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Care of the Perineum

Issue Date: May 2008 Page 1

 Care of the Perineum Practice Points

Antenatal perineal massage is an effective approach to increasing the chance of an

intact perineum (Labrecque et al. 1999; Shipman et al. 1997) and in reducing
instrumental deliveries (Shipman et al. 1997).

There is no evidence to support the practices of “ironing out” or massaging the

perineum during birth (Enkin et al. 2000). Traditional practices such as flexion and
extension of the head have been challenged (Myrfield et al. 1997).

Two methods of management of the perineum: “hands on” and “hands poised” have
been compared (McCandlish et al. 1998). The only significant difference in
outcome was more mild pain at ten days in the ”hands poised” group. Mayerhofer
et al. (2002) confirmed McCandlish et al.’s findings of no statistical difference in
overall perineal injury between the two groups but reported an increased rate of
episiotomy and third degree tears in the “hands on” group. The findings of this
study suggest that the “hands poised” method can effectively preserve the
perineum. The use of either should therefore reflect both the midwife’s skill and
the informed choice of the woman.

There is no evidence of short-term or long-term maternal benefit to support the use

of liberal episiotomy (Carroli and Belizan 2004). Like any surgical procedure,
episiotomy carries a number of risks (Enkin et al. 2000). Women report increased
pain and discomfort after episiotomy that interferes with the experience of early
motherhood (Kitzinger and Walters 1981). The practice should therefore be
restricted mainly to fetal indications (Sleep 1990).

Episiotomy is strongly associated with a higher frequency of serious trauma (third

and fourth degree lacerations) (Eason et al. 2000; Renfrew et al. 1998; Albers et al.
1999).

©RCM Evidence based guidelines for midwifery-led care in labour 4 th edition Page: 2
Care of the Perineum

It is highly unlikely that women will not have sustained some trauma in the urogenital region
following birth. An overall rate of 85% of women sustaining some degree of genital tract
trauma has been reported by Albers et al, (2005). The highest rates of trauma have been
observed in first births or operative vaginal deliveries and appear to increase with infant birth
weight, maternal weight gain in pregnancy and fetal malpositions (Albers 2003). There is
some evidence to suggest that the severity of the perineal injury is linked to the severity of
perineal pain (Kenyon & Ford 2004).

There have been two useful randomised controlled trials investigating the effect of antenatal
perineal massage. Labrecque et al. (1999), evaluating massage with sweet almond oil for 5-
10 minutes daily from 34 weeks until birth, reported a significant increase in perineums
remaining intact for women with first vaginal delivery, but not for women with a previous
vaginal birth. A similar trial by Shipman et al. (1997) found a significant benefit of such
massage in reducing second and third degree tears, episiotomies and instrumental deliveries.
Analysis by mothers’ age showed a much larger benefit in those aged 30 and over. Labrecque
et al. (2001) reported that the practice of massage was assessed positively by women.

Stamp et al.'s (2001) trial to determine the effects of perineal massage in the second stage of
labour concluded that it did not increase the likelihood of an intact perineum or reduce the
risk of pain, dyspareunia, or urinary and faecal problems, but was not harmful. The literature
provides little detail of what constitutes good management at birth. McCandlish et al.’s
(1998) trial, which involved 5,316 women, compared two methods of management. These
were ”hands on”, in which the midwife’s hands put pressure on the baby’s head and support
(“guard”) the perineum, lateral flexion then being used to facilitate delivery of the shoulders;
and “hands poised”, in which the midwife keeps her hands poised, not touching the perineum
or head and allowing spontaneous delivery of the shoulders. The results indicate more mild
perineal pain at 10 days in the “hands poised” group. The only other statistically significant
differences were in two secondary outcomes: the rate of episiotomy was lower in the ”hands
poised” group, whereas manual removal of the placenta was more common. Mayerhofer et
al.’s (2002) trial of 1, 076 women also compared “hands on” and “hands poised”. This study
confirmed McCandlish et al.’s findings of no statistical difference in overall perineal injury
between the two groups, but reported an increased rate of episiotomy and third degree tears in
the “hands on” group. The findings of this study suggest that the “hands poised” method can
effectively preserve the perineum. The use of either should therefore reflect both the
midwife’s skill and the informed choice of the woman.

There is no evidence to support the practices of “ironing out” or massaging the perineum
during birth (Enkin et al. 2000). However, a recent national survey has reported that the
practice of perineal massage during the 2nd stage of labour is being undertaken in 109 (52%)
of maternity units in the UK (Sanders et al, 2005). This survey also reported that 70 (33%) of
maternity units used hot packs and 44 (21%) used cold packs during the 2 nd stage of labour in
an attempt to reduce the severity of perineal injury and alleviate the associated burning
sensation when a baby’s head is crowning. Very recently, a randomised controlled trial
investigating perineal outcomes and maternal comfort with application of warm packs in 2 nd
stage of labour in nulliparous women reported that this practice does not reduce the need for
suturing but found evidence that it reduced the risk of 3rd and 4th degree tears and some
evidence that it reduced the severity of pain (Dahlen et al, 2007). No formal evaluation of the
use of cold packs during the 2nd stage of labour has be reported.

©RCM Evidence based guidelines for midwifery-led care in labour 4 th edition Page: 3
The traditions of flexion and extension of the head have been challenged in a critical analysis
of the scientific principles underpinning such practice (Myrfield et al. 1997). These authors
suggest that such techniques may increase the risk of perineal trauma.

A Cochrane’s review evaluating firstly the risks and benefits of restrictive vs routine
episiotomy and secondly the benefits or detrimental effects of the use of mediolateral vs
midline episiotomy reported that there was a lower risk of posterior perineal trauma, need for
suturing, healing complications at 7 days with restrictive use of episiotomy regardless of type
of episiotomy incision. However, evidence to support either type of episiotomy incision
(medio-lateral or midline was inconclusive). The researchers recommended a policy of
restrictive use (Carroli & Belizan, 2004). Liberal use is unwarranted (Enkin et al. 2000) and
probably harmful (Webb and Culhane 2002): the procedure, therefore, should be used mainly
for fetal indications (Sleep 1990). Episiotomy is an example of an intervention which was
introduced without accurate assessment and evaluation (Graham 1997) and without
considering women’s views. The NCT study (Kitzinger and Walters 1981) of 1795 women,
found that it caused pain at and following delivery, which could interfere with the initial
relationship with her baby and her sexual activity. Systematic reviews (Eason et al. 2000;
Renfrew et al. 1998;) have found that episiotomy is strongly associated with a higher
frequency of serious trauma (third and fourth degree lacerations). A recent study reported that
when nulliparous women have either a midline or medio-lateral episiotomy the perineal
length maybe an indicator of the occurrence of severe perineal lacerations and suggest a
critical value of 3 cm (Ayton et al. 2005). Further evidence is needed to support this claim.

©RCM Evidence based guidelines for midwifery-led care in labour 4 th edition Page: 4
References

Albers LL, Sedler KD, Bedrick EJ, et al. (2005) Midwifery care measures in the second stage
of labor and reduction of genital tract trauma at birth: a randomiezed trial. Journal of
Midwifery & Women’s Health. 50(5) 365-72. Back

Albers L (2003) Reducing genital tract trauma at birth launching a clinical trial in midwifery.
Journal of Midwifery and Women’s Health 48: 105-110. Back

Ayton H, Tapisiz OL, Tuncay G, et al. (2005) Severe perineal lacerations in nulliparous
women and episiotomy type. European Journal of Obstetrics & Gynecology. 121: 46-50.
Back

Carroli G, Belizan J (2004) Episiotomy for vaginal birth (Cochrane Review): In: The
Cochrane Library, Issue 1 Chichester, UK: John Wiley and Sons, Ltd. Back

Dahlen HG, Homer CSE, Cooke M, et al. (2007) Perineal outcomes and maternal comfort
related to the application of perineal warm packs in the second stage of labor: a randomized
controlled trial. Birth. 34:4 282-290. Back

Eason E, Labrecque M, Wells G, et al. (2000) Preventing perineal trauma during childbirth: a
systematic review. Obstetrics and Gynecology 95: 464-471 Back

Enkin M, Keirse MJNC, Neilson J, et al. (2000) A guide to effective care in pregnancy and
childbirth Oxford: Oxford University Press Back

Graham I (1997) Episiotomy: Challenging Obstetric Interventions Oxford: Blackwell

Science Back

Kenyon S, Ford F (2004) How can we improve women’s post-birth perineal health. MIDIRS
Midwifery Digest. 14(1) 7-12. Back

Kitzinger S, Walters R (1981) Some Women’s Experience of Episiotomy London: National

Childbirth Trust Back

Labrecque M, Eason E, Marcoux S (2001) Women’s views on the practice of prenatal

perineal massage. British Journal of Obstetrics and Gynaecology 108:499-504 Back

Labrecque M, Eason E, Marcoux S. Lemieux F, Pinault J, Feldman P, Lapperiere L (1999)

Randomized controlled trial of prevention of perineal trauma by perineal massage during
pregnancy. American Journal of Obstetrics and Gynecology 180 (3 pt 1): 593-600 Back

Mayerhofer K, Bodner-Adler B, Bodner K et al. (2002) Traditional Care of the Perineum

During Birth. A prospective, Randomised Multicentre Study of 1,076 women. The Journal
of Reproductive Medicine 47: 477-82 Back

McCandlish R, Bowler U, van Asten H, Berridge G, Winter C, Sames L, Garcia J, Renfrew

M, Elbourne E (1998) A randomised controlled trial of care of the perineum during second
stage of normal labour. British Journal of Obstetrics and Gynaecology 105: 1262-1272 Back

Myrfield K, Brook C, Creedy D (1997) Reducing perineal trauma: implications of flexion and
extension of the fetal head during birth. Midwifery 13: 197-201 Back

Renfrew MJ, Hannah W, Albers L, Floyd E (1998) Practices that Minimize Trauma to the
Genital Tract in Childbirth: A Systematic Review of the Literature. Birth 25: 143-60 Back

Sanders J, Peters TJ, Campbell R (2005) Techniques to reduce perineal pain during
spontaneous vaginal delivery and perineal suturing: a UK survey of midwifery practice.
Midwifery. 21: 154-160. Back

©RCM Evidence based guidelines for midwifery-led care in labour 4 th edition Page: 5
Shipman M, Boniface D, Tefft M, Mcloghry F (1997) Antenatal perineal massage and
subsequent perineal outcomes: a randomised controlled trial. British Journal of Obstetrics
and Gynaecology 104: 787-791 Back

Stamp G, Kruzins G, Crowther C (2001) Perineal massage in labour and prevention of

perineal trauma: a randomised controlled trial. British Medical Journal 322: 1277-80 Back

Sleep J (1990) Spontaneous delivery in Alexander J, Levy V, Roch S (eds) Intrapartum Care
A research-based approach. Hampshire and London: Macmillan Education Back

Webb D, Culhane J (2002) Hospital Variation in Episiotomy Use and the Risk of Perineal
Trauma During Childbirth. Birth 29: 132-136 Back

This updated guideline was authored by Jane Munro Research Midwife and Mervi Jokinen Practice
and Standards Development Adviser RCM with contributions on specific guidelines from Dr Mary
Steen, Community Midwifery, Leeds Teaching Hospitals NHS Trust.

We wish to thank following peer reviewers for their contribution:

Belinda Ackerman Consultant Midwife Guy’s & St Thomas’ NHS Foundation Trust
Tracey Cooper Consultant Midwife Worcestershire Acute Hospitals NHS Trust
Dr Marianne Mead Reader in Midwifery and Associate Research Leader
Health and Human Sciences Research Institute, University of Hertfordshire

The development and ratification of this guideline has been under the auspices of the Professional
Policy Committee of the RCM Council and the final version remains their responsibility.

Review date: 01/06/11 ©RCM Trust

©RCM Evidence based guidelines for midwifery-led care in labour 4 th edition Page: 6

)
Appendix A
Sources

Four bibliographic sources (Medline, CINAHL, MIDIRS and the Cochrane Library) were
searched in order to identify the published literature. As this document is an update of
research previously carried out, the publication time period was restricted to 2004 to January
2008

Search Terms

Separate search strategies were developed for each section of the review. Initial search terms
for each discrete area were identified by the authors. For each search, a combination of MeSH
and keyword (free text) terms was used

Journals hand-searched by the authors (2004) were as follows:

 Birth

 British Journal of Midwifery

 Midwifery

 Practising Midwife

 Evidence-based Midwfery

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