review of literature of SIM on perineal tear study

1. CHAPTER – II
REVIEW OF LITERATURE
The review of literature is defined as a broad, comprehensive, in depth,
systematic and critical review of scholarly publications, unpublished scholarly print
material, audio visual materials and personal communications.21
Review of literature refers to an extensive, executive and systematic
examination of publication relevant to the research project. The term literature review
is used in two ways by research community. The first refers to the activities involved
in identifying and searching for information on a topic and second is developing a
comprehensive picture of state of knowledge on that topic. Researcher may thus say
that he or she is doing literature review before conducting the study. The term is also
used to designate a written summary of the state of the art on the research problem.21
Review of literature is the key step in the research process. A literature review
helps to lay the foundation for a study and can also inspire new research ideas. It can
help with orientation to what is known and not known about an area of inquiry, to
ascertain what research can best make a contribution to the existing base of evidence.
Review of literature is a major aspect of any research process. The view of
literature for the present study has been taken from different sources like texts books,
journals, articles, & published & unpublished research studies and also online
sources.21
Before any research can be started whether it is single study or extended
project, a literature review of previous studies and experiences related to the proposed
investigation should be done. Literature review makes contribution to new knowledge
and scholarship of researcher. So Literature review is important aspect while doing
research.
Based on the objectives of the study, literature from various sources had been
reviewed & arranged under as following categories-
 Studies related to perineal tear
 Studies related to prevention of perineal tear

2. Studies Related To Perineal Tear
Taithongchai A, Veiga SI, Sultan AH (2018) was conducted a retrospective
cohort study on The consequences of undiagnosed obstetric anal sphincter injuries
(OASIS) following vaginal delivery. The aimed to compare anal and urinary
incontinence symptoms and anal manometry between women with undiagnosed
obstetric anal sphincter injuries (OASIS) and women who had OASIS diagnosed and
repaired. The results of the study was that forty missed OASIS were matched with 40
recognised OASIS (16 3a/b; 24 3c). The median modified St Mark's scores were
higher for missed tears [11 (4, 15) vs. 1 (0, 4), p < 0.001] as well as the urinary
incontinence scores [4 (0, 6) vs. 0 (0, 2), p = 0.01] than for the control group. Missed
OASIS patients had a shorter perineal body [1.6 ± 1.3 vs. 2.4 ± 0.8, p = 0.009]. A
l
l missed
OASIS had larger defects on endoanal ultrasound. One in four missed OASIS required
further surgery [aOR 4.1 (95% CI 1.0-16.3), p = 0.04] and almost all needed colorectal
input [aOR 24.1 (95% CI 7.3-80.0). it is concluded that Women with symptomatic
missed OASIS are compromised in terms of anal and urinary incontinence symptoms,
sphincter defect size and perineal body size requiring additional colorectal input. This
highlights the importance of preventing OASIS and perseverance with training to
diagnose OASIS.22
Leombroni M, Buca D (2017) et al were conducted a prospective study on
women with first- and second-degree perineal tears and episiotomy. The purpose of
the study was to evaluate the morphology and biometry of pelvic floor structures 3
months after birth in women experiencing first- or second-degree perineal tears or
undergoing episiotomy during labor. In this study including nulliparous women
delivering at term with a clinical diagnosis of first- or second-
degree perineal tears after birth or undergoing episiotomy. The results show that 115
women assessed 3 months after delivery were enrolled in the study. Compared with
controls, women who experienced first-degree perineal tears had higher bladder neck-
symphysis (versus 20.9 ± 4.9 versus 16.1 ± 4.9 mm, p = .017), bladder wal
l
-pubi
c
symphysis (22.4 ± 7.4 versus 14.2 ± 9.5 mm, p = .02) and anorectal angle-symphysis
distance (12.5 ± 4.7 versus 9.3 ± 4.3 mm, p = .018). Furthermore, they have thi
cker internal
and external anal sphincter. The incidence of partial right and left pubo- rectalis
muscle avulsion was higher in women experiencing first-degree

3. vaginal tear during labor (16.2 versus 0%, p = .004 for both). In women affected by
second-degree tears, the occurrence of partial avulsion of the right and left pubo-
rectalis muscle was 16.2%, while Oasis was detected in 10.8% of the cases. Women
receiving Kristeller maneuver during labor had a higher incidence of either right or
left puborectalis muscle avulsion. It is concluded that women who had either first- and
second-degree perineal tears or episiotomy show signs of abnormal pelvic
morphometry on 3D rotational ultrasound 3 months after birth.23
Morávková P, Hruban L (2017) et al were conducted a prospective case-
control study analysis on operative vaginal deliveries and their impact on maternal
and neonatal outcomes. The objective of the study was evaluation of maternal and
neonatal outcomes in operative vaginal deliveries in prospective study analysis. Type
and frequency of maternal and neonatal trauma occurence was observed in connection
with using vacuum-assisted delivery and forceps delivery, mainly the
cephalohematomas and their complications. Collected data were statistically analysed.
The results shows that overall 6056 deliveries there were 216 vacuumextractions
(3.6%) and 72 forceps deliveries (1.2%) performed. Both methods were used in four
patients (VEX and forceps). The most frequent trauma in newborns were
cephalohematomas. Remarkable cephalohematoma, requiring further observation has
occured in 40 newborns (18.5%) after vacuum-assisted delivery and in 5 newborns
(6.9%), (p = 0,017) after forceps delivery. Consequential punction of
cephalohematoma occured only after vacuumextraction delivery and in 6 newborns
(15.0 %). The third degree perineal rupture occured after vacuumextraction in 20
patients (9.3%) and after forceps delivery in 12 patients (16.7%), (p = 0,091). The
fourth degree perineal rupture occured only after vacuumextraction and in 1 case
(0.5%). It is concluded that vacuumextraction compared with forceps is more likely to
be associated with the statistically significant incidence of cephalohematomas and
their further treatment. Forceps deliveries compared with vacuumextraction are more
likely to be associated with the maternal perineal trauma, but the diference was not
statistically significant.24
Aasheim V, Nilsen AB (2017) was conducted a review on published and
unpublished randomized and quasi- randomized to assess the effect of perineal
techniques during the second stage of labour on the incidence of perineal trauma. The

4. study included 8 trials involving 11,651 randamised women .The result of the study
revealed that there was a significant effect of warm compresses on reduction of third
and fourth degree tears (risk ratio (RR) 0.48, 95% confidence interval (CI) 0.28 to
0.84 (two studies, 1525 women)). There was also a significant effect towards
favouring massage vs hands off to reduce third and fourth degree tears (RR 0.52, 95%
CI 0.29 to 0.94 (two studies, 2147 women)). Hands off vs hand on showed no effect
on third and fourth degree tears, but it observed a significant effect of hands off on
reduced rate of episiotomy (RR 0.69, 95% CI 0.50 to 0.96 (two studies, 6547 women).
The study concluded that the use of warm compresses on the perineum is associated
with a decreased occurrence of perineal trauma.25
Kudish B, Blackwell S, (2016) et al were conducted a study to determine the
impact of operative vaginal delivery and midline episiotomy on the risk of severe
perineal tear. Retrospective cohort study was done. Among nulliparous women,
12.1% had operative vaginal delivery, 22.4% had midline episiotmy,8.1%
experienced severe perineal tear. Among multiparous women, 3.4% had operative
vaginal delivery 4.2% had midline episiotomy and 1.2% had severe perineal tear. The
use of operative vaginal delivery, particularly in combination with midline
episiotomy, was associated with a significant increase in the risk of anal sphincter
trauma in both primigravidae and multigravidae women.26
Jansson MH, Nilsson K, Franzén K (2016) was conducted a study on
Development and validation of a protocol for documentation of
obstetric perineal lacerations. The aim of this study was to develop a new protocol for
documentation of perineal lacerations and to validate the latter against the most
common obstetric record system in Sweden. The results shows that a total of 187
women were included. The coverage of documentation regarding perineal laceration
was significantly higher (p < 0.001) in the new protocol (89%) compared with
ObstetriX (18%). Incidence of second-degree perineal tears was 26% according to the
new protocol and 11% according to ObstetriX. The incidence of third-
degree perineal tears A, B, and C was 2.7%, 2.1%, and 2.1%, respectively, according
to the new protocol, and 3.2%, 2.7%, and 1.1%. It is concluded that this validation
study of a new documentation protocol showed that it delivered significantly more

5. comprehensive information regarding perineal lacerations than the most common
obstetric record system in Sweden.27
Kimmich N, Grauwiler V (2016) were conducted a Prospective
Observational Study on Birth Lacerations in Different Genital Compartments and
their Effect on Maternal Subjective Outcome. This study aimed to evaluate the
frequency and distribution of birth lacerations and their association with maternal
discomfort. 140 women with singletons in vertex presentation at term, who gave birth
vaginally in our center and were affected by a laceration were selected as respondents.
The results was that the number of affected compartments was 1.33 objectively and
2.99 at T2 and 1.27 at T3 subjectively. The most affected compartment was the
right perineum (73%) followed by the right inner posterior (21%) and the right outer
anterior (14%) compartment. Subjective and objective assessment concurred in 83%
at T2 and 69% of cases at T3. Overall, impairment of women was low, reversible, and
not directly associated with the location of lacerations, although women were
psychologically affected. It is concluded that birth lacerations predominantly appear
at the right perineum. Physical impairment from these lacerations is generally low,
reversible, and not directly associated with the location of lacerations, although
psychological impairment is not negligible.28
Williams A, Herron-Marx S, (2016) et al conducted a retrospective cross-
sectional community survey of postnatal women to investigate the prevalence of
enduring postnatal perineal morbidity and its relationship to perineal trauma. The total
sample size was 2100 women form two maternity units in Birmingham. Findings of
the study showed that perineal morbidity was reported (53.8%) stress urinary
incontinence, 36.6% urge urinary incontinence, 9.9% liquid faecal incontinence,
54.5% with at least one index of sexual morbidity. Women with perineal trauma
reported significantly more morbidity (sexual morbidity, dyspareunia, stress and urge
urinary incontinence) than women with an intact perineum. Women with perineal
trauma also resumed sexual intercourse later than women with an intact perineum.
Study concluded that post natal perineal morbidity is common in women with all
types and grades of perineal trauma.29
Alexander JW, Karantanis E (2016) was conducted a study on Patient
attitude and acceptance towards episiotomy during pregnancy before and after

6. information provision. The data was collected through the structured knowledge
questionnaire. The results revealed that there were 105 responses, with 88% accepting
episiotomy, 2% declining and 10% seeking more information to decide. Eighty-one
percent of women agreed that the information provided helped them to understand
more about childbirth and 62% agreed that they felt more comfortable with the
birthing process after reading the material. There was a reduction in anxiety levels
regarding episiotomies after reading information (p = 0.002) and perineal tears
(p = 0.02). It is concluded that most women will accept an episiotomy if required.
Antenatal education about episiotomies is important to women and helps them feel
more comfortable with the birthing process. Written information increases acceptance
and reduces anxiety levels regarding episiotomies.30
Soong B, Barnes M (2015) conducted a study aimed to examine the
association between maternal positional at birth and perineal outcome in women who
had midwife attended, spontaneous vaginal birth and an uncomplicated pregnancy at
term. Sample size was 3,756. Most women (65.9%) gave birth in the semi recumbent
position. 44.5% who required perineal suturing semi recumbent was associated with
the need for perineal sutures, Semi recumbent was associated with highest need for
perineal suturing whereas lateral position was associated with reduced need for
suturing.31
Pintucci A, Consonni S (2015) et al were conducted a study on Operative
vacuum vaginal delivery: effect of compliance with recommended checklist. The
purpose of the study was to evaluate the role of a checklist implementation on the
compliance with the recommended rules in operative vacuum vaginal delivery (OVD)
and on maternal and perinatal tear. The results of the study was that introduction of a
checklist for OVD resulted in an increase in the compliance with the rules (83.3 versus
62.8%, p < .001). Cases in which the rules were respected had lower incidence of third-
and fourth-degree perineal lacerations after controlling for episiotomy, nulliparity, and
indication for OVD (OR = 0.4, 95% CI 0.18-0.89), but similar rates of failure of OVD
(2.1 versus 2.2%, p = 1) and adverse neonatal outcome (10.8 versus 11.7%, p=.71). the
results of the study concluded that knowledge and documented compliance with a
checklist of recommended rules in OVD may assist in achieving a

7. lower rate of severe perineal tear and anal sphincter injury but does not alter the
success of the procedure or neonatal outcome.32
Gommesen D, Nohr EA (2015) et al were conducted a prospective cohort
study on Obstetric perineal tears: risk factors, wound infection and dehiscence. The
main purpose of the study was that to assess risk factors for perineal tears, wound
infection and dehiscence among primiparous women. 603 primiparous women
sampled in three groups: 203 with none/labia/1st degree, 200 with 2nd degree, and
200 with 3rd/4th degree tears were included. Results revealed that instrumental
delivery and birthweight > 4000 g increased the risk of 3rd/4th degree tears (adjusted
Odds Ratio [aOR] 13.7, 95% confidence interval [CI] 5.48-34.1 and aOR 3.27, 95%
CI 1.52-7.04, respectively). BMI > 35 kg/m2 increased the risk of wound infection and
dehiscence (aOR 7.66, 95% CI 2.13-27.5 and aOR 3.46, 95% CI 1.10-10.9,
respectively). Episiotomy tripled the risk of infection (aOR 2.97, 95% CI 1.05-8.41).
Treatment with antibiotics during delivery and postpartum seemed to decrease the risk
of dehiscence (aOR 0.32, 95% CI 0.15-0.70). the conclusion was that instrumental
delivery and high birth weight increased the risk of perineal tears. Severe obesity and
episiotomy increased the risk of perineal wound complications. More focus on these
women may be warranted postpartum. The use of prophylactic antibiotics among
women in high risk of wound complications should be further investigated in
interventional studies.33
Woolner AM, Ayansina D (2015) et al were conducted a cohort study on
impact of third- or fourth-degree perineal tears on the second pregnancy. This study
aimed to investigate the reproductive impact of a third- or fourth-degree tear in
primigravid women. The results was that initial third- or fourth-degree tear occurred
in 2.8% women (5174/182445). The percentage of third- or fourth-degree tears in first
vaginal births increased from 1% in 1997 to 4.9% in 2010. There was no difference in
having a second pregnancy (adjusted Odds Ratio (aOR) 0.98 (99%CI 0.89-1.09)) or
the median interpregnancy interval to second pregnancy (adjusted Hazard Ratio
(aHR) 1.01 (99%CI 0.95-1.08)) after an initial third- or fourth-degree tear. Women
were over four times more likely to have a repeat injury in a subsequent vaginal birth
(n = 149/333, aOR 4.68 (99% 3.52-6.23)) and were significantly more likely to have
an elective caesarean section in their second pregnancy (n = 887/3333, 26.6%; 12.75

8. (11.29-14.40). It is concluded that third- and fourth-degree tears are increasing in
Scotland. Women do not delay or avoid childbirth after initial third- or fourth-
degree tear. However, women are more likely to have a repeat third- or fourth-
degree tear or an elective caesarean section in the second pregnancy. Strategies to
prevent third- or fourth-degree tears are needed.34
Martin S, Labrecqua M, (2015) were conducted a retrospective cohort study
to assess whether women who had a perineal trauma at the first delivery were at
increased risk for spontaneous perineal tears at the next delivery, and whether the risk
increases with the severity of previous perineal trauma. Study conducted at Saint-
Sacrement Hospital, Canada. Sample included 1895 women who had their first and
second deliveries at Saint-Sacrement Hospital, between 1985 and 1994. The result of
the study revealed that who have a perineal trauma at the first delivery more than
tripled the risk (relative risk=3.3; 95% confidence interval, 2.6-4.2) of spontaneous
perineal tears at the second delivery. The risk of spontaneous perineal tears at the
second delivery increased with the severity of previous perineal trauma at birth. The
study concluded that the risk of spontaneous perineal tears at subsequent deliveries
increases with the presence and the severity of perineal trauma at the first delivery.35
Hastings TM, Vincent D, (2015) et al were conducted a study on factors
related to perineal trauma in child birth, retrospective descriptive analysis of 510
pregnant women with singleton pregnancy. Results showed that factors related to
laceration with age and marital status .For all women laceration was more likely when
in lithotomy position for birth or when prolonged stage labour occurred. In this study
use of oils or lubricants increased laceration. It is implicated that side lying position
for birth and perineal support and compress use are important interventions for
decreasing perineal trauma.36
Dahlen HG, Ryan M, (2014) et al were conducted a study in Royal Prince
Alfred hospital, Australia to determine the risk factors for the occurrence of severe
perineal tear during child birth. A prospective cohort study was conducted. The study
subject included all women having vaginal births between 1998to2000, sample size
was 65. 95.2% of women experienced severe perineal tear, 122 women had third
degree tears, and 12 had fourth degree tears. Primiparity, instrumental delivery, Asian

9. ethnicity and heavier babies were associated with an elevated risk of severe perineal
tear.37
Sheiner E, Walfisch A, (2014) et al were conducted a study in Israel to
evaluate the possible risk factors for spontaneous and induced perineal damage during
vaginal delivery. A prospective observational study was conducted with 300 patients
at 37 – 42 weeks of singleton gestation. Perineal damage was assessed before repair
and 24 hours postpartum. Episiotomy was performed in 32% of the population.
Spontaneous perineal tear requiring suturing occurred in 28%. Severe perineal tears
occurred in 1%. Risk factors for adverse perineal outcome included younger maternal
age, non Israeli ethnic background, use of epidural analgesia nulliparity shorter
interval since last vaginal delivery, longer active phase and prolonged second stage.
Woman with a prolonged second stage labour and low parity are prone for
spontaneous damage and therefore deserve high attention.38
Uccella S, Manzoni P (2014) et al were conducted a prospective study on
Impact of Sport Activity and Physical Exercise on Obstetrical and Perineal Outcomes
at Delivery. This study was aimed to investigate the effects of physical activity on
perineal outcomes at delivery according to the different levels and types of maternal
physical activity before and during pregnancy. Women were divided into three groups
according to the features of physical activity performed before pregnancy: group 1:
"very sporty women," group 2: "moderately sporty women," and group 3: "inactive
women." The results that a total of 135, 84, and 85 women were included in group 1,
group 2, and group 3, respectively. The demographic characteristics were comparable
among all the groups. Sport activity during pregnancy was more frequent in groups 1
and 2 (59.3 and 53.6%, respectively, vs. 29.4% in group 3; p = 0.003). No differences
among groups were detected in terms of perineal outcomes. A lower rate of
episiotomy/lacerations ≥ 2nd degree was found among women who practiced sports
that specifically involved the perineal muscles and who continued this practice during
pregnancy. It is concluded that perineal outcomes are not influenced by the intensity
of sport activity performed before/during pregnancy. Continuous sports during
pregnancy that specifically train the perineal muscles are associated with a lower rate
of episiotomy and perineal lacerations ≥ 2nd degree.39

10. Albers LL, Selder KD, (2012) et al were conducted a study in Mexico to
identify the maternal and clinical factors related to genital tract trauma in normal
spontaneous vaginal births. A woman who had a first vaginal birth, risk factors for
trauma was maternal education, valsalva pushing, and the infant birth weight. Risk
factors for woman having second or higher vaginal births were prior sutured trauma
and infant birth weight. Delivery technique that is unrushed and controlled may help
to reduce obstetric trauma in normal spontaneous vaginal birth.40
Studies related to prevention of perineal tear
Studies Related To Prevention Of Perineal Tear
Pierce-Williams RAM, Saccone G, Berghella V (2018) were conducted a
meta-analysis of randomized controlled trials on Hands-on versus hands-off
techniques for the prevention of perineal trauma during vaginal delivery. The aim of
this systematic review with meta-analysis was to evaluate whether a hands-on
technique during vaginal delivery results in less incidence of perineal trauma than a
hands-off technique. Randomized controlled trials comparing a hands-on technique
of perineal support during vaginal delivery (i.e. intervention group) with a hands-off
technique (i.e. control group) were included in the meta-analysis. Hands-on was
defined as involving one hand on the fetal head, applying pressure to control
expulsion, with the other hand applying pressure on the maternal perineum. The
results of the study was that five trials, including 7287 women, were analyzed. All
studies included singleton gestations with cephalic presentation at term undergoing
spontaneous vaginal delivery. Women randomized to the hands-on technique had
similar incidence of severe perineal trauma (1.5 versus 1.3%; RR 2.00, 95% CI 0.56-
7.15). There was no significant between-group difference in the incidence of
intact perineum, first-, second- and fourth-degree laceration. Hands-on technique was
associated with increased risk of third-degree lacerations (2.6 versus 0.7%; RR 3.41,
95% CI 1.39-8.37) and of episiotomy (13.6 versus 9.8%, RR 1.59, 95% CI 1.14-2.22)
compared to the hands-off technique. It is concluded that hands-on technique during
spontaneous vaginal delivery of singleton gestations results in similar incidence of
several perinealtraumas compared to a hands-off technique. The incidence of third-
degree lacerations and of episiotomy increases with the hands-on technique. Key
Message A hands-on technique during vaginal delivery results in similar incidence of
severe lacerations compared to hands-off.41

11. Magoga G, Saccone G (2018) et al conducted a meta analysis study on
Warm perineal compresses during the second stage of labor for
reducing perineal trauma. The aim of this systematic review and meta-analysis of
randomized controlled trials was to evaluate the effectiveness of warm compresses
during the second stage of labor in reducing perineal trauma. . Inclusion criteria were
randomized trials comparing warm compresses (i.e. intervention group) with no warm
compresses (i.e. control group) during the second stage of labor. Types of participants
included pregnant women planning to have a spontaneous vaginal birth at term with a
singleton in a cephalic presentation. The primary outcome was the incidence of
intact perineum. Results revealed that seven trials, including 2103 participants, were
included in this meta-analysis. Women assigned to the intervention group received
warm compresses made from clean washcloths or perineal pads immersed in warm
tap water. These were held against the woman's perineum during and in between
pushes in second stage. Warm compresses usually started when the baby's head began
to distend the perineum or when there was active fetal descent in the second stage of
labor. We found a higher rate of intact perineum in the intervention group compared
to the control group (22.4% vs 15.4%; RR 1.46, 95% CI 1.22 to 1.74); a lower rate of
third degree tears (1.9% vs 5.0%; RR 0.38, 95% CI 0.22 to 0.64), fourth
degree tears (0.0% vs 0.9%; RR 0.11, 95% CI 0.01 to 0.86) third and fourth
degree tears combined (1.9% vs 5.8%; RR 0.34, 95% CI 0.20 to 0.56) and episiotomy
(10.4% vs 17.1%; RR 0.61, 95% CI 0.51 to 0.74). it is concluded that warm
compresses applied during the second stage of labor increase the incidence of
intact perineum and lower the risk of episiotomy and severe perineal trauma.42
Ma DM, Hu W, Wang YH (2017) were conducted a study on multicentre
study on the effect of moderate perineal protection technique: a new technique
for perineal management in labour. 31,249 women accepted the traditional technique
were selected as control group, and 57,056 women accepted the
Moderate Perineal Protection technique as the observation group. There was no
significant difference in demographic characteristics between the two groups. The
perineal episiotomy rate decreased (22.913% vs. 32.161%, p < .05), the
perineal integrity significantly increased (43.505% vs. 36.384%, p < .05) and
perineal trauma reduced in the observation group when compared to the control group
(54.630% vs. 61.239% in first degree tears, and 1.826% vs. 2.340% in second degree
tears, p < .05). The neonatal asphyxia rate in the observation group was lower

12. than that in the control group (p < .05). The observation group also had a higher rate of
total satisfaction, lower VAS score for perineal pain, shorter postpartum
hospitalisation days, lower rate of postpartum urinary retention and postpartum
incontinence (p < .05). We concluded that the Moderate Perineal Protection technique is
safe, effective and worth promoting widely.43
Frietman SK, Compagnie E (2017) et al were conducted a retrospective
study on single-stage reconstruction of third-degree perineal lacerations in horses
under general anesthesia: Utrecht repair method. The objective of the study was that
to describe perioperative management, surgical procedure, and outcome in mares with
third-degree perineal lacerations (TDPL) treated with a single-stage repair, the
Utrecht repair method (URM). The results of the study was that mares ranged in age
from 3.5 to 11 years. Long-term follow-up was available for 13 mares. Mean duration
of follow-up was 9 years (median, 9.5; range, 2-215 months (17.9 years)).
Standardized perioperative fasting and postoperative refeeding protocols were used.
Only five mares received supportive gastric medication. Reconstruction of the
rectovestibular shelf was successful in 18 of 20 mares. Two of 20 mares developed a
small rectovestibular fistula after the initial repair, which was successfully repaired
with a second surgery. Other postoperative complications were observed in 13 mares
and consisted of mild postanesthetic myositis, facial nerve paralysis, esophageal
obstruction, rectal obstipation, partial perineal dehiscence, and rectal or vestibular
wind-sucking. Six of seven mares that were subsequently bred became pregnant. It is
concluded that the alternative single-stage reconstruction for TDPL was successful in
18 of 20 mares after a single surgery. No major complications related directly to the
technique were noted.44
Dieb AS, Shoab AY (2017) et al were conducted a randomized controlled
trial on Perineal massage and training reduce perineal trauma in pregnant women
older than 35 years. The aim of this study was to evaluate the effectiveness
of perineal massage, pelvic floor muscle training (PFMT) and a pelvic floor
dysfunction (PFD) prevention educational program in pregnant women above the age
of 35 years to prevent perineal tear and episiotomy. The first group (n = 200) was
educated to do digital perineal massage and pelvic floor muscle training and received
an educational PFD prevention program. The second group (n = 200) received only the
prevention education program. Occurrence of perineallaceration was reported at

13. time of delivery as a primary outcome. The results shows that delivery was
significantly less complicated by perineal tear, episiotomy and postnatal pain in the
first than in the second group (p < 0.05). Grades of perineal tear were mostly of first and
second degree in the first group compared with the second group. We found a
significantly lower need for analgesia and fewer ampoules required during the
hospital stay in the first group (p < 0.001, 0.002, respectively). It is concluded that
performing antenatal digital perineal massage and PFMT in addition to health
education is recommended to reduce perinealcomplications.45
Garcia J, Renfrew M (2017) et al were conducted a descriptive study trial
participants who delivered spontaneously at term. The purpose of the study was to
describe the range and extent of childbirth trauma and related postnatal pain using
data from a large randomized clinical trial of perineal management techniques. Study
included 5471 sample. Data are reported for sites of trauma, and the relation to
episiotomy, suturing, and maternal reports of pain at 2 days, 10 days, and 3 months
after birth. Result of study showed that 85% of all women experienced some form of
trauma, with first- or second-degree perineal lacerations occurring in 2/3 of women
and outer vaginal tears occurring in one-half. Tears to the rectum and vaginal vault
were more common with episiotomy. Pain declined over time, and a gradient in pain
was observed according to the site and complexity of trauma. The study concluded
that genital tract trauma is extremely common with spontaneous vaginal birth.
Effective measures to prevent or reduce its occurrence would benefit many new
mothers.46
De Tayrae R, Panel L, Masson G, Mares P (2017) conducted a study to
assess the efficacy of episiotomy to prevent severe perineal tears, urinary
incontinence, fecal incontinence and genital prolapse. A systematic review on midline
data base was performed finally 43 articles were analyzed. The study showed that
routine use of episiotomy did not prevent severe perineal tears. It decreased the risk of
moderate anterior perineal lacerations. The risk of perineal tears during episiotomy
increased in primiparity Asian woman, forceps or vacuum assisted delivery and
macrosomia. Relevant studies were consistent in demonstrating no benefit for routine
episiotomy to prevent urinary and fecal incontinence or pelvic floor relaxation.47

14. Marko EK, Fausett MB, (2015) was conducted a study on Reducing
Perineal Lacerations Through Team-Based Simulation. The objective of this
study was to evaluate the effectiveness of an interprofessional simulation-based
teams-training program aimed at reducing severe perineal lacerations during
childbirth. A quasi- experimental pre-post single-group design was used to
examine the performance of labor. Results show that during an 18-month period,
675 personnel in 4 hospitals participated in the program. Significant
improvement was noted in pre-post scores of knowledge (59.86%, 93.87%, P <
0.0001), performance (36.54%, 93.45%, P <
0.0001), and safety culture (3.24, 1.45, 1 = high, 5 = low, P < 0.0001).
Severe perineal laceration rates decreased by 33.38% since initiation. Rates
fluctuated with the addition of new personnel and renewed educational programs.
It is concluded that a multimodal interprofessional simulation program of
strategies to prevent severe perineal lacerations significantly improved
knowledge, skills, and attitudes in labor and delivery personnel within a
healthcare system. Severe perineal laceration rates were reduced.48