This blog discusses two Cochrane reviews which looked at means of reducing perineal trauma during birth. A Cochrane review is a review of the available evidence – so they look at and combine the results of multiple studies to get a clearer picture of the effects (if any) of an intervention.

How Common Is Perineal Tearing During Childbirth?

Firstly, as noted in our previous blog, about 90% of women and birthing people giving birth for the first time will experience some form of perineal trauma and for the majority that trauma will be considered minor (first- or second-degree tear, or grazes) and will heal well with no long-lasting complications. Not all of these minor tears will require suturing. About 25% of women in England and Wales will experience an episiotomy during childbirth. Less than 4% of women and birthing people will experience a third- or fourth-degree tear (also called a severe perineal tear), which can result in both short- and long-term complications and requires specialist input.

What Are the Risk Factors for Tearing During Birth?

Some of the risk factors include:

• Having your first baby
• Having an instrumental assisted birth (forceps or ventouse)
• Having a baby over 4000g (you can’t accurately know a baby’s weight until they’ve been born)
• Having an induction of labour
• Having a connective tissue disorder

The Research on Perineal Trauma

A 2017 Cochrane review looked at the literature on methods of reducing perineal trauma in the second stage of labour (this is defined as the time when the cervix is fully dilated to when the baby is born). 20 studies, comprising of 15,181 women, contributed to this review. Below are the conclusions of the researched techniques:

Hands-On vs. Hands-Off: Which Technique Reduces Tearing?

This is when the midwife or doctor either has one hand ‘supporting’ the perineum and the other ‘controlling’ the birth of the baby’s head (hands-on) or where they keep their hands away from the perineum during the birth of a baby (hands-off). The Cochrane review found there was no difference in perineal trauma outcomes between using a hands-on or a hands-off technique. Which is interesting as there is a drive to introduce ‘perineal care bundles’ – such as the PEACHES and the OASI care bundles – both of which promote a ‘hands on’ approach with the aim of reducing third- and fourth-degree tears. Furthermore, the very recent All Party Parliamentary Group (APPG) report on birth trauma has recommended that the OASI care bundle be rolled out across all NHS trusts. Here is a great critique of the OASI care bundle and the lack of robust evidence to support it.

I have a funny memory of a being called in to a waterbirth that was going swimmingly (pun absolutely intended) and watching the lead midwife attempt to do a hands-on technique with the woman in the pool! Mind. Blown. For starters, that midwife’s back – ouch. Secondly, what is a hands-on technique going to achieve in a pool, when a woman is birthing physiologically and not being directed to push her baby out? Why disrupt the flow in that moment? Anyway, that’s a chat for another time. The final thing that the Cochrane review noted was that in a couple of studies, episiotomy rates were actually higher in the hands-on group.

Do Warm Compresses During Labour Reduce Tearing?

This is when a warm compress or flannel is gently applied to the perineum during the pushing phase. The Cochrane review found that they made no difference to the incidence of first- or second-degree tears or episiotomy rates, but they did appear to reduce the incidence of third- and fourth-degree tears. In our experience, some women and birthing people find a warm compress extremely soothing, and others would rather not have anyone near their perineum whilst they’re pushing a baby out. The choice, as always is yours. If you think a warm compress may be beneficial to you, include it in your birth plan. You can always ask for it if it has not been offered, and you can change your mind if actually having a warm compress on your perineum feels too invasive in the moment.

Does Perineal Massage During Labour Help?

In this context, the Cochrane review looked at the perineum being massaged by a midwife or doctor to try and stretch it as the baby’s head is coming, this is different to antenatal perineal massage which will be discussed later on. The Cochrane review concluded that there was poor quality data to suggest that it may reduce the incidence of episiotomy but made no difference to first- or second-degree tears. There was some evidence to suggest that women who received ‘warm’ perineal massage were less likely to experience third- or fourth-degree tears – athough, it is unclear what constitutes ‘warm’ perineal massage.

The perineal massage I have witnessed during my years of hospital-based midwifery has felt incredibly invasive – because it is. Notably if someone had an epidural, it was seen as a free pass to go overboard with the stretching, because hey – they can’t feel it right? And at that point in labour – how likely are we to be truly providing any stretch to the perineum? I think that perineal massage/stretching during the pushing phase is a way for healthcare professionals to feel like they’re ‘doing something’ or a bizarre attempt to speed the process up. Not a fan.

What Is Ritgen's Manoeuvre and Does It Work?

This is when the healthcare provider uses one hand to externally extract the baby’s chin from between the maternal anus and the coccyx and the other hand is placed directly on the baby’s head to control the speed of the birth and keep the baby’s head and neck flexed. The Cochrane review did not find much high-quality evidence regarding Ritgen’s manoeuvre, but what they did note from the research reviewed was that it made no difference to the likelihood of an intact perineum and actually increased the chance of a second-degree tear. There was no difference in rates of third- and fourth-degree tears or episiotomies.

This Cochrane review concluded that warm compresses and perineal massage in the second stage of labour, may reduce the incidence of third- and fourth-degree tears but that overall more research needs to be done to look at other outcomes. For example, are these techniques acceptable to women and birthing people? And if a labour is progressing physiologically and spontaneously, why mess with that process?

Does Antenatal Perineal Massage Reduce the Risk of Tearing?

A 2013 Cochrane review looked at studies on antenatal perineal massage for at least four weeks prior to giving birth, to reduce the incidence of perineal trauma. They included four trials and a total of 2497 women. This review found that antenatal perineal massage was ‘associated with an overall reduction in the incidence of perineal trauma requiring suturing…and women practicing perineal massage were less likely to experience episiotomy’. The findings of this review were however only statistically significant for women giving birth for the first time.

The overall reduction in perineal trauma was found to be 9% for women giving birth for the first time, and there was an overall reduction of 16% for episiotomies. The review found no difference in the incidence of first-, second-, third- or fourth-degree tears between women who used perineal massage and those who did not. So, the Cochrane review noted that the overall reduction in perineal trauma requiring suturing was likely to be due to less women giving birth for the first time experiencing an episiotomy. The review found that for every 15 women who practiced antenatal perineal massage, one fewer would require perineal suturing. In terms of the actual perineal massage, the review found that women who practised perineal massage more than 3.5 times a week did not experience an increased reduction in perineal trauma requiring suturing or episiotomy – which is good to know as some websites suggest massaging daily! Again, as per the last blog – it is worth remembering that an episiotomy is not a natural outcome of childbirth – a midwife or obstetrician has made the subjective decision (which should always be with consent) that one is necessary to help a baby be born – and this decision will be based on their experience and the culture of the maternity unit they practise in. 

If you’re giving birth for the first time, there may be some benefit to practising perineal massage in the weeks leading up to giving birth. Some women and birthing people may find this empowering and useful to ‘get to know’ their perineum, others may find it uncomfortable and tricky to do. If perineal massage is something you want to try, you can find plenty of online guides on how to do it and if the idea of it doesn’t float your boat, don’t stress about it!

The Surprising Factor That Reduces Your Risk of Episiotomy

An even more recent Lancet review of over ~500’000 women intending to give birth at home, found that for women giving birth for the first time there was 25% reduction in episiotomy (much higher than antenatal perineal massage…) and for women having a second or more baby, there was a 50% reduction in the chance of episiotomy! This doesn’t mean that all the women did give birth at home, but that planning to birth at home reduced this risk, regardless of the actual place of birth. This study also found that overall women who intended to birth at home were less likely to experience a third- or fourth-degree tear, although no difference was found between home and hospital when looking only at women giving birth for the first time.

We provide individualised, person-centred midwifery care from the antenatal period, through to labour & birth and the postnatal period. Continuity of care is associated with great outcomes for women, birthing people and their babies. You and your birth experience matter. If you would like to invest in a positive maternity experience, get in touch to arrange a free, no-strings attached consultation with us.