To prevent perineal lacerations, ob/gyns can use a variety of techniques, such as perineal compresses, on a patient during labor and should restrict the use of episiotomy, according to a practice bulletin from the American College of Obstetricians and Gynecologists.
Both of these recommendations have been classified as Level A (based on good and consistent scientific evidence).
"A number of different perineal management interventions have been used ... at the time of delivery in an effort to reduce perineal trauma, including ... manual perineal support, warm compresses, different birthing positions, and delayed pushing," reported ACOG's Committee on Practice Bulletins -- Obstetrics.
The is to be published as part of the July issue of , according to an ACOG press release.
Other Level A recommendations for clinical practice offered by the authors included:
- End-to-end repair or overlap repair is acceptable for full-thickness anal sphincter lacerations
- A single dose of antibiotic at the time of repair is recommended in the setting of obstetric anal sphincter injury
This is an update from a prior practice bulletin, which had previously only focused on episiotomy, co-author , told 51˶.
"The previous bulletin did not focus on the broader concept of perineal lacerations and anal sphincter injury," she said. "This was developed to be much more comprehensive and to reaffirm to physicians that episiotomy is not recommended as routine part of delivery."
found significantly reduced third-degree and fourth-degree lacerations (relative risk 0.48, 95% CI 0.28-0.84) associated with the use of warm compresses on the perineum during second-stage labor, though there was no reduction in the rate of women with an intact perineum after delivery. The authors note that warm compresses "have been shown to be acceptable to patients."
Perineal massage during the second stage of labor was also linked with a reduced risk of third-degree and fourth-degree tears compared with "hands off" the perineum, the authors wrote (RR 0.52, 95% CI 0.29-0.94), but again, there was no change in the rate of birth with an intact perineum.
Studies on birthing positions had , with on any birthing position being associated with a reduced risk of lacerations or episiotomy. Similar results were seen for studies examining delayed pushing (between 1 hour and 3 hours of full dilation).
Restricted use of episiotomy is still recommended over routine use of episiotomy. Cichowski said that while overall rates of this procedure have fallen, there are some data to indicate there are regional differences, where some individual practitioners will routinely perform episiotomy.
"Rates of episiotomy are about 12%, but when you think about the number of births nationwide, that ends up being a lot of women," she said. "The evidence really shows this should not be a routine part of delivery."
found that restrictive use of episiotomy (defined as a 28% rate) was linked with lower risk of such complications as severe perineal trauma (RR 0.67), need for suture repair of perineal trauma (RR 0.71), and healing complications at 7 days (RR 0.69).
Cichowski added that even in patients who have severe lacerations, such as obstetric anal sphincter injury, the vast majority could have a vaginal delivery in subsequent pregnancies.
"Having the conversation that the absolute risk of a recurrence is low, so it may be worth having another vaginal delivery versus risking morbidity associated with a cesarean delivery," she said.