences found were due to the treatment and not differences between the women. Randomisation produced three groups from 1211 women, with no significant difference in demographic and clinical variables.

It was not possible to conceal the management method from the midwife, potentially altering the midwives’ perception of any trauma, and while the possibility of bias makes the reliability of the study questionable, measures were taken to overcome such bias. Since each midwife only performed up to 13% of deliveries it was unlikely to affect the data, and second midwives observed 25% of deliveries, and in 84% of these there was agreement between the two. There were no changes in policies or staffing, and checks performed showed an error rate of less than 1 in 1000. These measures would standardise practice between midwives, and the 95% confidence levels for variables suggest that the results are unlikely to be due to chance. The study is not generalisable, however, as the majority of participants were Hispanic or white, so possibly are not representative of a larger group in some areas.

Major traumas were distributed through each group, risk factors being multiparity and high birth weight, and ethnicity and education also somewhat significant. While Bruce (2003) discussed the correlation between episiotomy and 3^rd and 4^th degree tears, no episiotomy in this study extended to such laceration, but the experience of the midwives in this study in maintaining episiotomy rates under 1%, means that this result is not generalisable to more medicalised areas (Wickham, 2007).

Another limitation is that birthing the baby’s head between contractions in a sitting position contributed to an intact perineum, but with 80% of participants adopting such a position, the results may be skewed, and correlation with other positions is not possible due to lack of data. Contractions can advance the baby faster than the perineum can stretch (Eason, Labrecque, Wells and Feldman, 2000), and this could explain why midwives like to deliver the head with contraction, rather than pushing between contractions, putting more pressure on the perineum. Practice should be reviewed in more depth regarding infant delivery techniques and maternal positioning, to identify special efforts which could minimise trauma.

Research Study No.2

Hastings-Tolsma, M., Vincent, D., Emeis, c. and Francisco, T. (2007) Getting Through Birth in One Piece. Protecting the Perineum. MIDIRS Midwifery Digest 17.3

This study was conducted due to a perineal trauma rate of over 65% in vaginal deliveries, and little having changed in perineal management other than decreased episiotomies. The aim was to identify risk factors and develop strategies to promote perineal integrity. Approval was sought by the ethics committee.

The study was a retrospective, descriptive analysis, which is positive in that the data already exists so can not be influenced by researcher bias, but the quality of the data can not be controlled by the researcher (Rees, 2003). Given that variables included both characteristics of the women and clinical care measures, it is possible that the information was not detailed enough to provide reliable data. There was no pilot study and reliability was not addressed by the author. While the NMCD tool, used to collect data, was seen as a valid measure with 75 interventions and outcomes, it may be insensitive to specific aspects of quality in midwifery care. Other limitations include non-randomisation of subjects, lack of data accuracy checks and data on outcomes of those under physician care, some data obtained from the late 1990s could be insignificant due to changes in practice brought about by the HOOP trial (1998). Also data was collected from 4 clinics and there was no mention of standardisation of practice across these areas.

There were no clear exclusions and the sample included 510 low risk women with uncomplicated pregnancies, although various health problems were present, The majority were unmarried, multiparous women, average age of 23.9 years, just under half of whom were Hispanic, and this sample may not be representative of a larger group, hence results are not generalisable. Tests of significance were performed to establish whether the results may be due to chance, and the results showed this to be unlikely.

Married, nulliparous women over 30 years old were more likely to tear, which can not be explained by this group being the majority of the sample. Factors such as high birthweight, foetal bradycardia and prolonged second stage were not recognised by Albers et al (2006). However, in nulliparous women in a lateral position, with warm compresses and manual support techniques, trauma was less likely. Lacerations were more likely with prolonged second stage and lithotomy position, so comparing to Albers et al (2006) which favoured a sitting position, it would be interesting to compare lateral and sitting positions. Also the higher incidence of trauma with lithotomy positions could be explained by the fact that instrumental deliveries, which tend to occur in this position, were not excluded.

These issues require further research in order to provide appropriate evidence based management. More awareness of maternal positioning and manual support techniques are needed in order to offer women an informed choice.

Research Study No.3

Eogan, M., Daly, L. and O’ Herlihy, C. (2006) The Effect of regular Antenatal Perineal Massage on Postnatal Pain and Anal Sphincter Injury: a prospective observational study. Journal of Maternal-foetal and Neonatal Medicine 19 (4) p225-229.

While this study involved antenatal massage, this was continued into labour, and the article regardless of the practice, and while Eogan at al discuss studies which show the effectiveness of massage in preventing tears, none of these examine anal sphincter injury rates.

This prospective, observational study, was a comparative study which correlated massage with postpartum anal sphincter structure. A massage group was compared to a control group, and clinical variables taken into account. The comparative design was appropriate to the aim, and the advantage of a prospective study, is that the data is collected as the study progresses, therefore, can be controlled by the researcher and may be more accurate.

While the observational design should ensure compliance because the participants chose which group they were in, the data was open to misinterpretation by midwives. Such a study has methodological limitations, and none of the women in the massage group actually complied fully, despite having chosen that group so the reliability of the study could be questioned. The trial was intended to be randomised, but due to difficulties in recruiting women on this basis, because some women refused to be massaged, it became a pilot study for future randomised trials.

The trial appeared ethically sound, having ethics committee approval and written consent. The women chose which group they were in so no harm was inflicted on them.

The sample showed some bias with all women being nulliparous and the majority n the massage group being over 30 years old. This meant that the results were not typical of the larger group and are not generalisable. There was also uneven allocation to the groups and the indifference between the groups can be explained by the non-compliance in the massage group, and a low incidence of anal sphincter injury.

Tests of significance performed to establish the likelihood of results being due to chance, showed results on postnatal pain to be statistically significant, but results for perineal trauma were quite possibly due to chance. Despite the unreliability of this study, it would be interesting to consider why there was non compliance in the massage group, since Albers et al’s study (2006), also showed that a significant number of women asked midwives to stop the massage.

Spontaneous labour was more significant in the massage group and overall, these women had an intact perineum, but no differences were seen regarding clinical variables such as epidural use or duration of labour, which is interesting, since both Albers et al (2006), and Hastings-Tolsma (2007) discussed prolonged second stage as a risk factor.

While this study is unreliable, and the majority of the results are insignificant, perineal massage may educate women about their bodies, helping them to feel more in control of labour and to overcome pain postnatally, hence the results of lower rates of pain postnatally in the massage group. In the massage group, women over 30 years old showed a lower rate of anal sphincter injury, and while the results are not statistically significant, for the reasons given, massage could have a potential role in maintaining continence in such women. A larger randomised study, however, is needed to examine these issues.

Research Study No.4

Caroci da Costa, A. de Souza and Riesco, M.L. Gonzalez (2006) A Comparison of hands off versus hands on techniques for decreasing perineal lacerations during birth. Journal of Midwifery and Women’s Health 51 (2) p106-111.

Despite studies such as the HOOP trial (1998), there is still insufficient evidence regarding protective perineal management to provide recommendations. Midwives need to provide evidence-based care because such techniques may adversely affect the perineum and neonatal outcome.

The randomised controlled trial aimed to evaluate the frequency, location and degree of perineal traumas and their association with each support technique, by correlation. A pilot study was conducted, during which time data forms were validated and women’s acceptance of techniques noted. Ethics committee approval was given and written consent obtained, with the women assured the right to withdraw at any time.

While randomised trials are generally more reliable, due to the lack of bias, the midwives were initially resistant to hands off technique, due to their education and experience of hands on, potentially causing some bias and the authors do not address the issue of reliability. No clear conclusions were drawn from the evidence and possibly a limitation of the study was that it didn’t account for enough clinical and demographic variables.

The sample of 70 women was divided equally between the two groups, and were chosen by an electronically produced randomised table, thus reducing bias. They were all nulliparous women aged 15 to 35 years, with straightforward histories. Exclusions were made, for example, prolonged labour, perineal massage, lithotomy position and other clinical factors. This may be positive, since other trials (Albers et al, 2006; Hastings-Tolsma et al, 2007; Eogan et al, 2006) have shown that these factors can influence perineal trauma rates. All women delivered in a left lateral position, shown by Hastings-Tolsma et al (2007), to be beneficial in reducing incidence of perineal injury. Perhaps the exclusion of other clinical factors would make the evidence clearer. However, this sample is not representative of the larger group and the results are not generalisable. Tests of significance established that perineal outcomes were quite possibly due to chance.

No significant differences in perineal trauma or neonatal outcome were found between the two groups, and consequently no evidence to either support or refute one technique over the other. The favourable environment of spontaneous pushing, very experienced midwives and unaugmented labours in the lateral position probably contributed to this result.

More studies are needed to examine the effects of delivery techniques and position on the severity of perineal trauma, as well as other factors such as maternal expulsive efforts and use of oxytocin. Until clear evidence on these issues is sought, women should be informed about these techniques so that they may choose for themselves.

Research Study No.5

Gottvall, K., Allebeck, P. and Ekeus, C. (2007) Risk factors for anal sphincter tears: the importance of maternal position at birth. British Journal of Obstetrics and Gynaecology 114 p1266-1272

Anal sphincter tears cause short and long term problems, impacting on quality of life, and current literature is unable to explain the increased incidence, hence the need for increased awareness of factors such as birthing positions, possibly improving women’s quality of life.

This observational cohort study uses a grounded theory approach, which identifies theories from the data to associate anal sphincter tears with maternal position (Rees, 2003). Observational studies can be methodologically limited and open to misinterpretation, but the advantage of a grounded theory is that the data is compared to previous data to ensure consistency, and when used with observation, provides a flexible research design.

The study lasted four years in a Stockholm hospital. 12,782 of the original 19,157 deliveries were included. Whereas previous studies were relatively small and analysed upright or horizontal positions, this larger study was able to examine specific birthing positions, and excluded multiple births, instrumental and caesarean deliveries which are associated with lithotomy position. Where complications arose, for example, breech, obstetricians were involved and women were not automatically excluded, so the sample was representative of the larger group, but one must be aware that there may be cultural differences between Swedish and English practice.

Although numerous factors were examined, there is always a risk of bias in observational studies, due to misinterpreting by midwives. Other limitations included exclusion of instrumental deliveries, which are associated with anal sphincter tears, thus reducing the occurrence of such tears to below the national average, giving a misleading result. Incidence of episiotomies was also low, so no statistically significant conclusion could be drawn regarding this factor. Data on perineal guarding, which has been discussed (HOOP trial, 1998; Albers et al, 2006; Hastings- Tolsma et al, 2007; Caroci da Costa and Riesco, 2006), and the length of time positions were adopted needs to be more detailed in order to understand how these factors contribute to perineal trauma rates.

While there was no mention of informed consent, approval by the ethics committee was given and no discomfort was caused to participants as they decided on the position they wanted to adopt.

The author has correlated variables together to compare the risk of anal sphincter tears in a certain position, with another factor, for example, primiparity. Results are explained well, and reasoning given for high or low figures, for example, exclusion of instrumental deliveries causing a low number of anal sphincter tears. These explanations combined with a 95% degree of certainty which was established from tests conducted, would suggest that the data is statistically significant and unlikely to have happened by chance.

The author met his objective, finding lithotomy and squatting positions to increase the risk of anal sphincter tears, after control for other factors, such as prolonged second stage and primiparity, as corroborated by Hastings-Tolsma et al (2007). Evidence remains inconclusive regarding positions in relation to perineal trauma and larger randomised studies are need to focus on anal sphincter tears in particular, to minimise occurrence and enhance women’s quality of life.

Discussion

The contributing factors to perineal trauma have been demonstrated by the five articles, but there are contradictions as well as comparisons between them. The findings of Albers et al (2006) and Hastings-Tolsma (2007) are consistent in that nulliparous women were more likely to tear more severely than multiparous women. The main discrepancy was with Albers et al’s (2006) small but significant risk of ethnicity and education, which Hastings-Tolsma et al (2007) did not find to be relevant, explained by the fact that Albers et al’s research (2006) was more ethically diverse. Both authors also agreed that high birth weight and prolonged second stage were associated with episiotomy, which would increase the laceration rate.

Episiotomy is probably the only factor in perineal management which appears to be well researched (Sleep et al, 1984), and links with anal sphincter injury have been suggested, despite Albers et al (2006) finding that no episiotomy extended to a third or fourth degree tear. While midline episiotomies tend not to be practices due to the increased risk of anal sphincter tears, the mediolateral approach doesn’t always protect against such trauma (Eason et al, 2000), and restrictive episiotomies carry an increased risk of anterior perineal tears (Thakar and Sultan, 2005), thus questioning the place of episiotomies in obstetrics. Hastings-Tolsma et al (2007) suggest that perineal massage may reduce perineal trauma and the need for episiotomies, while Eogan et al’s research (2006) suggests that massage did not affect the incidence of episiotomy or anal sphincter tears; the methodological limitations of the research and the low incidence of anal sphincter injury and episiotomy could suggest that these findings are due to chance. Their conclusion that the massage group overall had intact perineums could be related to spontaneous labour being more significant in that group, and the high number of intact perineums in women over thirty years old in the massage group can be explained by the fact that the majority of women in this group were in that age bracket, although shipman et al (1997) corroborate this finding (Albers and Borders, 2007). This research was thought to be unreliable, partly due to non-compliance by the massage group, and variation in technique since massage can not be quantified (Wickham, 2007). Findings by Albers et al (2006) and Stamp et al (2001) which were statistically significant, also showed that major trauma was split across the groups, and that there was neither an advantage or disadvantage to massage and that other issues such as positioning may be more significant, whereas Labreque et al (1999), concluded that massage reduced the risk of tears in primiparous women but nor multiparous, which would be beneficial, since the evidence seems to suggest that multiparous women are less likely to tear. Surely if massage helps women tolerate stretching and pressure sensations during labour, such a harmless technique should be considered, despite contradicting evidence (Albers and Borders, 2007).

A common factor in any research on perineal care is positioning at delivery. Both Hastings-Tolsma et al (2007) and Gottvall et al (2007) noted the increased risk of trauma with lithotomy and squatting positions. Gottvall et al’s study was large, thus was able to look at specific positions, whereas Albers et al (2006) concluded that a sitting position had a positive effect on the perineum, but they did not define what was meant by a sitting position. In the current high risk culture of obstetrics, with increased use of epidurals and instrumental deliveries, which are also common factors in perineal research (Hastings-Tolsma et al, 2007; Wickham, 2007), women should be discouraged from delivering in lithotomy or semi-recumbent positions, which Bruce (2003) suggests in cases of foetal malposition where the head is not optimally positioned to emerge, will increase the risk of tearing further. There is insufficient research at present to draw any conclusions regarding positioning, but with midwives being mostly trained in the hands on approach, as opposed to hands poised, semi-recumbent and lithotomy positions are encouraged by midwives, because it makes this approach easier.

Hastings-Tolsma et al (2007) contradicts the groundbreaking HOOP trial (1998) in its finding that manual support measures could be protective to the perineum. The HOOP trial (1998) suggested that manual support techniques may increase trauma and episiotomy rates, and that there is no advantage to hands on or hands poised, a view that is corroborated by Caroci da Costa and Gonzalez Riesco (2006). The HOOP trial showed that women in the hands poised group experienced more pain postnatally, a measure which is open to individual interpretation, and results on perineal integrity were inconclusive, but reliability could be questioned since compliance is less likely in the hands poised group, due to the possibility of emergency intervention (McCandlish, 1999;Wickham, 2007). Doubt over the trial’s reliability makes its use in practice questionable, and the use of either approach to maintain perineal integrity should be an informed decision between woman and midwife, based on her individual needs, something that the HOOP trial (1998) did not take into consideration (McCandlish et al, 2003; Robertson,2002). The results found by Caroci da Costa and Gonzalez Riesco (2006) could be influenced by the women adopting a lateral position, which has been suggested to be beneficial, the expertise of midwives in the trial, and the fact that pushing was spontaneous.

Albers et al (2006) suggested that slow, controlled delivery of the head between contractions helped to protect the perineum, rather than directed pushing, which can be more harmful to women who have a higher risk of tearing (Albers, Sedler et al, 2006), and whose labours tend to last longer. While directed pushing is useful in reducing risks to the foetus of a prolonged labour, and can be useful with epidural analgesia where the sensation to push is diminished, it overlooks the woman’s birthing instincts (Bosomworth et al, 2006). Bosomworth et al (2006) discuss the detrimental effects of directed pushing on the perineum, and while more research is needed, they suggest that this technique should be avoided to reduce the risk of tears. Thakar and Sultan (2005) suggest an association between directed pushing and difficult deliveries, which if lead to instrumental deliveries may increase the use of episiotomies, possibly causing further perineal trauma.

There are implications for practice to be taken from this discussion, mainly the need for special efforts to minimise perineal trauma and the need for evidence-based care. The incidence of anal sphincter injury, in particular, is increasing, and increased awareness is long term problems, such as incontinence and sexual dysfunction, which seriously impact on quality of life. Identification of previous anal sphincter injury is important in assessing for incontinence and recurrence in subsequent labours, and it is suggested that occurrence of such trauma is not properly identified in discharge data (Brubaker et al, 2007). Anal sphincter injury is not completely preventable regardless of practice, but the potential role of perineal massage should be recognised, if only as a guard against incontinence and a means of educating women about their bodies, giving them more control in childbirth to deal with pain (Eogan et al, 2006; Gottvall et al, 2007). Antenatal education on perineal care, emphasizing the importance of lateral positions and discussing delivery techniques to allow informed choice, particularly in primiparous women with risk factors such as macrosomia, should be made a priority (Albers et al, 2006; Caroci da Costa and Gonzalez Riesco, 2006; Hastings-Tolsma et al, 2007).

Further research is needed to examine clinical care measures, to develop appropriate evidence based interventions and update policies. The effects of delivery techniques and maternal effort, positioning, and use of oxytocin and epidurals on perineal trauma need to be examined further, as current evidence is still inconclusive. Large randomised trials to accurately assess the occurrence of anal sphincter injury are needed to improve women’s quality of life, alongside continuous auditing to minimise such trauma (Eogan et al, 2006; Gottvall et al, 2007). Research methods such as randomisation and correlation, which establishes associations between variables to determine the success of care measures, appear to provide more significant and reliable results than, for example, an observational study which is methodologically limited.

Conclusion

Perhaps the most important issues arising from this discussion are that there is no conclusive answer as to which care measures reduce perineal trauma. Women must be treated as individuals and, while interventions have advantages, this current high risk culture could be detrimental, and may be partly to blame for increased rates of perineal trauma.

Perineal care is a priority due to the detrimental effects of perineal morbidity on a woman’s physical, psychological and social wellbeing, and since perineal trauma occurs despite evidence based practice, maybe midwives should be more respectful of a woman’s natural ability to birth, and be influenced by traditions rather than interventions. Knowledge of research is essential to understand why interventions may be needed, but surely for low risk women, informing them of their options regarding perineal management, and allowing them to decide for themselves is a better option (Jackson, 2000; Robertson, 2002). Rather than defining labour by stages, perhaps focusing on the woman’s natural urges will ensure that pushing commences at the correct time, rather than as an automatic response to 10cm dilatation, which could potentially increase the risk of laceration (Bruce, 2003).

Midwives must not underestimate the effect of perineal morbidity on women’s lives, to their health and their ability to breastfeed and bond with their baby. Community midwives play a vital role in antenatal education about possible measures in reducing trauma, for example, perineal massage, to allow women an informed choice, and also in providing information postnatally when severe trauma has occurred, to prevent further problems. While mandatory training on issues such as massage would not necessarily mean that midwives would be motivated to discuss this, at least they would have the information to pass onto women should they choose to (Fitzgerald et al, 2007; Gomme et al, 2003). Perhaps midwives could focus such discussion on women with factors that have been observed in research, for example, socioeconomic status, foetal size and previous perineal trauma (Albers et al, 2006).

Alongside teaching perineal massage, informing women about the benefits of upright and lateral positions for delivering, and reasons for avoiding Valsalva pushing, unless quick delivery is needed, could promote maternal comfort in labour and postnatally. Midwives can take measures themselves by avoiding episiotomy, unless an emergency, allowing a rest period after full dilatation where possible, before commencing pushing, and considering the possibility of delivering the baby’s head slowly between contractions, although this may be more suited to multiparous women, whose perineal muscles have previously stretched. These are issues that are supported by research, although limited, and such measures allow childbirth to be the normal physiological event that it is (Albers et al, 2006).

Individualised care may be challenging when a woman’s preference contradicts evidence-based policies and clinical guidelines, but if the woman’s preference is informed, surely midwives should support that decision, even though not entirely evidence-based. Since research on perineal management is limited still, practice should be based on what is available, combined with experience of the midwife (McCandlish et al, 2003).

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