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Renfrew MJ, Hannah W, Albers L, Floyd E. Practices that minimize trauma to the genital tract in childbirth: a systematic review of the literature. Birth 1998; 25:143-60.

Clinical question During childbirth, which practices minimize trauma to the maternal genital tract?

Background Lower genital tract trauma during childbirth is a common event that may cause both short-and long-term complications including acute and chronic pain; blood loss; and bowel, sexual, and urinary dysfunction. The authors sought to summarize the evidence regarding practices intended to minimize lower genital trauma during childbirth.

Population studied The study reviewed a total of 77 papers and textbook chapters. The authors included 25 randomized and quasi-randomized studies, 4 meta-analyses, 4 prospective studies, 36 retrospective studies, and 8 descriptions of practice from textbooks. Databases were searched through May 1997 for the following key terms: childbirth management of labor, labor second stage, and perineum or perineal injury. Data sources included the Cochrane Data Base; MEDLINE; Index Medicus; midwifery databases; and current textbooks of obstetrics, midwifery, and nursing.

Study design and validity A comprehensive review of the English language literature was conducted. Computer and hand searches were performed. The stated goal was to retrieve all relevant materials, with no explicit exclusions based on quality. At least 2 researchers read each study and assessed it for content and quality. Studies were grouped into categories according to methodology.

This study gets high marks for comprehensiveness but includes a large amount of very weak evidence. Fortunately, the grouping by methodology is somewhat helpful, enabling the reader to dismiss weaker methodologies, such as nonrandomized studies, if so desired. Little information regarding the quality assessment of individual studies was included, however.

Outcomes measured This review measured various attempts to reduce intrapartum perineal trauma by means of qualitative synthesis using a tabular format The tables included author and year, intervention assessed, number of subjects studied, entry criteria, outcome measures, and results.


Randomized and quasi-randomized trials. Avoiding episiotomy results in less overall perineal trauma but an increased risk for labial and anterior vaginal lacerations. When restricting episiotomy to clinical evidence of fetal or maternal jeopardy, the rate of use in an unselected population of mixed parity drops to approximately 10%. The trials suggest no significant difference in perineal trauma between the upright or recumbent delivery position. There is an increased risk of third- and fourth-degree lacerations with midline episiotomy compared with mediolateral episiotomy. There was equivalent pain and analgesic use with both types of episiotomy, but sexual function returned more quickly to those patients with midline episiotomy. Studies of other practices suggested no difference but lacked sufficient size to draw conclusions.

Meta-analyses. The available evidence does not support the routine performance of episiotomy. Neither directed nor spontaneous pushing resulted in decreased perineal trauma.

Prospective (nonrandomized) studies. These studies suggest that directed sustained pushing in the second stage resulted in increased perineal trauma. Degree of trauma may be less predictive of long-term perineal function than use of exercise in the postnatal period. Incomplete healing, infection, and pain appear to be more common after episiotomy.

Retrospective studies and data set analyses. These studies demonstrated higher rates of perineal trauma in patients attended by obstetricians in large urban hospitals and lower rates in patients attended by midwives. Factors associated with increased perineal trauma included primiparity, instrumental delivery, episiotomy, rapid second stage, fetal malpresentation, and fetal macrosomia. Factors associated with reduced risk of perineal trauma include slow, gentle delivery in a relaxed atmosphere, and application of warm compresses to the perineum during the second stage of labor.

Opinions and Descriptions of Practice. Agreement existed on the following points: avoiding sustained pushing with a closed glottis (Valsalva's maneuver); avoiding episiotomy; delivering between contractions; maintaining light pressure to prevent rapid expulsion of the infant; and delivering the anterior shoulder first.

Recommendations for clinical practice This is a nice reference for finding studies on prevention of perineal trauma in a convenient tabular format. We have solid evidence that restricting the use of episiotomy reduces lower genital tract trauma. If an episiotomy is needed and third- or forth-degree laceration is a concern, use a mediolateral incision. The available evidence favors some maternal positions (sitting, semisitting, or lateral) more than others (standing upright or lithotomy with stirrups) and spontaneous more than forceful pushing with sustained breath-holding. These latter topics require further data from well-designed trials before making definitive recommendations.
David T. Walsworth, MD
Linda French, MD
Oakwood Hospital and Medical Center
Dearborn, Michigan
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Article Details
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Author:Walsworth, David T.; French, Linda
Publication:Journal of Family Practice
Date:Dec 1, 1998

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