title: How can second-stage management prevent perineal trauma? Critical review.
abstract: OBJECTIVE
  To learn which factors influencing perineal integrity were modifiable by physicians and pregnant women.
  
  
  METHODS
  Medical, nursing, and midwifery literature was searched mainly for randomized controlled trials.
  
  
  METHODS
  We chose articles on perineal trauma pattern, sexual dysfunction or satisfaction, urinary incontinence, and pelvic floor function. We identified 80 papers and studied 16 in detail.
  
  
  RESULTS
  Five factors affected perineal integrity: episiotomy, third-trimester perineal massage, mother's position in second-stage labour, method of pushing, and administration of epidural analgesia. Episiotomy does not improve perineal outcomes when used routinely. Third-trimester perineal massage was discussed only in inadequate studies. Studies comparing position in birth chairs and recumbent versus upright positions were inadequate for making firm recommendations. Studies of methods of pushing and use of epidural analgesia were limited and uncontrolled; no recommendations were possible.
  
  
  CONCLUSIONS
  Only limiting episiotomy can be strongly recommended. In the absence of strong data to the contrary, women should be encouraged to engage in perineal massage if they wish and to adopt the birth positions of their choice. Caretakers should be aware of the possibility of interfering with placental function when women hold their breath for a long time when pushing.
authors.affiliation: University of British Columbia's (UBC) Department of Family Practice.
authors.forename: P
authors.initials: P
authors.lastname: Flynn
authors.forename: J
authors.initials: J
authors.lastname: Franiek
authors.forename: P
authors.initials: P
authors.lastname: Janssen
authors.forename: W J
authors.initials: WJ
authors.lastname: Hannah
authors.forename: M C
authors.initials: MC
authors.lastname: Klein
mesh_terms: D036861:Delivery, Obstetric / Q000009:adverse effects / Q000379:methods*; D004414:Dyspareunia / Q000209:etiology; D004841:Episiotomy; D005260:Female; D006801:Humans; D007748:Labor Stage, Second; D008405:Massage; D007744:Obstetric Labor Complications / Q000517:prevention & control*; D010502:Perineum / Q000293:injuries*; D011187:Posture; D011247:Pregnancy; D011644:Puerperal Disorders / Q000209:etiology; D012107:Research Design; D016896:Treatment Outcome; D014549:Urinary Incontinence / Q000209:etiology; D014950:Wounds, Penetrating / Q000150:complications / Q000517:prevention & control*