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Some Techniques May Help Reduce Perineal Trauma. (Perineal Massage, Warm Compresses).

SAN FRANCISCO -- Episiotomy rates are down. Now what?

It's time to turn attention to other means of reducing perineal trauma during childbirth, certified nurse-midwife Judith Bishop said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The rate of primiparous women with intact perinea or first-degree lacerations has tripled at the university since 1979 as the episiotomy rate for term, spontaneous deliveries has decreased from 69% to 10%.

Restricting the use of episiotomy is the only intervention proven to help reduce perineal trauma; it's backed by six randomized, controlled trials and many retrospective reviews, said Ms. Bishop of the university. Although minimizing episiotomy use may increase the number of anterior and vaginal lacerations reported, these carry minimal morbidity compared with other lacerations that are more common with episiotomy.

The strongest predictor of episiotomy use is the patient's type of health care provider. Private obstetricians have the highest episiotomy rate, midwives have the lowest rate, and faculty obstetricians and family physicians have rates in between these two extremes.

Data suggest that minimizing instrumental deliveries--or choosing vacuum delivery over forceps--may reduce perineal trauma. The instruments can damage tissue and are more likely to be accompanied by episiotomy to make room for the devices.

Few delivery positions have been studied with regard to perineal injury. A review of 16 randomized, controlled trials found no difference in perineal trauma rates between women who delivered in an upright position or in a supine position.

Epidural anesthesia indirectly increases the rate of vaginal deliveries, studies suggest. Judicious use of anesthesia could reduce perineal trauma by increasing the woman's active participation in labor and helping to avoid the lithotomy position and use of stirrups, which have been associated with increased trauma, Ms. Bishop said.

Continuous support during labor by doulas or other caregivers also has been associated with fewer operative deliveries.

A number of hand maneuvers and delivery techniques used in an attempt to preserve the perineum have been poorly studied.

Hands-on approaches include prenatal perineal massage by the woman or her partner during the last 4-6 weeks of pregnancy to increase perineal elasticity. Three recent studies found an association between prenatal perineal massage and reduced lacerations in nulliparous women, with a 6% increase in intact perinea in one study and a 9% increase in another, she said.

There are no data to support or discredit four other techniques: warm compresses on the perineum, lubrication at the time of crowning, supporting the perineal body by bracing it with the whole hand or pressing the ends inward, or "ironing" the perineum with the fingers in the second stage of labor to increase circulation and help it stretch.

Some health care providers believe that any manipulation of the perineum increases the risk of lacerations by causing edema, bruising, or abrasions.

Delivery of the head may not be facilitated by some hand maneuvers. A 1998 randomized trial in 5,471 women found no difference in perineal trauma with spontaneous delivery of the head and shoulders, compared with a group that flexed the head, supported the perineum, and provided lateral flexion to deliver the shoulders, Ms. Bishop noted.

Nevertheless, there is general agreement that some techniques aimed at a slow, controlled delivery of the head are useful in preventing it from "popping" through the perineum.

These techniques include keeping the mother involved and coaching her when to push and when to hold back. A hand is kept poised on or dose to the crowning head. Flexion of the advancing head is maintained, while smaller parts of the head such as the occipital prominence and parietal eminences are delivered first.

When possible the head is delivered between contractions or at the end of a contraction, so that it exits with less force.
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Author:Boschert, Sherry
Publication:OB GYN News
Date:Oct 15, 2001
Previous Article:Findings, Hx Flag Need for Fetal Echocardiogram. (Fetal Hydrops, Maternal Cardiac Disease).
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