Risk Of Severe Perineal Laceration Research Articles

Real-time imaging as visual biofeedback in active second stage of labor among nulliparas: a randomized controlled trial

A prolonged second stage of labor increases the risk of severe perineal laceration, postpartum hemorrhage, operative delivery, and poor Apgar score. The second stage is longer in nulliparas. Maternal pushing during the second stage of labor is an important contributor to the involuntary expulsive force developed by uterine contraction to deliver the fetus. Preliminary data indicate that visual biofeedback during the active second stage hastens birth. This study aimed to evaluate if visual feedback focusing on the perineum reduced the length of the active second stage of labor in comparison with the control. A randomized controlled trial was conducted in the University Malaya Medical Centre from December 2021 to August 2022. Nulliparous women about to commence the active second stage, at term, with singleton gestation, reassuring fetal status, and no contraindication for vaginal delivery were randomized to live viewing of the maternal introitus (intervention) or maternal face (sham/placebo control) as visual biofeedback during their pushing. A video camera Bluetooth-linked to a tablet computer display screen was used; in the intervention arm, the camera was focused on the introitus, and in the control arm, on the maternal face. Participants were instructed to watch the display screen during their pushing. The primary outcomes were the intervention-to-delivery interval and maternal satisfaction with the pushing experience assessed using a 0-to-10 visual numerical rating scale. Secondary outcomes included mode of delivery, perineal injury, delivery blood loss, birthweight, umbilical cord arterial blood pH and base excess at birth, Apgar score at 1 and 5 minutes, and neonatal intensive care unit admission. Data were analyzed with the t test, Mann-Whitney U test, chi-square test, and Fisher exact test, as appropriate. A total of 230 women were randomized (115 to intervention and 115 to control arm). The active second stage duration (intervention-to-delivery interval) was a median (interquartile range) of 16 (11-23) and 17 (12-31) minutes (P=.289), and maternal satisfaction with the pushing experience was 9 (8-10) and 7 (6-7) (P<.001) for the intervention and control arm, respectively. Women randomized to the intervention arm were more likely to agree to recommend their management to a friend (88/115 [76.5%] vs 39/115 [33.9%]; relative risk, 2.26 [95% confidence interval, 1.72-2.97]; P<.001) and more likely to have less severe perineal injury (P=.018). Real-time viewing of the maternal introitus as visual biofeedback during pushing resulted in higher maternal satisfaction compared with the sham control of viewing the maternal face; however, the time to delivery was not significantly shortened.

Risk factors for severe perineal lacerations during childbirth: A systematic review and meta-analysis of cohort studies.

To evaluate and quantify the best available evidence regarding risk factors for severe perineal lacerations. Many studies have evaluated the risk factors for severe perineal lacerations. However, the results of those studies are inconsistent, and meta-analysis which thoroughly evaluates the risk factors for severe perineal lacerations is still lacking. Systematic review and meta-analysis of cohort studies based on the PRISMA guideline. PubMed, Embase, the Cochrane Library, CINAHL, ClinicalTrials.gov, CNKI, Wanfang Data, VIP and SinoMed were systematically searched for cohort studies reporting at least one risk factor for severe perineal lacerations from 1 January 2000 to 2 June 2021. Two reviewers independently conducted quality appraisal by NOS scale and extracted data. Data synthesis was conducted via RevMan 5.3 using a random-effects or fixed-effects model. A total of 47 studies with 7,043,218 women were included. The results showed that prior caesarean delivery (OR: 1.46, 95% CI 1.12-1.92) and pre-pregnant underweight (OR: 1.31, 95% CI 1.22-1.41) significantly increased the risk of severe perineal lacerations. The results also demonstrated that episiotomy was protective against severe perineal lacerations in forceps delivery (OR: 0.56, 95% CI 0.42-0.74), but not spontaneous vaginal delivery (OR: 1.30, 95% CI 0.81-2.07) or vacuum delivery (OR: 0.76, 95% CI 0.45-1.28). Nulliparity, foetus in occipitoposterior or occipitotransverse position, and midline episiotomy were also independent risk factors for severe perineal lacerations. Severe perineal lacerations are associated with many factors, and evidence-based risk assessment tools are needed to guide the midwives and obstetricians to estimate women's risk of severe perineal lacerations. This systematic review and meta-analysis identified some important risk factors for severe perineal lacerations, which provides comprehensive insights to guide the midwives to assess women's risk for severe perineal lacerations and take appropriate preventive measures to decrease the risk.

Reducing Perineal Lacerations Through Team-Based Simulation.

Vaginal deliveries that result in perineal trauma involve significant morbidity to women. Multiple strategies have been identified to reduce the risk of severe perineal lacerations. The objective of this study was to evaluate the effectiveness of an interprofessional simulation-based teams-training program aimed at reducing severe perineal lacerations during childbirth. A quasi-experimental pre-post single-group design was used to examine the performance of labor and delivery personnel at a large multihospital system after participating in a mixed-modality simulation program for reducing perineal lacerations. Multiple educational strategies aimed at management of second stage of labor (including laboring down, warm compresses, coaching, positioning, perineal support, controlled delivery of fetal head, and mediolateral episiotomy techniques) were taught using patients, task trainers, and a standardized curriculum during interprofessional educational sessions. Primary study outcomes were as follows: (a) pre-post differences in knowledge; (b) pre-post differences in team performance assessments; and (c) pre-post differences in safety culture. Secondary outcomes were severe perineal laceration rates. During an 18-month period, 675 personnel in 4 hospitals participated in the program. Significant improvement was noted in pre-post scores of knowledge (59.86%, 93.87%, P < 0.0001), performance (36.54%, 93.45%, P < 0.0001), and safety culture (3.24, 1.45, 1 = high, 5 = low, P < 0.0001). Severe perineal laceration rates decreased by 33.38% since initiation. Rates fluctuated with the addition of new personnel and renewed educational programs. A multimodal interprofessional simulation program of strategies to prevent severe perineal lacerations significantly improved knowledge, skills, and attitudes in labor and delivery personnel within a healthcare system. Severe perineal laceration rates were reduced.

Relation between Epidural Analgesia and severe perineal laceration in childbearing women in Catalonia

ObjectiveOur objectives were to study the association between epidural analgesia and risk of severe perineal laceration (SPL), and identify additional risk factors for SPL. This multicentre study consisted of an analysis of data from the MidconBirth Phase I Database, on the use of EA and perineal results during childbirth. (World Health Organization, International Clinical Trials Registry Platform, 2016: http://apps.who.int/trialsearch/Trial2.aspx?TrialID=ISRCTN17833269). MethodsWe conducted a prospective study of pregnant women at term between July 2016 and July 2017 in 30 public maternity hospitals in Catalonia, Spain. Inclusion criteria were an uncomplicated singleton pregnancy, in cephalic presentation and vaginal birth. Data was analysed separately for instrumental births and spontaneous vaginal births, as the former is more frequently associated with episiotomy and more perineal lacerations. Risk factors as well as protective factors in each cohort of women (instrumental and spontaneous vaginal birth), were identified. Multivariate logistic regression model was performed to study the association between epidural analgesia and SPL to identify potential confounders. Odds ratios (OR), using 95% confidence intervals (CI) were constructed. FindingsDuring the study period, 5497 eligible women gave birth, 77.46% of them received epidural analgesia. SPL occurred in 1.63% of births. The univariate analysis showed births with epidural analgesia had significantly higher rates of inductions, augmentation of labour, lithotomy position for birth and episiotomy. However, this association disappeared when the variable "type of vaginal birth" was introduced. In multivariate logistic regression, nulliparity was the major predictor for SPL (OR: 0.17; CI 95%: 0.08–0.34, p: 0.000). Key conclusionsEpidural analgesia was not associated with SPL once confounding factors were included. Other interesting factors associated with SPL were identified. Implications for practiceThis paper identifies important practice areas which contribute to SPL and which have the potential to be rectified. It offers evidence on the role that EA plays on pelvic floor injuries and it adds to existing evidence about the disadvantages of using the lithotomy position for birth, especially in relation to SPL. It highlights the need for practice change in Catalonia from what can be considered a medical model of care to one more aligned with the midwifery philosophy of care through the development of clinical guidelines. It also signals the need to provide women with evidence base upon which to make informed choices on the use of EA, specifically in relation to SPL.

Does meperidine analgesia affect the incidence of obstetric lacerations at vaginal delivery?

Purpose: To study whether meperidine analgesia affects the incidence of obstetric lacerations at normal vaginal deliveries.Materials and methods: A retrospective cohort study of all women with term vertex singleton pregnancies, who underwent normal vaginal deliveries, in a single tertiary hospital, between 2011 and 2015, was performed. The incidence of various obstetric lacerations was compared between deliveries with meperidine analgesia and deliveries with no analgesia. Deliveries with epidural analgesia and instrumental deliveries were excluded. An intravenous infusion of 75 mg of meperidine was administered together with 25 mg of promethazine. A multivariate logistic regression analysis was performed to assess the association between meperidine analgesia and obstetric lacerations, after controlling for confounders.Results: Overall, 5227 (91.8%) deliveries with no analgesia and 466 (8.1%) deliveries with meperidine analgesia were included. Meperidine analgesia was associated with a decreased risk of first- and second-degree perineal lacerations (adjusted OR = 0.63, 95% CI = 0.49–0.81), and a decreased risk of any suturing (adjusted OR = 0.73, 95% CI = 0.59–0.91), after controlling for confounders. Meperidine analgesia did not affect the risk of severe perineal lacerations or episiotomies.Conclusion: Meperidine analgesia may have a protective effect against first- and second-degree perineal lacerations.

Duration of second stage of labor and instrumental delivery as risk factors for severe perineal lacerations: population-based study

BackgroundWe sought to investigate the impact of the duration of second stage of labor on risk of severe perineal lacerations (third and fourth degree).MethodsThis population based cohort study was conducted in the Stockholm/Gotland region, Sweden, 2008–2014. Study population included 52 211 primiparous women undergoing vaginal delivery with cephalic presentation at term. Unconditional logistic regression analysis was used to calculate crude and adjusted odds ratios (OR), using 95% confidence intervals (CI). Main exposure was duration of second stage of labor, and main outcome was risks of severe perineal lacerations (third and fourth degree).ResultsRisk of severe perineal lacerations increased with duration of second stage of labor. Compared with a second stage of labor of 1 h or less, women with a second stage of more than 2 h had an increased risk (aOR 1.42; 95% CI 1.28–1.58). Compared with non-instrumental vaginal deliveries, the risk was elevated among instrumental vaginal deliveries (aOR 2.24; 95% CI 2.07–2.42). The risk of perineal laceration increased with duration of second stage of labor until less than 3 h in both instrumental and non-instrumental vaginal deliveries, but after 3 h, the ORs did not further increase. After adjustments for potential confounders, macrosomia (birth weight > 4 500 g) and occiput posterior fetal position were risk factors of severe perineal lacerations.ConclusionsThe risk of severe perineal laceration increases with duration until the third hour of second stage of labor. Instrumental delivery is the most significant risk factor for severe lacerations, followed by duration of second stage of labor, fetal size and occiput posterior fetal position.

Selective Episiotomy: Indications, Techinique, and Association with Severe Perineal Lacerations.

Introduction Episiotomy is a controversial procedure, especially because the discussion that surrounds it has gone beyond the field of scientific debate, being adopted as an indicator of the "humanization of childbirth". The scientific literature indicates that episiotomy should not be performed routinely, but selectively. Objectives To review the literature in order to assess whether the implementation of selective episiotomy protects against severe perineal lacerations, the indications for the procedure, and the best technique to perform it. Methods A literature search was performed in PubMed using the terms episiotomy or perineal lacerations, and the filter clinical trial. The articles concerning the risk of severe perineal lacerations with or without episiotomy, perineal protection, or episiotomy techniques were selected. Results A total of 141 articles were identified, and 24 of them were included in the review. Out of the 13 studies that evaluated the risk of severe lacerations with and without episiotomy, 5 demonstrated a protective role of selective episiotomy, and 4 showed no significant differences between the groups. Three small studies confirmed the finding that episiotomy should be performed selectively and not routinely, and one study showed that midline episiotomy increased the risk of severe lacerations. The most cited indications were primiparity, fetal weight greater than 4 kg, prolonged second stage, operative delivery, and shoulder dystocia. As for the surgical technique, episiotomies performed with wider angles (> 40°) and earlier in the second stage (before "crowning ") appeared to be more protective. Conclusions Selective episiotomy decreases the risk of severe lacerations when compared with the non-performance or the performance of routine episiotomy. The use of a proper surgical technique is fundamental to obtain better results, especially in relation to the angle of incision, the distance from the vaginal introitus, and the correct timing for performing the procedure. Not performing the episiotomy when indicated or not applying the correct technique may increase the risk of severe perineal lacerations.

Are Asian American women at higher risk of severe perineal lacerations?

Objective: To evaluate whether Asian race is an independent risk factor for severe perineal lacerations.Methods: We performed a nationwide population-based retrospective cohort study examining the relationship between Asian race and severe perineal lacerations (third and fourth degree). The data were collected from the 2012 Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS). Characteristics of Asian American women were compared with those of non-Asian women. The primary outcome of interest was severe perineal lacerations. Multivariable logistic regression was used to refine the associations between Asian race and severe perineal lacerations while adjusting for confounding effects. Results were compared with previously published data using a pooled odds ratio.Results: 2,270,044 Women with singleton vaginal deliveries were identified, and 120,452 (5.3%) were Asian. After adjusting for confounders, Asian women were more likely to experience severe perineal lacerations than any other racial group (3.5% versus 6.3%, adjusted odds ratio [aOR] 1.50, 99% CI 1.29–1.74, p < 0.0001). Analysis of literature indicated that Asian American women are 74% more likely to experience severe perineal lacerations (aOR 1.74, 99% CI 1.72–1.76, p < 0.0001) than non-Asians.Conclusion: Asian race is an independent risk factor for severe perineal lacerations in the United States.

Conséquences maternelles de la prolongation des efforts expulsifs

Some studies found an association between duration of expulsive efforts (DEE) and risk of postpartum haemorrhage (PPH). But none demonstrated an association between DEE and severe perineal lacerations. Our aim was to evaluate the impact of prolonged expulsive efforts (EE) beyond 45min on the risk of maternal complication, especially risk of severe perineal laceration. We performed a retrospective study comparing 2 groups, 1: women with an instrumental vaginal delivery performed before 45min for non-fetal progression without FHR abnormalities (VBI for NP<45min) and 2: women with a DEE longer than 45min (DEE≥45min). We compared maternal issues (3rd and 4th degrees perineal lacerations and PPH), using uni- and multivariate analysis. We compared 85 women in group VBI for NP<45min with 124 women in group EE≥45min. In the group EE≥45min, 39% of women had an instrumental vaginal delivery versus 100% in the group VBI for NP<45min (P<0.001). The rate of severe perineal lacerations was significantly higher in the group VBI for NP<45min (8.2% versus 1.7%, P=0.027) and its risk remained significant after adjustment (adjusted OR=6.5 [1.1-40.1]). The rate of PPH was higher in the group EE≥45min (12.9% versus 3.5%, P=0.016), however this association was not significant after adjustment (adjusted OR=3.4 [0.9-12.4]). There was no difference about neonatal issues between the two studied groups. In comparison with a limitation of EE, to prolong EE beyond 45min allows a spontaneous vaginal delivery for more than half of women, if FHR is normal. Such strategy should also decrease the risk of severe perineal laceration.

Identification of women at high risk for severe perineal lacerations

ObjectivesTo evaluate the frequency and to identify the risk factors of severe perineal lacerations and the subgroup of women exposed to the highest risk for these complications. Study designWe conducted a case-control study in a large cohort of women for which vaginal delivery management consisted in systematic perineal support and restrictive use of mediolateral episiotomy. The case group comprised women with severe perineal lacerations while the control group comprised women without severe perineal lacerations. Maternal, labor, delivery and neonatal characteristics were analyzed in logistic regression models and a classification and regression tree (CART) was constructed. ResultsBetween 2000 and 2009, 19,442 women delivered vaginally in our centre, 88 of whom had severe perineal lacerations (0.5%). Instrumental delivery (aOR 4.17, 95% CI 2.51–6.90), nulliparity (aOR 2.58, 95% CI 1.55–4.29), persistent posterior orientation (aOR 2.24, 95% CI 1.02–4.94) and increased birth weight (aOR 1.28, 95% CI 1.03–1.60) were independent risk factors of severe perineal lacerations whereas mediolateral episiotomy had a protective effect (aOR 0.38, 95% CI 0.23–0.63). CART identified instrumental delivery of neonates smaller than 4500g in persistent posterior orientation in nullipara without mediolateral episiotomy as the clinical situation associated with the highest risk of severe perineal lacerations (12.5%). Conversely, patients with the lowest risk (0.1%) were those delivering spontaneously, neonates larger than 3200g after mediolateral episiotomy. ConclusionsInstrumental delivery, nulliparity, persistent posterior orientation and increased birth weight are independently associated with severe perineal lacerations. Restrictive use of mediolateral episiotomy protects against severe perineal lacerations especially in case of instrumental delivery.

Racial/ethnic variations in perineal length and association with perineal lacerations: a prospective cohort study

Objective: To examine the association between race/ethnicity, perineal length and the risk of perineal laceration.Methods: This is a prospective cohort study of a diverse group of women with singleton gestations in the third trimester of pregnancy. Perineal length was measured and mean values calculated for several racial/ethnic groups. Chi-squared analyses were used to examine rates of severe perineal laceration (third or fourth degree laceration) by race/ethnicity among women considered to have a short perineal length. Further, subgroup analyses were performed comparing nulliparas to multiparas.Results: Among 344 study participants, there was no statistically significant difference in mean perineal length by race/ethnicity (White 4.0 ± 1.1 cm, African-American 3.7 ± 1.0 cm, Latina 4.1 ± 1.1 cm, Asian 3.8 ± 1.0 cm, and other/unknown 4.0 ± 0.9 cm). Considering parity, more multiparous Asian and African-American women had a short perineal length (20.7 and 23.5%, respectively, p = 0.05). Finally, the rate of severe perineal lacerations in our cohort was 2.6% overall, but was 8.2% among Asian women (p = 0.04).Conclusions: We did not find a relationship between short perineal length and risk of severe perineal laceration with vaginal delivery, or a difference in mean perineal length by maternal race/ethnicity. However, we did find that women of different racial/ethnic groups have varying rates of severe perineal laceration, with Asian women comprising the highest proportion.

Perineal Body Stretch in the Second Stage of Labor does not Predict Obstetric Trauma or Postpartum Pelvic Floor Function

Short perineal body length (PBL) has been associated with an increased risk of severe perineal laceration at the time of delivery and postpartum functional disorders. Stretch damage to pelvic floor muscles is thought to occur during the second stage of labor. We aimed to describe changes in PBL during the second stage of labor and evaluate whether degree of PBL stretch predicted perineal lacerations or postpartum urinary incontinence (UI), fecal incontinence (FI) or sexual activity.

Fundal pressure during the second stage of labor in a tertiary obstetric center: A prospective analysis

To ascertain whether uterine fundal pressure should have a role in the management of the second stage of labor and to determine its prevalence, benefits and adverse maternal-fetal outcomes. This was a prospective observational study set in a tertiary teaching and research obstetric hospital. A total of 8097 women in labor between 37 and 42 gestational weeks with a singleton cephalic presentation were enrolled. Subjects were subdivided into two groups: fundal pressure group (n=1974 women) and control group (n=6123 women). The primary outcome measure was the duration of the second stage. The secondary outcome measures were maternal outcomes (immediate or delayed) and neonatal outcomes. The prevalence of fundal pressure in our center was 24.38%. Fundal pressure maneuver significantly shortened the duration of the second stage among primiparous women, increased the risk of severe perineal laceration and admission to neonatal intensive care unit in comparison to the non-fundal group. Delayed maternal outcomes showed significant increase in dyspareunia and de novo stress urinary incontinence in the fundal pressure group. Although fundal pressure maneuver shortens the duration of the second stage of labor among primiparous women, it should not be used except when indicated, and under strict guidelines owing to its adverse maternal and fetal outcomes.

294: Quantifying the risk of severe perineal lacerations in the setting of a protracted second stage

Multiple risk factors are known to be associated with third and fourth degree perineal lacerations (TFPL), and only a few are potentially modifiable. We quantified the risk of TFPL in the setting of a long second stage, when the clinician is faced with the alternatives of the potential interventions of cesarean delivery (CD), instrumental vaginal delivery (ID), and spontaneous vaginal delivery (SVD) with episiotomy.

Les présentations postérieures augmentent-elles le risque de déchirures périnéales sévères ?

Objective To assess the risk of severe perineal lacerations (III and IV degrees) during vaginal deliveries in occiput posterior position. Patients and methods We conducted a retrospective cohort study of 9097 vaginal deliveries in a teaching hospital's maternity between January 1st 2005 and December 31st 2008. Risk factors associated with tears of the 3rd or 4th degree were studied by a multivariate logistic regression. Results Severe perineal lacerations occurred in 1.69% of cases ( n = 152) and did not significantly vary between 2005 and 2008. Parity was a protective factor (OR 0.42; P < 0.001; IC 95% 0.29–0.60) whereas instrumental extraction was associated with an increased risk: vacuum (OR 3.95; P < 0.001, IC 95% 2.23–7.00) and forceps (OR 3.55; P < 0.001, IC 95% 2.33–5.42). macrosomia. Risks were also increased in fetal macrosomia and episiotomy did not protect the mother (respectively OR 1.41 P < 0.001, IC 95% 1.19–1.68 and OR 1.73; P < 0.001, IC 95% 1.16–2.57). Persistent occiput posterior position was not significantly associated with an anal sphincter injury (OR = 1.70 P = 0.059; IC 95% 0.98–2.94). Discussion and conclusion In our series, occiput posterior position did not significantly impact the risk of severe perineal laceration. A manual rotation of the fetal head should be performed in case of associated risk factors.

Risk Factors for Perineal Lacerations in Teen Deliveries

: Severe perineal lacerations have been associated with the development of fecal incontinence. This study was designed to identify risk factors for severe perineal lacerations in vaginal delivery in a teen population. : This was a retrospective database analysis of 534 teen term, singleton, cephalic vaginal deliveries. The primary outcome was the occurrence of a third- or fourth-degree laceration. Categorical and continuous variables were compared using the χ and Student t tests, respectively. : Overall, 43 (8.1%) of our patients had third- or fourth-degree lacerations. In a multivariate regression model, the use of insulin in pregnancy, episiotomy, operative vaginal delivery, and increased infant birth weight all had an increased odds ratio for severe perineal laceration. : Operative vaginal delivery, episiotomy, increased infant birth weight and gestational diabetes requiring insulin for glucose control all appear to increase the risk of severe perineal laceration at the time of vaginal delivery in a teenage population.

Use of uterine fundal pressure maneuver at vaginal delivery and risk of severe perineal laceration

Matsuo et al. [1] published a very interesting, retrospective cohort study about the use of uterine fundal pressure maneuver at vaginal delivery and the risk of severe perineal laceration. A total of 661 vaginal deliveries were evaluated, in 39 (5.9%) of these cases fundal pressure maneuver was applied. The authors concluded the use of uterine fundal pressure during the second stage of labor increased the risk of severe perineal laceration, defined as a third- or fourth degree perineal tear. The risk of severe perineal laceration was 28.1% in the group that received fundal pressure versus 3.7% in the non-fundal pressure group, odds ratio 7.81 (95% CI 3.33–18.3) and P < 0.001. Even adjusted for previously described confounders like, primiparity, length of labor, episiotomy and vacuum extraction there was a significant higher rate of severe laceration in the fundal pressure group [1, 2]. We compliment the authors for publishing these interesting data, since fundal pressure is frequently used during second stage as reported by Kline-Kaye et al. [3] but unfortunately seems to be underreported in medical literature. Merhi and Awonuga [4] concluded in their sceptical reappraisal that the role of fundal pressure is understudied and remains controversial in the management of the second stage of labor, and caution should be exercised using this maneuver until it’s proven to be safe and effective. An interesting review published by Berghella et al. recommends against routinely providing fundal pressure in the termination of the second stage of labor. They conclude there are no significant better outcomes studied in women who received fundal pressure, while these women were less satisfied with the second stage of labor. The authors state the use of obstetric interventions should be studied and associated with the highest risk of safety and effectiveness, with avoidance of less safe and less effective interventions [5, 6]. Although the study by Matsuo et al. is the first to determine the risk for severe perineal laceration associated with the use of fundal pressure, we feel there are some concerns about the interpretation of these data. As already stated by the authors, the study is limited to the lack of information about the indication of fundal pressure, the number and the duration of the maneuver, and the position of the fetal presenting part. In our opinion the indication of fundal pressure is important for the interpretation of the data. When fundal pressure is performed due to prolonged second stage fetal presentation plays an important role in the risk of severe perineal laceration. As described by Pearl et al. [7], deliveries with the fetal occiput in posterior position had a significant higher incidence of severe perineal laceration than presentation with the occiput in anterior position. Unfortunately the study by Matsuo et al. was unable to obtain information about the presentation. On the contrary, when fundal pressure is used to accelerate second stage due to fetal distress with a normal fetal presentation, the risk of severe perineal laceration would probably be less when compared to abnormal presentation and prolonged second stage. A total of nine severe perineal lacerations in the fundal pressure group of 39 women seems to be a rate of severe perineal laceration of 23.1% in contrary to the 28.1% as described by the authors. Although the authors clearly demonstrate that in the synergistic effects of episiotomy, vacuum extraction and fundal pressure, fundal pressure indeed seems to increase the risk of severe perineal laceration, we should know why these deliveries were instrumental deliveries to fully understand these results. Api et al. [8] recently published a randomized controlled trial about the role of fundal pressure on the duration of the second stage of labor. This study randomized a total of 197 women between fundal pressure concomitant with each uterine contraction and normal pushing during second stage, without a medical indication. The authors concluded that fundal pressure was ineffective in shortening the second stage of labor, with no adverse outcomes of mother or child. There was no significant difference in severe perineal laceration between both groups. However, there seemed to be a trend towards a shorter second stage in a subgroup of nulliparous women. It would be interesting to compare the outcome of the study of Matsuo et al. comparing nulliparous women only. The association described between a larger maternal body weight gain during pregnancy and the use fundal pressure maneuver of 11.16 ± 0.4 versus 10.05 ± 0.16 kg in the non-fundal pressure group seems to be a statistically significance without clinical relevance [1]. The contribution of the trial by Matsuo et al. is important for further studies regarding fundal pressure related to the rate of adverse events. Documentation of fundal pressure when applied with clear indication seems to be the first step towards insight in the obstetrical practice of fundal pressure.

Use of uterine fundal pressure maneuver at vaginal delivery and risk of severe perineal laceration

Owing to the lack of evidence supporting the use of uterine fundal pressure maneuver in vaginal delivery, the role of the maneuver is undetermined and remains controversial. The aim of this study was to identify the prone factor of the use of uterine fundal pressure maneuver and to evaluate its obstetrical outcomes. All vaginal delivery records between 1 January 2005 and 30 April 2006 were evaluated. Maternal and neonatal variables and obstetrical complications were analyzed for subjects underwent uterine fundal pressure maneuver. Six hundred sixty-one vaginal deliveries were evaluated. Fundal pressure maneuver was performed in 39 cases (5.9%, 95% CI 4.4-7.1). Primiparity (76.9 vs. 53.3%; odds ratio 2.92, 95% CI 1.36-6.25, P = 0.004), larger maternal body weight gain during pregnancy (11.16 +/- 0.4 kg vs. 10.05 +/- 0.16 kg, P = 0.013), and longer duration of labor (922.3 +/- 111.7 vs. 566.6 +/- 18.3 min, P = 0.003) were prone risk factors for the use of uterine fundal pressure maneuver at vaginal delivery. One case of shoulder dystocia following uterine fundal pressure maneuver was reported (2.5 vs. 0%). Episiotomy (76.9 vs. 44.9%, P < 0.001) and vacuum extraction (41.0 vs. 3.8%, P < 0.001) were frequently performed with uterine fundal pressure maneuver. Uterine fundal pressure maneuver increased the risk of severe perineal laceration (28.1 vs. 4.8%; odds ratio 2.71, 95% CI 1.03-7.15, P = 0.045). The risk of severe perineal laceration was synergistically increased with the concurrent use of uterine fundal pressure maneuver with vacuum extraction and episiotomy. Uterine fundal pressure maneuver during the second stage of labor increased the risk of severe perineal laceration. The use of the maneuver must be cautioned and careful attention must be paid to its application.

Predictors of severe perineal lacerations in Chinese women

Chinese women have been shown to have a higher incidence of severe perineal laceration compared to other ethnic groups. We sought to test the hypothesis that this risk is related to body mass index (BMI) or to a relative fetal-maternal size disproportion as measured by the ratio of the newborn birthweight to maternal BMI (BW:BMI). A retrospective cohort study was performed using a pre-existing obstetric database. Third- and fourth-degree perineal lacerations served as the primary outcome of interest. Logistic regression was used to compare Chinese women to other ethnic groups and adjust for confounders. Three thousand and eighty-five singleton vaginal deliveries were identified, with BMI data available for 2281. Chinese women had a greater risk for severe perineal laceration compared to Caucasian (OR: 3.22; 95% CI: 0.73-14.32) and Hispanic women (OR: 2.88; 95% CI: 1.92-4.30). Multivariate analysis found that newborn birth weight plays a role (OR: 1.0012; 95% CI: 1.0007-1.0016), but BMI alone did not explain the discrepancy (P=0.89). However, the BW:BMI ratio appears to be a stronger predictor of laceration rate than either variable alone (OR: 1.011; 95% CI: 1.003-1.020). The higher risk of severe perineal laceration in Chinese women compared to other ethnicities can be attributed, in part, to a relative fetal-maternal size disproportion.

Severe perineal lacerations in nulliparous women and episiotomy type

Objective: To determine the patient-related factors associated with severe perineal lacerations in nulliparous women and to evaluate the effect of episiotomy type on the risk of severe perineal tears. Study design: In all, 400 nulliparous women admitted in labor between June and December 2001 were prospectively enrolled. Maternal height, perineal length, fetal birth weight, fetal head circumference, and severe perineal lacerations (third and fourth degrees) were recorded. Results: The rate of severe perineal lacerations was 2% (8/400); 3% with midline, 1% with mediolateral groups. In patients with severe lacerations, perineal length was significantly ( p < 0.001) shorter and the head circumference of their babies in the midline significantly ( p < 0.05) greater than normal, and birth weights were also significantly ( p < 0.05) greater in the mediolateral group. A cut-off value for perineal length of 3.05 cm was found for severe lacerations in the midline group. Conclusion: If episiotomy is to be performed, it must be borne in mind that patients with a perineal length of ≤3 cm have an elevated risk of severe perineal lacerations, and if clinical or ultrasound examination suggests that the fetal head is large, mediolateral episiotomy may be preferred. Otherwise, midline episiotomy must be considered.