Application of warm compresses during labor reduce perineal lacerations

Robin Wulffson MD's picture
perineal trauma, episiotomy, warm compresses, incontinence, laceration
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BERGEN, NORWAY - Delivering an infant often results in trauma to the perineum—the area between the vagina and rectum. In some cases, the tear extends to the rectum; this is known as a third-degree laceration. A fourth-degree laceration occurs when the tear extends through the rectal sphincter muscle. To reduce tearing, an incision, known as an episiotomy, can be made, with the goal of replacing a clean cut with a jagged tear. However, an episiotomy sometimes is extended through the rectal sphincter during the delivery.

According to a new study, the application of warm compresses on the perineum during the second stage of labor (after the cervix is fully dilated) is associated with a decreased incidence of perineal trauma. Vigdis Aasheim, MD and colleagues at the Department of Postgraduate Studies at Bergen University College in Norway published their findings online December 7 and in the December issue of the Cochrane Database of Systematic Reviews.

Interventions, which have been evaluated for preventing perineal trauma, have included perineal massage, warm compresses, and perineal management techniques. The authors wrote: "No systematic reviews have been published comparing different perineal support and other techniques used during the second stage of labour for reducing perineal trauma."

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To evaluate perineal trauma reduction strategies, the researchers assessed several databases, including the Cochrane Pregnancy and Childbirth Group's Trials Register, the Cochrane Central Register of Controlled Trials, MEDLINE, and Cumulative Index to Nursing and Allied Health Literature. Studies published in or before May 2011 were included.

For the analysis, eight randomized trials, involving 11,651 women and conducted in hospital settings in six nations, were included. The participants had no medical complications and were expecting a vaginal birth. The investigators found a significant effect for the use of warm compresses compared with "hands-off" or no warm compress on the incidence of third- and fourth-degree tears. The risk was reduced by 52% in two studies t(total: 1,525 women). They also found a reduction in third- and fourth-degree tears with massage of the perineum vs. hands-off, with a risk reduction of 48% in two studies (total: 2,147 women). Hands-off vs. hands-on showed no effect on third- and fourth-degree tears; however, hands-off was associated with a significantly reduced rate of episiotomy in two studies (total: 6,547 women).

"We conclude that there is sufficient evidence to support the use of warm compresses to prevent perineal tears," wrote the authors. "The procedure has been shown to be acceptable to both women and midwives." They added, "It showed a reduction in severe perineal trauma and also other benefits, such as reduced pain and reduced incidence of urine incontinence."

The researchers noted that the terms hands-on, hands-off, standard care, and perineal support were not necessarily adequately defined, and that the methodologic quality of the included studies also varied. For example, one study defined hands-off as no hand on the perineum and infant's head until the head was born, whereas another study also included no manual assistance for the birth of the shoulders as part of the definition. Yet another definition, the most extreme, meant no hands on the perineum until crowning of the head.

The authors noted, “The question of how to prevent the tears is complicated and involves many other factors in addition to the perineal techniques that are evaluated here, e.g. birth position, women's tissue, speed of birth. More research is necessary in this field, to evaluate perineal techniques and also to answer the questions of determinants of perineal trauma."
See Also:
Forceps delivery linked to lower brain injury risk

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Comments

"...with the goal of replacing a clean cut with a jagged tear." Um... think about this a minute.