The Perineal management techniques (flexion technique “Hands-on Approach” and Ritgen’s maneuver) are the most widely used and are claimed to reduce perineal trauma by reducing the presenting diameter of the fetal head through the woman’s vaginal opening and slowing down the birth of the head so to allow the perineum to stretch slowly. The flexion technique involves the maintenance of flexion of fetal head, by exerting pressure on the emerging occiput in a downward direction, preventing its extension until crowning, and placing a hand against the perineum to support this structure.

In Ritgen’s maneuver, the fetal chin is reached in an area between the anus and coccyx and pulled interiorly, while using the finger of the other hand on the fetal occiput to control delivery speed and keep the fetal head flexed [39]. The Ritgen’s maneuver is called modified [40] when performed during a contraction, rather than between contractions as originally recommended.

The “Hands-off Approach” is a well documented [41] birth technique: the accoucheur has his/her hands poised to readily touch the head of the baby and guard the perineum when necessary (if rapid expulsion of the head is occurring then the accoucheur will be able to apply light pressure to the head), allowing the shoulders to birth spontaneously. The National Institute for Health and Clinical Excellence (NICE) Intrapartum Care Guideline 2007 [42], states that both birth techniques are appropriate to facilitate spontaneous vaginal delivery. A Cochrane review [43] carried out a meta-analysis of 8 RCTs (involving more than 11,000 women) regarding the perineal management techniques and concluded that: “Hands off (or poised)” and “Hands on” showed no significant difference in frequency of intact perineum, laceration rates and third- and fourth-degree tears, but “hands off” is more effective in reducing the rate of episiotomy.

No significant differences in the risk of severe perineal trauma and episiotomy were observed when comparing modified Ritgen’s maneuver versus standard techniques.

National Plan Programme in Norway to reduce obstetric anal sphincter injury (OASIS) rate employing a “hands-on technique” (Fig. 10.4) also showed a significant reduction in the incidence of obstetric anal sphincter tears from 4–5 % to 1–2 % during the study period (P < .001). LEVEL OF EVIDENCE II [44, 45].

The above perineum protection program consisted of four components during the last part of the second stage of delivery (when the baby’s head is crowning):

This perineum protection programme (PEERS 5P’s Project) is supported by the results of biomechanical assessment with a finite element model of vaginal delivery, where the appropriate application of the thumb and index finger of the accoucheur’s hand to the surface of the perineum (Fig. 10.5) significantly reduces tissue tension throughout the entire thickness of the perineum [46].

In primitive cultures, women naturally give birth in upright positions like kneeling, standing, or squatting (Fig. 10.6). In western societies, doctors have influenced women to give birth on their backs, sometimes with their legs up in stirrups.

The upright positions favor:

An Australian retrospective analysis of 2002 [47] evaluated the effects of 6 different birth positions on perineal outcomes including episiotomy, lacerations requiring suture, and intact perineum. The authors found that the lateral birth position had the highest rate of intact perineum (66.6 % intact, 28.3 % lacerations requiring suture), whereas squatting was associated with the highest rate of lacerations (41.9 % intact perineum, 53.2 % lacerations requiring suture).

The Cochrane review [48] analyzed 22 studies involving 7,280 women and found that non-supine positions were associated with less assisted births, episiotomies, and fetal heart rate abnormalities, but with more second-degree lacerations. Furthermore, there are no conclusive data about the effect of position for the second stage of labor for women with epidural analgesia and therefore women with epidural analgesia should be encouraged to use whatever position they find comfortable in the second stage of labor.

In summary, there is good evidence that supine positioning should be avoided in second-stage labor. Squatting or sitting may be of benefit when second stage is prolonged or expeditious birth is indicated, while side-lying or hands–knees positions may help prevent lacerations. Therefore, women should be discouraged from lying supine or semi-supine in the second stage of labor and should be encouraged to adopt any other position that they find most comfortable [49].

Interventions during the passive and active phases of the second stage of labor have also been considered to reduce perineal trauma.

The average duration of both first and second stages of labor have trended up in the recent decades, and it is postulated that increased rates of epidural analgesia use and other maternal demographics are at least partly responsible [38, 51, 55]. There is a strong association between prolonged second stage and increased maternal morbidity: large retrospective and prospective observational studies report increased rates of third- and fourth-degree lacerations [25, 26] and other maternal complication – uterine atony, postpartum hemorrhage, intrapartum fever, and hysterectomy [47]– following prolonged second stage or pushing for more than 3 h or 4 h. The American College of Obstetrics and Gynecology (ACOG) hence recommends considering the diagnosis of prolonged second stage in nulliparous woman after 3 h with regional anesthesia or 2 h without, and for multiparous women after 2 h with regional anesthesia or 1 h without [57].

In conclusion:

Evidence suggests that water immersion during the first stage of labor reduces the perception of pain [41], the use of epidural/spinal analgesia, and the duration of the first stage of labor [58]. Furthermore, several studies have shown that delivery in water reduce the frequency and severity of perineal injuries, because immersion in hot water promotes relaxation of perineum tissues [59, 60]. On the contrary, Cochrane review [58] and our data [61] could not find significant differences between usual delivery and water delivery regarding rate of episiotomy, second-, third-, and fourth-degree tears.

A recently published meta-analysis [43], assessing the effect of holding warm gauzes against the perineum, showed that such procedure is more effective than hands off or no warm compression in preventing the incidence of third- and fourth-degree tears and concluded that there is sufficient evidence to support the use of warm compresses in the second stage of labor.

In addition, treated women reported significantly lower pain score after birth and this simple and inexpensive procedure has been shown to be acceptable to both women and midwives.

The stretching massage of the perineum during each contraction is used to ease the perineum back over the head as it crowns. Two studies [62, 63] comparing massage versus “hands off” or usual care showed that the risk of third- and fourth-degree tears was significantly lower in the massage group, but the intervention did not increase the likelihood of an intact perineum and nor reduce the risk of pain and dyspareunia. Therefore, according to NICE guidance [41] perineal massage should not be performed in the second stage of labor.

Episiotomy is the topic of another chapter of this book. However, regarding to perineal trauma prevention, the recent review of Hunter [64] showed that restrictive use of episiotomy appears to give a reduced number of side effects compared with routine episiotomy. Women experienced less severe perineal trauma, especially posterior perineal trauma, less suturing, but no difference in occurrence of pain, urinary or anal incontinence, and painful sex. Episiotomy should be performed if there is a clinical indication such as instrumental birth or suspected fetal compromise.

Perineal trauma is more likely to occur with forceps delivery, therefore, the Royal College of Obstetricians and Gynaecologists recommends that the vacuum extractor should be the instrument of choice for operative vaginal birth [65].

Epidural has become an increasingly popular method of pain relief for women in labor. Evidence suggests that epidural or combined spinal-epidural (CSE) does effectively manage pain in labor, but may increase the rate of adverse effects. A Cochrane review on epidural versus non-epidural or no analgesia in labor [66], including 38 randomized controlled studies and involving 9,658 women, showed that epidural analgesia was associated with an increased risk of assisted vaginal birth, sutured perineal trauma, longer second stage of labor, and urinary retention. During pregnancy, women should be told about the benefits and potential adverse effects on themselves and their babies of the different methods of pain control and they should be let free to choose whatever pain management during labor.

There is some evidence of benefit of continuous one-to-one intrapartum support from a midwife compared with usual care, in terms of reducing the rate of instrumental deliveries. However, the overall rates of perineal trauma were not reduced [1].

Pelvic floor muscle training (PFMT) is commonly recommended both during pregnancy and after the birth to prevent and treat incontinence [29], but the effect on perineal trauma is not known yet. In a large cohort study [67] PFMT in pregnancy was not associated with increased risk of perineal trauma.

During the first stage of labor, 10–34 % of fetuses are in occipito-posterior (OP) position. Persistent OP can result in a longer second stage and is associated with an increased risk for surgical or instrumental birth [68] and severe perineal tears. Therefore, it is important to accurately diagnose fetal position and utilize interventions that encourage rotation to OA position. Usual care in the case of OP position is to wait spontaneous rotation to OA position. Manual rotation of the fetal head from OP to OA has been shown to be a successful intervention and can reduce the incidence of cesarean and vacuum-assisted births [69]. Evidence from the PEOPLE study suggests that delayed pushing when the fetus is OP may increase the chance for spontaneous vaginal birth without the need for rotational or instrumental intervention [52]. Specific maternal positions, such as kneeling on “hands and knees,” could facilitate the rotation from OP to OA position. World Health Organization encourages walking and changing of maternal position to promote spontaneous rotation of the fetal head in OA position during labor [70]. A Cochrane review [71] on the effects of “hands and knees” posture on fetal malposition (lateral or posterior) concluded that the adoption of this posture 10 min daily in late pregnancy has the short-term potential to change the fetal position and reduce lumbar pain, and that its use in labor was associated with reduced backache, but did not influence delivery outcomes and could be recommended as an intervention.