Antibiotic prophylaxis for prevention of postpartum perineal wound complications: a randomized controlled trial. Perineal massage in labour and prevention of perineal trauma: randomised controlled trial. Modified Ritgen's maneuver for anal sphincter injury at delivery: a randomized controlled trial. Episiotomy and perineal tears presumed to be imminent: randomized controlled trial. Does perineal suturing make a difference? The SUNS trial. Perineal outcomes and maternal comfort related to the application of perineal warm packs in the second stage of labor: a randomized controlled trial. Antenatal perineal massage and subsequent perineal outcomes: a randomised controlled trial. Effective analgesia following perineal injury during childbirth: a placebo controlled trial of prophylactic rectal diclofenac. Failure of topically applied antibiotics, added to systemic prophylaxis, to reduce perineal wound infection in abdominoperineal excision of the rectum. Traditional care of the perineum during birth. A prospective, randomized, multicenter study of 1,076 women. Factors associated with postpartum urinary/anal incontinence in primiparous women in Quebec.
To estimate whether prophylactic antibiotics at the time of repair of third- or fourth-degree perineal tears after vaginal delivery prevent wound infection and breakdown.
                This was a prospective, randomized, placebo-controlled study. Patients who sustained third- or fourth-degree perineal tears after a vaginal delivery were recruited for the study. Each patient was given a single intravenous dose of a second-generation cephalosporin (cefotetan or cefoxitin) or placebo before repair of third- or fourth-degree perineal tears. Obstetricians and patients were blinded to study drug. The perineum was inspected for evidence of infection or breakdown at discharge from the hospital and at 2 weeks postpartum. Primary end points were gross disruption or purulent discharge at site of perineal repair by 2 weeks postpartum.
                One hundred forty-seven patients were recruited for the study. Of these, 83 patients received placebo and 64 patients received antibiotics. Forty patients (27.2%) did not return for their 2-week appointment. Of the patients seen at 2 weeks postpartum, 4 of 49 (8.2%) patients who received antibiotics and 14 of 58 (24.1%) patients who received placebo developed a perineal wound complication (P=.037). There were no differences between groups in parity, incidence of diabetes, operative delivery, or third-degree compared with fourth-degree lacerations.
                By 2 weeks postpartum, patients who received prophylactic antibiotics at the time of third- or fourth-degree laceration repair had a lower rate of perineal wound complications than patients who received placebo.
                ClinicalTrials.gov, www.clincaltrials.gov, NCT00186082.
                I. To determine the effects of perineal massage in the second stage of labour on perineal outcomes.
                Randomised controlled trial. Participants: At 36 weeks' gestation, women expecting normal birth of a singleton were asked to join the study. Women became eligible to be randomised in labour if they progressed to full dilatation of the cervix or 8 cm or more if nulliparous or 5 cm or more if multiparous. 1340 were randomised into the trial.
                Massage and stretching of the perineum during the second stage of labour with a water soluble lubricant.
                Primary outcomes: rates of intact perineum, episiotomies, and first, second, third, and fourth degree tears.
                pain at three and 10 days postpartum and pain, dyspareunia, resumption of sexual intercourse, and urinary and faecal incontinence and urgency three months postpartum.
                Rates of intact perineums, first and second degree tears, and episiotomies were similar in the massage and the control groups. There were fewer third degree tears in the massage group (12 (1.7%) v 23 (3.6%); absolute risk 2.11, relative risk 0.45; 95% confidence interval 0.23 to 0.93, P<0.04), though the trial was underpowered to measure this rarer outcome. Groups did not differ in any of the secondary outcomes at the three assessment points.
                The practice of perineal massage in labour does not increase the likelihood of an intact perineum or reduce the risk of pain, dyspareunia, or urinary and faecal problems. To investigate whether Ritgen's maneuver decreases the risk of third- to fourth-degree perineal tears compared with simple perineal support.
                A total of 1,623 nulliparous women in term labor, singleton pregnancy, and cephalic presentation were randomly assigned to Ritgen's maneuver or standard care. Ritgen's maneuver denotes extracting the fetal head, using one hand to pull the fetal chin from between the maternal anus and the coccyx, and the other on the fetal occiput to control speed of delivery. Ritgen's maneuver was performed during a uterine contraction, rather than, as originally recommended, between contractions. Our standard care entailed perineal support with one hand and control of the speed of crowning with the other, and use of Ritgen's maneuver only on specific indications. Women delivered by cesarean delivery (n=10) or instrumentally (n=142) were excluded, as well as 39 erroneously included women (parous or in preterm labor), six inaccurately assigned participants, one with missing data, and two participants who withdrew consent. For the remaining 1,423 women, the result was analyzed according to intention to treat.
                Ritgen's maneuver was performed in 554 (79.6%) of 696 women randomly assigned to this procedure and in 31 (4.3%) of 727 women randomly assigned to simple perineal support. The rate of third- to fourth-degree tears was 5.5% (n=38) in women assigned to Ritgen's maneuver and 4.4% (n=32) in those assigned to simple perineal support (relative risk 1.24; 95% confidence interval 0.78-1.96).
                Ritgen's maneuver does not decrease the risk of anal sphincter injury at delivery, at least not when performed during a contraction. The indication of the restricted use of episiotomy at tears presumed to be imminent is not clear.
                Randomized controlled trial with two perineal management policies. Use of episiotomy: (a). only for fetal indications and (b). in addition at a tear presumed to be imminent. Participants: 146 primiparous women with an uncomplicated singleton pregnancy at >34 weeks of gestation. For the intention-to-treat analysis those 109 women were included who vaginally delivered a live full-term baby between January 1999 and September 2000: 49 women in group a, 60 in group b.
                Reduction of episiotomies, increase of intact perinea or only minor perineal trauma (intact perineum and first-degree tears), third-degree tears, anterior perineal trauma, perineal pain in the postpartum period, pH of the umbilical artery, Apgar scores, maternal blood loss.
                Episiotomy rates were 41% in group a and 77% in group b (p < 0.001). Women in the restrictive policy group had a greater chance of an intact perineum (29% vs. 10%; p = 0.023) or only minor perineal trauma (39% vs. 13%; p = 0.003) and had significant lower pain scores postpartum at different activities. There were no statistically significant differences with regard to third-degree tears, anterior trauma, pre- and postpartum hemoglobin concentrations, Apgar scores and pH of the umbilical artery.
                Avoiding episiotomy at tears presumed to be imminent increases the rate of intact perinea and the rate of only minor perineal trauma, reduces postpartum perineal pain and does not have any adverse effects on maternal or fetal morbidity. To examine differences in outcome between primiparous women who do and who do not have suturing to first or second degree perineal lacerations sustained during spontaneous vaginal births after 37 weeks of gestation.
                Parallel group randomised controlled trial.
                Bellshill Maternity Hospital, Lanarkshire, and St John's Hospital, Livingston.
                Primigravidae with perineal lacerations following spontaneous birth.
                One thousand and three hundred fourteen women were recruited to the trial antenatally from whom 74 were randomised either to be sutured or not sutured immediately after giving birth. Randomisation was stratified by degree of tear.
                Using standardised measures, perineal pain and healing were measured at 1 and 10 days and 6 weeks postpartum. In addition, postnatal depression was assessed at 10 days and 6 weeks postpartum.
                Findings indicated that there were no significant differences between the groups with regard to pain or depression but there were differences with regard to healing. At six weeks, there remained a significant difference in wound closure between the groups, with women who had not been sutured having poorer wound approximation.
                While acknowledging the small sample size, the results are nonetheless important, showing persistent evidence of poorer wound approximation in those women who had not been sutured. Practitioners need to review the present practices of not suturing perineal lacerations until research examining the longer term implications is undertaken. Perineal warm packs are widely used during childbirth in the belief that they reduce perineal trauma and increase comfort during late second stage of labor. The aim of this study was to determine the effects of applying warm packs to the perineum on perineal trauma and maternal comfort during the late second stage of labor.
                A randomized controlled trial was undertaken. In the late second stage of labor, nulliparous women (n = 717) giving birth were randomly allocated to have warm packs (n = 360) applied to their perineum or to receive standard care (n = 357). Standard care was defined as any second-stage practice carried out by midwives that did not include the application of warm packs to the perineum. Analysis was on an intention-to-treat basis, and the primary outcome measures were requirement for perineal suturing and maternal comfort.
                The difference in the number of women who required suturing after birth was not significant. Women in the warm pack group had significantly fewer third- and fourth-degree tears and they had significantly lower perineal pain scores when giving birth and on "day 1" and "day 2" after the birth compared with the standard care group. At 3 months, they were significantly less likely to have urinary incontinence compared with women in the standard care group.
                The application of perineal warm packs in late second stage does not reduce the likelihood of nulliparous women requiring perineal suturing but significantly reduces third- and fourth-degree lacerations, pain during the birth and on days 1 and 2, and urinary incontinence. This simple, inexpensive practice should be incorporated into second stage labor care. To study the effects of antenatal perineal massage on subsequent perineal outcomes at delivery.
                A randomised, single-blind prospective study.
                Department of Obstetrics and Gynaecology, Watford General Hospital.
                Eight hundred and sixty-one nulliparous women with singleton pregnancy and fulfilling criteria for entry to the trial between June 1994 and October 1995.
                Comparison of the group assigned to massage with the group assigned to no massage showed a reduction of 6.1% in second or third degree tears or episiotomies. This corresponded to tear rates of 75.1% in the no-massage group and 69.0% in the massage group (P = 0.073). There was a corresponding reduction in instrumental deliveries from 40.9% to 34.6% (P = 0.094). After adjustment for mother's age and infant's birthweight these reductions achieved statistical significance (P = 0.024 and P = 0.034, respectively). Analysis by mother's age showed a much larger benefit due to massage in those aged 30 and over and a smaller benefit in those under 30.
                Antenatal perineal massage appears to have some benefit in reducing second or third degree tears or episiotomies and instrumental deliveries. This effect was stronger in the age group 30 years and above. To determine if diclofenac suppositories administered prophylactically produce effective and lasting analgesia following perineal injury.
                A randomised double blind placebo controlled trial.
                York District Hospital.
                One hundred women sustaining objective perineal injury (second degree tear or episiotomy) during spontaneous vaginal delivery at term.
                Suppositories were administered at the time of repair and approximately 12 hours later. The suppositories were randomised prior to issue by the pharmacy department and contained either 100 mg diclofenac or placebo.
                Pain scores assessed at 12, 24, 48 and 72 hours after delivery using a six point numerical scoring system and the use of additional analgesia and local treatments to the perineum.
                The mean pain score was significantly reduced in the diclofenac group at 24, 48 and 72 hours after delivery (0.86, 0.7 and 0.59, respectively) compared with the control group (1.64, 1.31 and 1.5; P < 0.005). In addition there was less supplementary analgesia required (eight women only at 72 hours compared with 15 in the control group) and this was limited to paracetamol or topical treatments to the perineum.
                Prophylactic rectal diclofenac provides effective analgesia after perineal repair and its effect appears to be maintained into the second and third postpartum days. In a prospective, randomized trial, prophylactic use of topical antibiotics in addition to systemic prophylaxis was studied in patients undergoing abdominoperineal amputation of the rectum. All patients received gentamicin 80 mg and metronidazole 500 mg intravenously at induction of anesthesia, followed by the same dose 8 hourly for 48 hours. In accordance with the randomization, half of the patients were additionally given gentamicin 160 mg + metronidazole 400 mg topically into the perineal wound at closure. Perineal wound infection appeared in 19 of the 41 patients who received both systemic and topical prophylaxis, and in 18 of the 38 with only systemic antibiotics. Cell-mediated immunity was preoperatively assessed with a skin test (Multitest) in all but three patients. Impairment of cell-mediated immunity was associated with significantly heightened rate of wound infection, and these patients did not benefit from topical antibiotics. To investigate the influence of the traditional hands-on versus the innovative hands-poised method on the risk of perineal trauma during vaginal delivery and on neonatal outcomes.
                In a prospective, randomized, multicenter study, 1,161 of 1,505 women giving birth at the Departments of Obstetrics and Gynecology of the University Hospital of Vienna and Semmelweis Women's Hospital, Vienna, between February and September 1999, were randomized into the trial. In the hands-on method, the left hand of the midwife puts pressure on the infant's head, and the right hand is placed against the perineum. In the hands-poised method, the midwife guides the parturient through the birth without touching the perineum, prepared to apply light pressure on the infant's head.
                One hundred eighty-seven of 574 women (32.5%) in the hands-on group and 180 of 502 women (35.8%) in the hands-poised group experienced perineal tears (P = .5). Sixteen women (2.7%) treated with the hands-on method developed third-degree perineal tears as compared with five women (0.9%) treated with the hands-poised method (P < .05). In the hands-on group, 103 women (17.9%) underwent episiotomy as compared with 51 cases (10.1%) in the hands-poised group (P < .01). No significant differences in neonatal outcomes were observed between the two groups.
                Our data suggest that a policy of hands-poised care is more suitable for preserving the perineum during birth and is a safe and effective birthing alternative for women. To identify the factors associated with urinary incontinence (UI), anal incontinence (AI), and combined UI and AI (UI/AI) in primiparous women in Quebec at six months postpartum.
                A questionnaire was mailed to 2492 primiparous women at six months postpartum to collect data on incontinence status, sociodemographic characteristics, elimination habits, lifestyle, and severity index scales. Obstetric characteristics were obtained via Quebec's Med-Echo databank. Pearson chi-square, t test, analysis of variance, univariate regression, and stepwise modelling techniques were used for data analysis.
                The prevalence of UI in responders was 29.6%, of AI, 20.6%, and of combined UI/AI, 10.4%. Significant adjusted odds ratios were (1) for UI, English spoken (2.04 [95% confidence intervals 1.13-3.69]) and shoulder dystocia (2.90 [1.09-7.69]); (2) for AI, age > 35 years (2.13 [1.12-4.03]), duration of second stage of labour (1.67 [1.11-2.51]), and third or fourth degree tears (4.00 [2.32-6.89]); and (3) for UI and AI, age (2.00 [1.04-3.83]), English spoken (2.55 [1.25-5.19]), shoulder dystocia (4.91 [1.76-13.71]), instrumental delivery (2.28 [1.30-3.99]), third or fourth degree tears (3.58 [1.95-6.57]), and episiotomy (2.24 [1.162-4.33]). Caesarean section was associated with less UI (0.45 [0.28-0.72]), and smoking was associated with less AI (0.38 [0.19-0.76]).
                Combined UI/AI is associated with several obstetrical factors. The association of UI and AI is observed more frequently after complicated delivery (requiring the application of forceps) or involving perineal damage and episiotomy. As most of the identified factors are modifiable, a preventive treatment policy is advisable.
Although the data suggest that prophylactic antibiotics help to prevent perineal wound complications following third- or fourth-degree perineal tear, loss to follow-up was very high. The results should be interpreted with caution as they are based on one small trial.