A randomised controlled trial of care of the perineum during second stage of normal labour

Objective To compare the effect of two methods of perineal management used during spontaneous vaginal delivery on the prevalence of perineal pain repo rted at 10 days after birth. Design Randomised controlled trial, Setting Two English maternity care units. Sample 5471 women who gave birth between December 1994 and December 1996. Methods At the end of the second stage of labour women were allocated to ei ther the 'hands on' method, in which the midwife's hands put pressure on th e baby's head and support ('guard') the perineum; lateral flexion is then u sed to facilitate delivery of the shoulders, or the 'hands poised' method, in which the midwife keeps her hands poised, not touching the head or perin eum, allowing spontaneous delivery of the shoulders. Main outcome measure Perineal pain in the previous 24 hours reported by wom en in self-administered questionnaire 10 days after birth. Results Questionnaires were completed by 97% of women at 10 days after birt h. 910 (34.1%) women in the 'hands poised' group reported pain in the previ ous 24 hours compared with 823 (31.1%) in the 'hands on' group (RR 1.10, 95 % CI 1.01 to 1.18: absolute difference 3%, 0.5% to 5%, P = 0.02). The rate of episiotomy was significantly lower in the 'hands poised' group (RR 0.79, 99% CI 0.65 to 0.96, P = 0.008) but the rate of manual removal of placenta was significantly higher(RR 1.69, 99% CI 1.02 to 2.78; P = 0.008). There w ere no other statistically significant differences detected between the two methods. Conclusion The reduction in pain observed in the 'hands on' group was stati stically significant and the difference detected potentially affects a subs tantial number of women. These results provide evidence to enable individua l women and health professionals to decide which perineal management is pre ferable.