Effects of manual perineal protection and pushing techniques used in the second stage of labor on perineal outcomes: a randomized controlled trial of combinations of strategies

Background: Manual perineal protection and pushing techniques can impact the incidence of perineal trauma. Limited data exist on the impact of combinations of management strategies employed during the second stage of labor on perineal outcomes. The objective of this study was to evaluate the combined impact of interventional and relatively more spontaneous techniques employed during the second stage of labor on perineal outcomes. Materials and methods: This randomized controlled study was carried out in the maternity clinic of a state hospital. Low-risk, term nulliparous women with vertex presentation upon admission to the delivery unit were included in the study. The participants in the study were randomly assigned to either the hands-on perineal protection and directed pushing group or the hands-poised perineal protection and coached pushing group at the onset of the second stage of labor. The frequencies of episiotomy and perineal injury were the primary outcomes of the study. The secondary outcomes included maternal satisfaction, breastfeeding, Apgar scores, perineal muscle function and perineal pain scores, and the amount of postpartum hemorrhage. Results: The frequency of episiotomy was significantly lower in the hands-poised–undirected pushing group than in the hands-on–coached pushing group (RR: 0.65, 95% CI: 0.44–0.98, P = 0.04). The frequency of first-degree perineal injury was significantly greater in the hands-poised – undirected pushing group than in the hands-on–directed pushing group (RR: 2.04, 95% CI: 1.06–3.90, P = 0.02). The frequencies of second-degree and higher perineal injuries were similar between the groups. No significant differences were observed between the groups in terms of secondary outcomes. Conclusions: Second-stage management strategies with fewer interventions can be used to reduce the frequency of episiotomy. Both hands-on directed pushing and hands-poised undirected pushing combinations for second-stage management exhibit similar frequencies of intact perineum. Trial and protocol registration: Clinical Trials; ID: NCT04823598; Date: 25.03.2021; URL: https://clinicaltrials.gov/study/NCT04823598.