Perineal warm compress reduces risk of third- and fourth- degree tears and should be part of second stage care
- Correspondence to Hannah G Dahlen
School of Nursing and Midwifery, University of Western Sydney, Locked Bag 1797, Penrith South DC, NSW 2751, Australia;
Implications for practice and research
As an effective and acceptable technique, warm compress should be a standard part of second stage perineal care.
‘Hands off’ technique, involving no routine hand manoeuvres to flex the fetal head or guard the perineum, may reduce the incidence of episiotomy.
Perineal massage during second stage may reduce severe trauma, however, acceptability to women should be further evaluated.
Early historical records have shown that reducing perineal trauma during childbirth is of interest to both women and health professionals.1 Perineal trauma has been reported to affect around 85% of women giving birth,2 however, not all these women (44–79%) require suturing.3 Around 0.5–7.0% of women experience severe perineal trauma (third- or fourth-degree tears). There is substantial evidence of short- and long-term morbidity associated with perineal trauma.4
During the past century, a surgical focus has displaced a previously strong social approach to perineal care, with episiotomy being the most significant surgical intervention.1 However, recent research has evaluated ancient practices, such as the use of warm perineal compresses during second stage, and found them to be beneficial to women.5 ,6
Ashiem et al conducted a Cochrane Systematic Review examining perineal techniques during second stage of labour for reducing perineal trauma. They included eight trials involving 11 651 randomised women. Published, unpublished, randomised and quasi-randomised controlled trials (RCTs) were included. The studies took place in the USA, Australia, UK, Brazil, Sweden and Austria and in a variety of hospital settings.
The objective was to assess the effect of perineal techniques during second stage of labour on the incidence and morbidity associated with perineal trauma. The techniques examined were (1) perineal massage (two studies), (2) Ritgen's manoeuvre (one study), (3) warm compresses (two studies), (4) hands on or hands-poised (three studies) and (5) application of petroleum jelly (one study). Meta-analysis was performed on all interventions except for the last of these.
The authors concluded that there was reasonable data to support the use of warm compresses, which showed a reduction in severe perineal trauma (RR 0.48, 95% CI 0.28 to 0.84). A reduction in episiotomy was seen with hands off technique (RR 0.65, 95% CI 0.50 to 0.96) and a reduction in severe perineal trauma was observed with second stage perineal massage (RR 0.52, 95% CI 0.29 to 0.94).
Unfortunately, evaluations of the various techniques by women and clinicians have been excluded. For example, while second stage perineal massage may lead to a reduction in severe perineal trauma, women often dislike the technique, and it can be especially traumatic in cases of previous sexual abuse. The RCT regarding application of warm compress examined two hypotheses: (1) perineal suturing and (2) comfort during and after birth.5 Reduction in second stage and postpartum pain was the most significant part of this trial, along with the high acceptability to women and midwives.6 This did not form part of the meta-analysis, most likely because it was not examined in other primary RCTs.
Other limitations identified in this review include the fact that it is virtually impossible for clinicians performing the technique to be blinded, and this may have biased the studies. There was variation in methodological quality of the studies, with five studies having low risk of bias and three with uncertain risk of bias. Researchers used different outcome measures and there was substantial clinical heterogeneity observed in the studies.
Reducing perineal trauma during birth is important to women and remains a high priority for health professionals. Future research should include women's evaluations and long-term follow-up when assessing techniques/technologies. Factors such as ethnicity, culture, nutrition and fear should be considered in future research, along with birth position, pushing methods, mechanical perineal dilators, pelvic floor exercises, cold compresses, labour support, place of birth and models of care.