Manual perineal support: learn the skills before you intervene.

Abstract

Obstetric anal sphincter injuries (OASIS) are a serious complication of vaginal birth. Despite adequate primary repair it may cause anal incontinence in 30–50% of the cases, and might cause perineal pain and sexual dysfunction. Hence primary prevention is important. The reported OASIS rates vary from 0.6% to 10.2%. The variation may be the result of differences in reporting systems, birth populations, diagnostic skills and definitions, but different delivery practice regarding perineal protection and use of episiotomy are probably more important. Bulchandani et al. (BJOG 2015; DOI: 10.1111/1471-0528.13431) carried out a systematic review and meta-analysis of both randomised controlled trials (RCTs) and non-randomised studies (NRSs) to evaluate the effect of manual perineal support during childbirth on OASIS. The meta-analysis of RCTs did not demonstrate a protective effect (relative risk 1.03, 95% confidence interval 0.32–3.36), whereas the NRSs showed a significant risk reduction (relative risk 0.45, 95% confidence interval 0.40–0.50). Randomised controlled trials are designed to measure the efficacy of interventions and are considered to be the most rigorous form of research, allowing for a causal inference to be made between treatments and outcomes. But the quality of complex, multifaceted interventions may be good or bad. In the three RCTs included in the meta-analysis, the technique of perineal support and delivery practice is not well described. The method and duration of teaching, training and supervision used to learn the intervention is unknown, which makes it difficult to judge the quality. Among the three NRSs that qualified for the meta-analysis, the two largest were from Norway (Hals et al. Obstet Gynecol 2010;116:901–8, Laine et al. BMJ Open 2012;2(5)pii:e001649). In these studies the intervention period lasted 6–14 weeks, and the training included compulsory lectures, simulation training and education of a group of trainer-midwives who taught and supervised the entire staff in the clinical setting before the intervention started. In these studies the classical Finnish delivery method was used (in Finland the OASIS rates have been 0.5–1.0% for decades). The main focus of the intervention was on (i) good communication between the accoucheur and woman who was asked to do fast upper-costal breathing without pushing just before delivery of the fetal head; (ii) adequate perineal support; (iii) a delivery position that allows visualisation of the perineum; and 4) episiotomy only on indication and with protective characteristics (Stedenfeldt et al. BJOG 2012;119:724–30). The coordination of all these components was stressed. The OASIS rate was reduced by more than 50% (from 4–5% to 2%) in a total population of >75 000 deliveries, and was not restricted to low-risk births as in the RCTs. We agree with Bulchandani et al., who propose a stepped wedge cluster randomised trial (Hemming et al. BMJ 2015;350:h391) in the UK including six large maternity units. In such a trial, we believe that a strong focus on the type and quality of the intervention is essential. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.