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Modeling manual perineal protection during vaginal delivery

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Abstract

Introduction and hypothesis

We compared hands-on manual perineal protection (MPP) and hands-off delivery techniques using the basic principles of mechanics and assessed the tension of perineal structures using a novel biomechanical model of the perineum. We also measured the effect of the thumb and index finger of the accoucheur’s dominant-posterior hand on perineal tissue tension when a modified Viennese method of MPP is performed.

Methods

Hands-off and two variations of hands-on manual perineal protection during vaginal delivery were simulated using a biomechanical model, with the main outcome measure being strain/tension throughout the perineal body during vaginal delivery.

Results

Stress distribution with the hands-on model shows that when using MPP, the value of highest stress was decreased by 39 % (model B) and by 30 % (model C) compared with the hands-off model A. On the cross section there is a significant decrease in areas of equal tension throughout the perineal body in both hands-on models. Simulation of the modified Viennese MPP significantly reduces the maximum tension on the inner surface of the perineum measured at intervals of 2 mm from the posterior fourchette.

Conclusions

In a biomechanical assessment with a finite element model of vaginal delivery, appropriate application of the thumb and index finger of the accoucheur’s dominant-posterior hand to the surface of the perineum during the second stage of delivery significantly reduces tissue tension throughout the entire thickness of the perineum; thus, this intervention might help reduce obstetric perineal trauma.

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References

  1. Minassian VA, Jazayeri A, Prien SD, Timmons RL, Stumbo K (2002) Randomized trial of lidocaine ointment versus placebo for the treatment of postpartum perineal pain. Obstet Gynecol 100:1239–1243

    Article  CAS  PubMed  Google Scholar 

  2. Johnson A, Thakar R, Sultan AH (2012) Obstetric perineal wound infection: is there underreporting? Br J Nurs 21:S28, S30, S32-5

    PubMed  Google Scholar 

  3. Connolly AM, Thorp JM Jr (1999) Childbirth-related perineal trauma; Clinical significance and prevention. Clin Obstet Gynecol 42:820–835

    Article  CAS  PubMed  Google Scholar 

  4. Raisanen S, Vehvilainen-Julkunen K, Gissler M, Heinonen S (2011) A population-based register study to determine indications for episiotomy in Finland. Int J Gynaecol Obstet 115:26–30

    Article  PubMed  Google Scholar 

  5. DeWees WB (1889) Relaxation and management of the perineum during parturition. JAMA 24:841–848

    Article  Google Scholar 

  6. Ritgen G (1855) Ueber sein Dammschutzverfahren. Monatschrift fur Geburtskunde u Frauenkrankh 6:321–347

    Google Scholar 

  7. Berghella V, Baxter JK, Chauhan SP (2008) Evidence-based labor and delivery management. Am J Obstet Gynecol 199:445–454

    Article  PubMed  Google Scholar 

  8. National Institute for Health and Clinical Excellence Intrapartum care: care of healthy women and their babies during childbirth. RCOG 2007; CG55 London. www.nice.org.uk/CG55

  9. Munro J, Jokinen M. Midwifery practice guideline: care of the perineum (2008) RCM evidence based guidelines for midwifery-led care in labour. 4th edn. Royal College of Midwives, London. www.rcm.org.uk

  10. Trochez R, Waterfield M, Freeman RM (2011) Hands on or hands off the perineum: a survey of care of the perineum in labour (HOOPS). Int Urogynecol J 22:1279–1285

    Article  PubMed  Google Scholar 

  11. McCandlish R, Bowler U, van Asten H, Berridge G, Winter C, Sames L et al (1998) A randomised controlled trial of care of the perineum during second stage of normal labour. Br J Obstet Gynaecol 105:1262–1272

    Article  CAS  PubMed  Google Scholar 

  12. Mayerhofer K, Bodner-Adler B, Bodner K, Rabl M, Kaider A, Wagenbichler P et al (2002) Traditional care of the perineum during birth. A prospective, randomized, multicenter study of 1,076 women. J Reprod Med 47:477–482

    PubMed  Google Scholar 

  13. Albers LL, Sedler KD, Bedrick EJ, Teaf D, Peralta P (2005) Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: a randomized trial. J Midwifery Wom Health 50:365–372

    Article  Google Scholar 

  14. Zemčík R, Karbanova J, Kalis V, Lobovsky L, Jansova J, Rusavy Z (2012) Stereophotogrammetry of the perineum during vaginal delivery. Int J Gynaecol Obstet 109:136–139

    Google Scholar 

  15. Tsai PJ, Oyama IA, Hiraoka M, Minaglia S, Thomas J, Kaneshiro B (2012) Perineal body length among different racial groups in the first stage of labor. Female Pelvic Med Reconstr Surg 18:165–167

    Article  PubMed  Google Scholar 

  16. Dua A, Whitworth M, Dugdale A, Hill S (2009) Perineal length: norms in gravid women in the first stage of labour. Int Urogynecol J Pelvic Floor Dysfunct 20:1361–1364

    Article  PubMed  Google Scholar 

  17. Kalis V, Karbanova J, Bukacova Z, Bednarova B, Rokyta Z, Kralickova M (2010) Anal dilation during labor. Int J Gynaecol Obstet 109:136–139

    Article  PubMed  Google Scholar 

  18. Reginelli A, Mandato Y, Cavaliere C, Pizza NL, Russo A, Cappabianca S et al (2012) Three-dimensional anal endosonography in depicting anal-canal anatomy. Radiol Med 117:759–771

    Article  CAS  PubMed  Google Scholar 

  19. Knowles AM, Knowles CH, Scott SM, Lunniss PJ (2008) Effects of age and gender on three-dimensional endoanal ultrasonography measurements: development of normal ranges. Tech Coloproctol 12:323–329

    Article  CAS  PubMed  Google Scholar 

  20. Handa VL, Lockhart ME, Fielding JR, Bradley CS, Brubaker L, Cundiff GW et al (2008) Racial differences in pelvic anatomy by magnetic resonance imaging. Obstet Gynecol 111:914–920

    Article  PubMed Central  PubMed  Google Scholar 

  21. Gupta S (2011) A comprehensive textbook of obstetrics and gynecology, Sec 1, 1st edn. Basic science in obstetrics and gynecology. Pelvic skeleton. Jaypee Brotherspp 23–30

  22. Berger MB, Doumouchtsis SK, Delancey JO (2013) Bony pelvis dimensions in women with and without stress urinary incontinence. Neurourol Urodyn 32(1):37–42. doi:10.1002/nau.22275

    Article  PubMed  Google Scholar 

  23. Dietz HP, Shek C, Clarke B (2005) Biometry of the pubovisceral muscle and levator hiatus by three-dimensional pelvic floor ultrasound. Ultrasound Obstet Gynecol 25:580–585

    Article  CAS  PubMed  Google Scholar 

  24. Gregory WT, Nardos R, Worstell T, Thurmond A (2011) Measuring the levator hiatus with axial MRI sequences: adjusting the angle of acquisition. Neurourol Urodyn 30:113–116

    Article  PubMed  Google Scholar 

  25. Svabik K, Shek KL, Dietz HP (2009) How much does the levator hiatus have to stretch during childbirth? BJOG 116:1657–1662

    Article  CAS  PubMed  Google Scholar 

  26. Lien KC, DeLancey JO, Ashton-Miller JA (2009) Biomechanical analyses of the efficacy of patterns of maternal effort on second-stage progress. Obstet Gynecol 113:873–880

    PubMed Central  PubMed  Google Scholar 

  27. Schimpf MO, Harvie HS, Omotosho TB, Epstein LB, Jean-Michel M, Olivera CK et al (2010) Does vaginal size impact sexual activity and function? Int Urogynecol J 21:447–452

    Article  PubMed Central  PubMed  Google Scholar 

  28. Ashton-Miller JA, Delancey JO (2009) On the biomechanics of vaginal birth and common sequelae. Annu Rev Biomed Eng 11:163–176

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  29. Altair, Hypermesh, Version 2012

  30. ESI Group, Pamcrash, Version 2012

  31. Fung YC (1993) Biomechanics—Mechanical properties of living tissues, 2nd edn. Springer-Verlag, New York

    Google Scholar 

  32. Foroughipour A, Firuzeh F, Ghahiri A, NorbaKhsh V, Heidari T (2011) The effect of perineal control with hands-on and hand-poised methods on perineal trauma and delivery outcome. J Res Med Sci 16:1040–1046

    PubMed Central  PubMed  Google Scholar 

  33. Sohrabi M, Bagha IR, Shirinkam R, Koushavar H (2009) A comparison of “hands off”versus “hands on”(Ritgen) techniques on perineal trauma during birth in nulliparous women. JAUMS 9:235–241

    Google Scholar 

  34. Parnell C, Langhoff-Roos J, Møller H (2001) Conduct of labor and rupture of the sphincter ani. Acta Obstet Gynecol Scand 80:256–261

    Article  CAS  PubMed  Google Scholar 

  35. Samuelsson E, Ladfors L, Wennerholm UB, Gareberg B, Nyberg K, Hagberg H (2000) Anal sphincter tears: prospective study of obstetric risk factors. BJOG 107:926–931

    Article  CAS  PubMed  Google Scholar 

  36. Pirhonen JP, Grenman SE, Haadem K, Gudmundsson S, Lindqvist P, Siihola S et al (1998) Frequency of anal sphincter rupture at delivery in Sweden and Finland–result of difference in manual help to the baby’s head. Acta Obstet Gynecol Scand 77:974–977

    Article  CAS  PubMed  Google Scholar 

  37. Laine K, Pirhonen T, Rolland R, Pirhonen J (2008) Decreasing the incidence of anal sphincter tears during delivery. Obstet Gynecol 111:1053–1057

    Article  PubMed  Google Scholar 

  38. Laine K, Skjeldestad FE, Sandvik L, Staff AC (2012) Incidence of obstetric anal sphincter injuries after training to protect the perineum: cohort study. BMJ. doi:10.1136/bmjopen-2012-001649

    Google Scholar 

  39. Laine K, Rotvold W, Staff AC (2013) Are obstetric anal sphincter ruptures preventable?- Large and consistent rupture rate variations between the Nordic countries and between delivery units in Norway. Acta Obstet Gynecol Scand 92:94–100

    Article  PubMed  Google Scholar 

  40. Hals E, Øian P, Pirhonen T, Gissler M, Hjelle S, Nilsen EB et al (2010) A multicenter interventional program to reduce the incidence of anal sphincter tears. Obstet Gynecol 116:901–908

    Article  PubMed  Google Scholar 

  41. Stedenfeldt M, Øian P, Gissler M, Blix E, Pirhonen J (2012) Risk factors for obstetric anal sphincter injury after a successful multicenter intervention programme. BJOG 119:724–730

    Article  CAS  PubMed Central  PubMed  Google Scholar 

Download references

Acknowledgments

The study was supported by the internal grant project SGS-2013-026 of the University of West Bohemia, by the European Regional Development Fund (ERDF), project “NTIS - New Technologies for the Information Society”, European Centre of Excellence, CZ.1.05/1.1.00/02.0090 and by the Charles University Research Fund (project number P36).

Ethical approval and funding

No formal ethical approval was required for this study; no external funding was obtained.

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Correspondence to Vladimir Kalis.

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Jansova, M., Kalis, V., Rusavy, Z. et al. Modeling manual perineal protection during vaginal delivery. Int Urogynecol J 25, 65–71 (2014). https://doi.org/10.1007/s00192-013-2164-1

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  • DOI: https://doi.org/10.1007/s00192-013-2164-1

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