title: Manual perineal support at the time of childbirth: a systematic review and meta-analysis.
abstract: BACKGROUND
  Genital tract trauma is common with vaginal births and is associated with significant morbidity, particularly with obstetric anal sphincter injuries (OASIS). Debate continues regarding the effectiveness of perineal support during childbirth in reducing the risk of trauma.
  
  
  OBJECTIVE
  This review aimed to assess the effect of routine 'hands on'/manual perineal support (MPS) during childbirth, versus ad hoc/no perineal support ('hands off/poised'), on the risk and degree of perineal trauma.
  
  
  METHODS
  This review is registered on PROSPERO (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014007058). We searched the CENTRAL, Embase, Medline, CINAHL, and OVIDs midwifery and infant care databases (from inception to December 2014).
  
  
  METHODS
  Published randomised controlled trials (RCTs) and non-randomised studies (NRSs) evaluating any 'hands on' perineal support technique during childbirth.
  
  
  METHODS
  Two reviewers independently assessed trials for inclusion, data extraction, and methodological quality. Discrepancies were resolved by discussion with a third reviewer.
  
  
  RESULTS
  We included five RCTs and seven NRSs in the review. Meta-analysis of RCTs did not demonstrate a statistically significant protective effect of MPS on the risk of OASIS (three studies, 6647 women; relative risk, RR 1.03; 95% confidence interval, 95% CI 0.32-3.36; statistical test for heterogeneity I(2) = 71%). Meta-analysis of NRSs showed a significant reduction in the risk of OASIS with MPS (three studies, 74,744 women; RR 0.45; 95% CI 0.40-0.50; I(2) = 32%).
  
  
  CONCLUSIONS
  Current evidence is insufficient to drive change in practice. An adequately powered randomised trial with an efficient design to evaluate the complex interventions adopted as part of MPS policies, ensuring controlled childbirth, is urgently needed.
authors.affiliation: Birmingham Women's NHS Foundation Trust, Birmingham, UK.
authors.forename: S
authors.initials: S
authors.lastname: Bulchandani
authors.affiliation: Medical School, University of Birmingham, Birmingham, UK.
authors.forename: E
authors.initials: E
authors.lastname: Watts
authors.affiliation: The Royal Wolverhampton NHS Trust, Wolverhampton, West Midlands, UK.
authors.forename: A
authors.initials: A
authors.lastname: Sucharitha
authors.affiliation: Birmingham Women's NHS Foundation Trust, Birmingham, UK.
authors.forename: D
authors.initials: D
authors.lastname: Yates
authors.affiliation: Birmingham Women's NHS Foundation Trust, Birmingham, UK.|The Birmingham Centre of Women's and Children's Health, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
authors.forename: K M
authors.initials: KM
authors.lastname: Ismail
mesh_terms: D000328:Adult; D001003:Anal Canal / Q000293:injuries*; D036861:Delivery, Obstetric / Q000009:adverse effects* / Q000379:methods; D005260:Female; D006801:Humans; D007748:Labor Stage, Second; D022125:Lacerations / Q000209:etiology / Q000517:prevention & control*; D008405:Massage; D007744:Obstetric Labor Complications / Q000517:prevention & control*; D010502:Perineum / Q000293:injuries*; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D016032:Randomized Controlled Trials as Topic; D012306:Risk
keywords: Obstetric anal sphincter injuries; parturition; perineal support; perineal trauma