Minimizing Genital Tract Trauma and Related Pain Following Spontaneous Vaginal Birth

Leah L. Albers, CNM, DrPH; Noelle Borders, CNM, MSN


J Midwifery Womens Health. 2007;52(3):246-253. 

In This Article

Perineal Management Techniques

Hand maneuvers for perineal management with second stage pushing and for expulsion of the infant have been studied to determine whether any is preferable in terms of reduced childbirth lacerations and subsequent pain. The largest midwifery clinical trial to date was the HOOP trial from the United Kingdom.[26] In this study, 5471 healthy women in the care of English midwives were randomized to either "hands on" (one hand flexing the baby's head and the other hand guarding the perineum) or "hands poised" (both hands off, but ready to apply light pressure to the emerging baby in the case of too-rapid expulsion) for the actual birth of the baby. The primary outcome was perineal pain at the tenth postpartum day. This was the first study to systematically collect complete data on all types of genital tract trauma (perineum and other sites) sustained after normal vaginal births. The genital tract trauma profiles of women in the two groups were virtually identical. Nearly 16% had no trauma at all and 11% had episiotomies. Spontaneous lacerations of the perineum occurred in 68% of study participants, the vagina in 61%, and the labia in 35%. However, women in the "hands on" group reported slightly less perineal pain at the 10th postpartum day (31% vs. 34% of women in "hands poised"). At 3 months postpartum, no differences were observed in perineal pain or other functional outcomes (sexual, bowel, or urinary function or risk of depression).

More recently, Brazilian midwives compared "hands on" versus "hands off" in 70 nulliparous women to examine the relationship between these hand maneuvers and perineal trauma.[27] With 35 women per group, genital tract trauma distributions were equal, indicating no advantage for one delivery method. A lack of statistically significant differences in small samples may indicate that too few women were studied to ascertain a true difference.

Perineal massage during second-stage labor has been tested in a randomized trial by Australian midwives to determine the effect on perineal trauma.[28] Women were randomized (n = 1340) to either perineal massage with lubricant or "usual care," which included a variety of perineal management approaches but excluded perineal massage during the second stage of labor. No differences between groups were found in episiotomies (26% overall), or first- or second-degree perineal tears (43%). Third- or fourth-degree lacerations, while infrequent, occurred in 12 women who received massage, and 24 women in the usual care group. Because this is a rare outcome (2.7% in the study), this difference was not statistically significant; however, it is clinically important. Assessments at 3 months postpartum showed no group differences in perineal pain, sexual difficulties, or bowel or urinary symptoms. Perineal massage conferred no clear benefit, but caused no harm.

Finally, 1211 women in New Mexico were randomized to one of three methods of perineal management in the second stage of labor: warm compresses to the perineum, perineal massage with lubricant, or keeping the hands completely off the perineum until the infant's head was crowning.[29] The purpose was to identify if any of these methods decreased the incidence of spontaneous lacerations of the birth canal. Data collection recorded all sites of genital tract trauma, as first done in the HOOP study. Verification of midwife compliance with the study protocol and their accuracy in assessing childbirth lacerations was built into the study. Verification of midwife compliance with the study protocol and their accuracy in assessing childbirth lacerations was built into the study. In each of the three study groups, 23% of the women had no trauma whatsoever, 40% had a first- or second-degree perineal laceration, and 40% had a vaginal laceration. Only 1% of study participants had an episiotomy. Women in this study sustained less genital tract trauma overall than did women in the other perineal management studies. No differences in protracted pain or faulty healing were observed at the 6-week office visit according to the assigned perineal management method. This study used multivariate analysis to examine the role of factors beyond the hand techniques. Two elements of delivery technique were associated with reduced genital tract trauma: a sitting position for birth (RR = 0.68; 95% CI, 0.50-0.91) and controlled delivery of the infant's head between uterine contractions (RR = 0.82; 95% CI, 0.67-0.99).

These studies indicate that specific perineal management techniques in the second stage of labor, such as warm compresses or massage with lubricant, hands on or hands off, are not helpful in lowering overall rates of genital tract trauma with birth. Because none cause harm, they may have a role in provision of comfort or relaxation in selected situations and with particular women. What appears important in reducing genital tract trauma is having a reasonably comfortable mother, a slow and controlled expulsion of the infant, and shared responsibility for the outcome.


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