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Background
Most vaginal births are associated with trauma to the genital tract. The morbidity associated with perineal trauma can be significant, especially when it comes to third- and fourth-degree tears. Different interventions including perineal massage, warm or cold compresses, and perineal management techniques have been used to prevent trauma. This is an update of a Cochrane review that was first published in 2011.

Objectives
To assess the effect of perineal techniques during the second stage of labour on the incidence and morbidity associated with perineal trauma.

Search methods
We searched Cochrane Pregnancy and Childbirth's Trials Register (26 September 2016) and reference lists of retrieved studies.

Selection criteria
Published and unpublished randomised and quasi-randomised controlled trials evaluating perineal techniques during the second stage of labour. Cross-over trials were not eligible for inclusion.

Data collection and analysis
Three review authors independently assessed trials for inclusion, extracted data and evaluated methodological quality. We checked data for accuracy.

Main results
Twenty-two trials were eligible for inclusion (with 20 trials involving 15,181 women providing data). Overall, trials were at moderate to high risk of bias; none had adequate blinding, and most were unclear for both allocation concealment and incomplete outcome data. Interventions compared included the use of perineal massage, warm and cold compresses, and other perineal management techniques.

Most studies did not report data on our secondary outcomes. We downgraded evidence for risk of bias, inconsistency, and imprecision for all comparisons.

Hands off (or poised) compared to hands on

Hands on or hands off the perineum made no clear difference in incidence of intact perineum (average risk ratio (RR) 1.03, 95% confidence interval (CI) 0.95 to 1.12, two studies, Tau² 0.00, I² 37%, 6547 women; moderate-quality evidence), first-degree perineal tears (average RR 1.32, 95% CI 0.99 to 1.77, two studies, 700 women; low-quality evidence), second-degree tears (average RR 0.77, 95% CI 0.47 to 1.28, two studies, 700 women; low-quality evidence), or third- or fourth-degree tears (average RR 0.68, 95% CI 0.21 to 2.26, five studies, Tau² 0.92, I² 72%, 7317 women; very low-quality evidence). Substantial heterogeneity for third- or fourth-degree tears means these data should be interpreted with caution. Episiotomy was more frequent in the hands-on group (average RR 0.58, 95% CI 0.43 to 0.79, Tau² 0.07, I² 74%, four studies, 7247 women; low-quality evidence), but there was considerable heterogeneity between the four included studies.

There were no data for perineal trauma requiring suturing.

Warm compresses versus control (hands off or no warm compress)

A warm compress did not have any clear effect on the incidence of intact perineum (average RR 1.02, 95% CI 0.85 to 1.21; 1799 women; four studies; moderate-quality evidence), perineal trauma requiring suturing (average RR 1.14, 95% CI 0.79 to 1.66; 76 women; one study; very low-quality evidence), second-degree tears (average RR 0.95, 95% CI 0.58 to 1.56; 274 women; two studies; very low-quality evidence), or episiotomy (average RR 0.86, 95% CI 0.60 to 1.23; 1799 women; four studies; low-quality evidence). It is uncertain whether warm compress increases or reduces the incidence of first-degree tears (average RR 1.19, 95% CI 0.38 to 3.79; 274 women; two studies; I² 88%; very low-quality evidence).

Fewer third- or fourth-degree perineal tears were reported in the warm-compress group (average RR 0.46, 95% CI 0.27 to 0.79; 1799 women; four studies; moderate-quality evidence).

Massage versus control (hands off or routine care)

The incidence of intact perineum was increased in the perineal-massage group (average RR 1.74, 95% CI 1.11 to 2.73, six studies, 2618 women; I² 83% low-quality evidence) but there was substantial heterogeneity between studies). This group experienced fewer third- or fourth-degree tears (average RR 0.49, 95% CI 0.25 to 0.94, five studies, 2477 women; moderate-quality evidence).

There were no clear differences between groups for perineal trauma requiring suturing (average RR 1.10, 95% CI 0.75 to 1.61, one study, 76 women; very low-quality evidence), first-degree tears (average RR 1.55, 95% CI 0.79 to 3.05, five studies, Tau² 0.47, I² 85%, 537 women; very low-quality evidence), or second-degree tears (average RR 1.08, 95% CI 0.55 to 2.12, five studies, Tau² 0.32, I² 62%, 537 women; very low-quality evidence). Perineal massage may reduce episiotomy although there was considerable uncertainty around the effect estimate (average RR 0.55, 95% CI 0.29 to 1.03, seven studies, Tau² 0.43, I² 92%, 2684 women; very low-quality evidence). Heterogeneity was high for first-degree tear, second-degree tear and for episiotomy - these data should be interpreted with caution.

Ritgen's manoeuvre versus standard care

One study (66 women) found that women receiving Ritgen's manoeuvre were less likely to have a first-degree tear (RR 0.32, 95% CI 0.14 to 0.69; very low-quality evidence), more likely to have a second-degree tear (RR 3.25, 95% CI 1.73 to 6.09; very low-quality evidence), and neither more nor less likely to have an intact perineum (RR 0.17, 95% CI 0.02 to 1.31; very low-quality evidence). One larger study reported that Ritgen's manoeuvre did not have an effect on incidence of third- or fourth-degree tears (RR 1.24, 95% CI 0.78 to 1.96,1423 women; low-quality evidence). Episiotomy was not clearly different between groups (RR 0.81, 95% CI 0.63 to 1.03, two studies, 1489 women; low-quality evidence).

Other comparisons

The delivery of posterior versus anterior shoulder first, use of a perineal protection device, different oils/wax, and cold compresses did not show any effects on perineal outcomes. Only one study contributed to each of these comparisons, so data were insufficient to draw conclusions.

Authors' conclusions
Moderate-quality evidence suggests that warm compresses, and massage, may reduce third- and fourth-degree tears but the impact of these techniques on other outcomes was unclear or inconsistent. Poor-quality evidence suggests hands-off techniques may reduce episiotomy, but this technique had no clear impact on other outcomes. There were insufficient data to show whether other perineal techniques result in improved outcomes.

Further research could be performed evaluating perineal techniques, warm compresses and massage, and how different types of oil used during massage affect women and their babies. It is important for any future research to collect information on women's views.

Perineal techniques during the second stage of labour for reducing perineal trauma

Genital tract trauma after spontaneous vaginal childbirth is common, and evidence-based prevention measures have not been identified beyond minimizing the use of episiotomy. This study randomized 1211 healthy women in midwifery care at the University of New Mexico teaching hospital to 1 of 3 care measures late in the second stage of labor: 1) warm compresses to the perineal area, 2) massage with lubricant, or 3) no touching of the perineum until crowning of the infant's head. The purpose was to assess whether any of these measures was associated with lower levels of obstetric trauma. After each birth, the clinical midwife recorded demographic, clinical care, and outcome data, including the location and extent of any genital tract trauma. The frequency distribution of genital tract trauma was equal in all three groups. Individual women and their clinicians should decide whether to use these techniques on the basis of maternal comfort and other considerations.

Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: a randomized trial

New strategies for local treatment of vaginal infections.

Background: Numerous empirical evidences have shown that social and environmental circumstances and social relations have an important impact on pregnancy outcomes, women's ability to cope with stressful situations, and childbirth pain management. The present study was conducted to determine the relationship between perceived social support and fear of childbirth. Materials and Methods: The present descriptive correlational study was conducted on 270 nulliparous pregnant women who referred for pregnancy care in 2016. The subjects were selected through convenience sampling method. The data collection tools were a demographic characteristics form, the Multidimensional Scale of Perceived Social Support (MSPSS), and the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ). The collected data were analyzed using descriptive and inferential statistics tests. Results: The mean perceived social support score of the participants was 77.90 and a significant correlation was observed between the perceived social support score and fear of childbirth score (β = −0.18, p = 0.004). The participants' mean score of fear of childbirth was 36.8. The results of study after the evaluation of the effect of predictive variables on the fear of childbirth are as follows: pregnancy preparation classes: (β = 3.50, p = 0.220); observation of natural childbirth videos: (β = 5.26, p = 0.040); and use of educational software: (β =5.82, p = 0.080). Conclusions: In order to reduce the fear of childbirth, women's social support structure during pregnancy should be assessed. Moreover, demographic characteristics form the structure and determine the extent of individuals' social network and, through the evaluation of these characteristics during pregnancy, the rate of effective support can be predicted in individuals.

The Relationship between Perceived Social Support in the First Pregnancy and Fear of Childbirth.

BACKGROUND : Vaginitis is the most prevalent gynecological problem for which women look for treatment and is responsible for 10 million physician visits annually. Use of herbal treatments has been recorded in many of patient groups as well as in general populations to increase health level. The present study was conducted with the purpose of determination and comparison of the effect of vaginal cream containing garlic and thyme compared to clotrimazole cream for the treatment of mycotic vaginitis. METHODS : This clinical trial is a prospective, multivariate, single-blind, two-stage, two-group study with randomized assignment of samples into the two groups. From the clinics in Isfahan in 2010, 64 cases (32 individuals in each group) entered the study. Data collection was accomplished by demographic information questionnaire and clinical performance checklist, and data analysis was performed by SPSS 16.0 software. RESULTS : Abundance distributions of clinical symptoms (vaginal discharge; vulval erythema and edema), patients’ complaints (secretions, itching, dyspareunia, painful urination, and vaginal irritation) and clinical symptoms (existence of germinating hypha, acidity under 4.5, and culture of vaginal secretions) were different in each group prior to and after the intervention; these factors however were not different between the two groups before and after the intervention. CONCLUSIONS : The vaginal cream containing garlic and thyme is effective as much as clotrimazole vaginal cream for the treatment of candida vaginitis and there is no difference between responses to treatment by these two drugs. KEY WORDS : Mycotic vaginitis, clotrimazole, garlic, thyme.

/pdf/investigating-the-therapeutic-effect-of-vaginal-cream-541ld14io2.pdf

Investigating the therapeutic effect of vaginal cream containing garlic and thyme compared to clotrimazole cream for the treatment of mycotic vaginitis.

BACKGROUND : Labor pain relief has been considered since many years ago. Heat as a non pharmacological method of pain relief helps reducing the pain intensity and increases the pain consistency. The aim of the study was to determine the effect of the heat therapy on the labor pain in primigravida women. METHODS : In this clinical trial study, 64 low risk nulliparous women were randomly divided into two heat therapy  and routine care groups. In addition to the routine cares, warm bag were used for the heat therapy group for the low back, from cervix dilatation of 3-4 cm to the end of the labor’s first stage and for perinea at the second stage. The pain intensity was determined by McGill pain questionnaire in dilatation of 3-4, 6-7 and 9-10 cm and at the end of the labor‘s second stage. Data was analyzed using t-test and chi square test by using SPSS 11. RESULTS : Results of research showed a significant decrease in the pain intensity in the heat therapy group at the first stage and the second stage of labor and comparing two groups showed significant difference(p < 0.001). CONCLUSIONS : According to the results of this study, it seems that heat therapy in addition to its beneficial effects, causes the mother to sense the labor pain in a lower pain severity. KEY WORDS : Heat therapy, nonpharmacological pain relief, labor pain.

/pdf/effect-of-heat-therapy-on-pain-severity-in-primigravida-2l14fmxead.pdf

Effect of heat therapy on pain severity in primigravida women

BACKGROUND: With regard to an increase in the life expectancy for women and the consistency of the menopause age, a significant portion of women's age is passed after the menopause. Menopause is considered as a critical and sensitive period due to the changes and the disorders that are involved in it. Vasomotor symptoms, sleep disorders and psycho-mental changes are among the most prevalent symptoms of this period. Hormone therapy is a common treatment and it involves some problems for most individuals. The purpose of this study was to comparatively examine the effects of two herbal medications, Hypericum Perforatum and Passion Flower, on menopause symptoms. METHODS: This study was of a clinical-experimental type whic h was done in 1388 in Isfahan. The sample included 59 menopausal women who had the conditions for entering into the study. The individuals were selected via simple sampling and were assigned randomly into two groups of Hypericum Perforatum treatment group (30 women) and Passion Flower group (29 women). The required data were filled out through interview, Personal Characteristics Questi onnaire, and Cooperman's Index for menopause symptoms in three stages of pre-intervention, the third week of intervent ion, and the sixth week of intervention. The results were analyzed by descriptive and inferential statistical methods and the statistical software of SPSS. RESULTS: The findings showed that the average score of meno pause symptoms in two treatment groups of Hypericum Perforatum and Passion Flower had a significant dec rease throughout the third and the sixth weeks of s tudy (p 0.05). CONCLUSIONS: With regard to the effects of Hypericum Perforatum and Passion Flower on treating menopause precocious symptoms (vasomotor signs, insomnia, depression, anger, headache, etc.), these two herbs can be used a s an alternative treatment for individuals who cannot, whatsoever, u se hormone therapy.

http://www.ijnmr.mui.ac.ir/index.php/ijnmr/article/download/315/255

A comparative study on the effects of Hypericum Perforatum and passion flower on the menopausal symptoms of women referring to Isfahan city health care centers.

BACKGROUND Sexual instinct which is the cause of numerous changes in an individual's life could be influenced by different factors such as menopause and ageing. This study was designed to compare sexual dysfunction before and after menopause. MATERIALS AND METHODS This was a cross-sectional study. Participants were 174 menopausal women who referred to medical health centers of Isfahan, Iran. Data were collected through self constructed sexual dysfunctions questionnaire in relation to their sexual activities before and after menopause. The reliability and validity of this questionnaire was determined by content validity and Cronbach's alpha coefficient. FINDINGS Findings showed that the relative frequency of sexual dysfunctions was 38% in the productive period and 72.4% in the menopause period. There was a significant association between sexual dysfunctions before and after the menopause period (p < 0.001). Sexual dysfunctions in these women in the productive and menopause period were 49.2% and 62.6% in desire disorder, 34.3% and 34.9% in dyspareunia, 26.8% and 75.3% in arousal disorder, 23.5% and 56.3% in orgasmic disorder and 16.4% and 15.6% in vaginismus, respectively. CONCLUSIONS A considerable percentage of women experienced sexual dysfunctions in productive and menopause periods, and menopause could be a factor to maintain or intensify sexual dysfunctions.

/pdf/a-comparative-study-on-sexual-dysfunctions-before-and-after-k9gb6v592k.pdf

Fariba Fahami

Papers

The Relationship between Perceived Social Support in the First Pregnancy and Fear of Childbirth.

Investigating the therapeutic effect of vaginal cream containing garlic and thyme compared to clotrimazole cream for the treatment of mycotic vaginitis.

Effect of heat therapy on pain severity in primigravida women

A comparative study on the effects of Hypericum Perforatum and passion flower on the menopausal symptoms of women referring to Isfahan city health care centers.

A Comparative Study on Sexual Dysfunctions Before and After Menopause