Assessment of Manual Perineal Protection Techniques Applied in The Second Stage of Labor and Its Relation To Women's Birth Outcome

ISSN 2394-7330
International Journal of Novel Research in Healthcare and Nursing

Vol. 11, Issue 2, pp: (44-55), Month: May - August 2024, Available at: www.noveltyjournals.com
Assessment of Manual Perineal Protection

Techniques Applied in the Second Stage of
Labor and its relation to women's Birth
Outcome
Fatema AbdulAziz Owais1, Prof. Sahar Anwar Rizk2,
Assistant Prof. Dr. lamyaa Yousef alyaba3
1
Nurse Specialist at East Jeddah hospital, Saudi Arabia.
2
Associate Professor Maternity, Nursing, KSAU Saudi Arabia.
3
Assistant Professor Oncology, KSAU, Saudi Arabia.
DOI: https://doi.org/10.5281/zenodo.11146417
Published Date: 08-May-2024
Abstract: Background: Perineal trauma can expose many women to short/ long-term physical, psychological, and
social complications. As birth is imminent, the primary priority ismaintaining perineal integrity and avoiding
perineal tear. Different perineal techniques are being used to protect the perineum and prevent injury including the
three proposed methods (FMPP- VMPP-MRM). Aim: This study aimed to assess the relationship between various
manual perineal protection techniques and birth outcomes during the second stage of labour. Methodology: a non-
experimental quantitative study was performed at East Jeddah hospital, KSA. The study population consisted of a
non-probability convenience sampling of 180 parturient women. Data collection was done by filling out the
questionnaire through direct questions and observation of the childbirth process after consenting. Result: The main
finding of the current study shows that the mean age was 31.8± 5.8 years (P <0.05), More than three- quarters of
participants were multigravida and used a directed way of pushing, The vast majority of newborns were in cephalic
presentation, occipito-posterior position, their weights were average (2.5-3.5kg). The VMPP technique was the most
dominant MPP technique used by the attendants. The mean of the first stage, second stage, and pushing time was
(8.3 ±3.9/Hr., 38.6 ±24.7/ min, & 27.5 ±18.8/ min) respectively. No complications during childbirth had been
observed, and all newborns were vigorous 7-10 APGAR scores at the first and fifth minutes of life. Conclusion: This
study concluded that there were no significant differences between the use of VMPP or FMPP techniques regarding
birth outcomes. Worth mentioning that there was no single case of OASIs has been reported.
Keywords: MPP, parturient, perineum, Hands- on, Guarding, OASI.
1. INTRODUCTION
Nothing is more beautiful, unique, and powerful than a woman giving birth. This ceremony simultaneously births a new
mother and a new baby, an unforgettable moment (Schenker, 2019). As birth is imminent, the primary priority is maintaining
perineal integrity and avoiding perineal tear (King et al., 2019). Perineal trauma/ laceration or tear is any damage to the
perineum (from the vagina to the anus) during childbirth. It can occur spontaneously or result from a surgical incision:
episiotomy (Althaydi et al., 2018).
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Worldwide, around 9 of 10 primiparous' women will experience some tear or laceration, 3.5% of them will experience third-
degree tear during the active stage of labor. However, it is much less in multigravida. Eventually, most of the spontaneous
tear will heal quickly (Aasheim et al., 2017; Royal College of Obstetricians and Gynaecologists, 2021).
Royal and American College of obstetrics and gynecology; classifies perineal lacerations into 4 degrees. The first-degree
tear is superficial trauma to vaginal mucosa that may include perineal skin and heals on its own. The second-degree tear
consists of the vaginal mucosa, perineal skin, and muscles of the posterior fourchette. It does not include the anal sphincter
and usually needs stitching. The third-degree tear involves vaginal mucosa, skin, perineal muscles, and external anal
sphincter. The third-degree tear is subdivided into three categories: 3A < 50% of the external anal sphincter affected, 3B >
50% of the external anal sphincter affected, and 3C if the internal anal sphincter is involved. The fourth-degree tear consists
of the skin, vaginal mucosa, perineal muscles, posterior fourchette reaching internal and external anal sphincters, and the
anterior mucosa of the rectum (Royal College of Obstetricians and Gynecologists, 2021). (OASIS), require suturing in the
operation theater (Al-Ghamdi et al., 2018)
One of the most contributing causes of increasing or decreasing the risk of perineal trauma is the birth attendant. Some birth
attendants make it very likely to have a perineal tear.
Parity is considered a contributing factor to perineal tear. Multiparous are less likely to experience third- and fourth-degree
tear than primiparous. Furthermore, the baby's weight and position of presenting part may also increase or decrease the
chance of having a perineal tear (Dekker, 2022).
Perineal trauma can expose many women to short/ long-term physical, psychological, and social complications. They may
not be life-threatening, but they can affect every aspect of women's life. The perineal tear is likely to affect self-esteem,
which means it will affect relationships at home with partners and children and other relationships with friends, family,
social life, work, and employment opportunities (Frankel, 2022). Furthermore, perineal pain may be a long-term
complication (Goh et al., 2018).
Physical complications such as bleeding, perineal trauma, and pain are the first complications that can occur immediately
after childbirth. Women who experience perineal trauma have longer and more intense perineal pain than those with intact
perineum (Goh et al.,
2018). Other complications may also occur, including rectovaginal (perineal) fistula, perineal hematomas, wound infection,
dehiscence, necrotizing fasciitis, stress incontinence, pelvic organ prolapse, and unintentionally leaving a foreign body.
Dyspareunia and flatal & fecal incontinence have been the most significant long-term issues. Indeed, OASIS is a substantial
risk factor for delayed sexual intercourse resumption after birth and dyspareunia one year after childbirth. Flatal
incontinence might occur up to ten years post-OASIS. Therefore, anal sphincter incompetence is still a major problem.
These complications affect the mother, both physically and psychologically, and affect her care for the newborn and herself
(Goh et al., 2018). Despite this, mothers should be reassured that approximately 80% of women do not suffer from
symptoms after a year of repairing the OASIS and muscle healing (Goh et al., 2018).
Different perineal techniques are being used to slow down the birth of the baby's head and allow the perineum to stretch
slowly to prevent injury. Those techniques may include massage, warm compresses, several manual perineal protection
(MPP) techniques (Finnish manual perineal protection (FMPP), Viennese Manual Perineal Protection (VMPP), and
Modified Ritgen Maneuver (MRM) (see figure 1-2) (Aasheim et al., 2017; Kleprlikova et al., 2020) are widely used by
birth attendants.
A randomized control trial (RCT) study has shown that midwives in different countries tried various measures for guarding
the perineum during birth, including (MPP) and its impact on decreasing OASIS (Zhou et al., 2019). Nevertheless, it is
critical to recognize that most of the (RCTs) that assessed the subject did not focus on providing details about the method
used for perineal guarding (Kleprlikova et al., 2020).
A retrospective study that was conducted in Abha, Saudi Arabia, reported that a total of (85 out of 19,374) women had a
vaginal tear (0.43%), (81) had a third-degree and four had a fourth-degree perineal tear, (52) of the (85) women (61%) were
primiparous (al Ghamdi, 2020). The low incidence of OASIS in this study results from proactive manual protection of the
perineum, valid indications for episiotomy, and attendance of senior staff members at all difficult deliveries (al Ghamdi,
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2020). Moreover, a meta-analysis of MPP at the time of childbirth reported that there is a significant drop in the rate of
OASIS with MPP (three studies, 74,744 women; RR 0.45; 95% CI 0.40–0.50; I2 = 32%) (Bulchandani et al., 2015).
Significance of the study:
A randomized control trial (RCT) study has shown that midwives in different countries tried various measures for guarding
the perineum during birth, including (MPP) and its impact on decreasing OASIS (Zhou et al., 2019). Nevertheless, it is
critical to recognize that most of the (RCTs) that assessed the subject did not focus on providing details about the method
used for perineal guarding (Kleprlikova et al., 2020). To the author's knowledge, no studies reported MPP on the birth
outcome among the Saudi population. The current study will be a pioneer in Saudi Arabia. It will uncover the performance
of various birth attendants, either midwives or obstetricians, toward using Manual Perineal Protection techniques that play
an essential role in reducing perineal trauma during the childbirth process.
Aim of the Study: The current study aimed to assess the relationship between the use of Manual Perineal Protection
techniques and birth outcomes during the second stage of labour among parturient women at East Jeddah Hospital. Thus,
the study objectives are:
Research questions:
1. What is the relation between Manual Perineal Protection techniques: FMPP, VMPP, and MRM and the maternal outcome
among parturient women?
2. What is the relation between the Manual Perineal Protection techniques: FMPP, VMPP, and MRM and the neonatal
outcome among parturient women?
3. What is the association between MPP techniques and perineal trauma among parturient women?
2. METHODOLOGY
Research design: A non-experimental, observational design was employed for the study. The non- experimental research
is defined as research that does not involve the manipulation of an independent variable. Instead of controlling an
independent variable, non-experimental researchers simply observe variables as they occur naturally in the real world (Price
et al., 2017).
Research setting: The study was conducted at the labour and delivery unit in East Jeddah general hospital, Saudi Arabia.
East Jeddah general hospital is one of the largest and most advanced governmental hospitals in Jeddah province, with a
300-bed capacity. The hospital also has an expanded obstetric department as one of the largest maternity units in Jeddah. It
includes 12 single delivery rooms with a resuscitator, and 31 staff including midwives and nurses, responsible for the women
since admission to childbirth. Midwives conduct most low-risk childbirths. But high-risk like; pregnancies with medical
diseases, and assisted instrumental delivery are conducted by obstetricians.
Study Population Based on the inclusion criteria, parturient women scheduled to be admitted to the labour and delivery
unit were recruited for this study. The inclusion criteria consist of all women willing to participate in the study, >18 years
old, with gestational age >37wk, primipara and multipara in the second stage of labour with cephalic presentation and
spontaneous vaginal delivery, and with an estimated baby weight <4.00 Kg.The exclusion criteria include: All preterm
labour <37 wk, assisted vaginal delivery using ventose or forceps, epidural analgesia, labour augmentation by oxytocin,
malpresentation, congenital fetal anomaly, and multiple pregnancies, obese women ˃30 BMI, all pregnant women with
medical/chronic diseases.
Sample Size: The Calculator.net website was utilized to determine the appropriate sample size (calculator.net, 2021). Based
on the power analysis, the desired sample size was 177. However, the number was increased to 180 to avoid any withdrawal
rate, with a margin error of 4.73%. The parameters included for the calculation were 327, which is the number of
spontaneous vaginal delivery per 3 months at East Jeddah General Hospital, and the confidence interval was set to 95%
with a ± 5%margin of error which means the real value is within ±5% of the measured or surveyed value.
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Sampling Technique: A non-probability convenience sampling method was used. This sampling technique relies on
collecting data from the population members who are suitably and readily available to participate in the study. It is used
commonly and is incredibly rapid, straightforward, and economical. In many prospective members are readily available to
participate in the study (Saunders et al., 2012).
Data collection process: Data was collected after the participant's voluntary consent, first by direct questions using the tool
(I). When the woman goes into the pushing stage, the tool (II&III) was completed via direct observation for the whole birth
event until finishing two hours postpartum. The observation includes an assessment of the MPP technique (see figure 1&2)
and an assessment of the perineum by an expert midwife or obstetrician according to RCOG’s definition of perineal
lacerations. The assigned midwife or the nurse assessed the newborn using ABGAR scoring for the first and the fifth minute
of life. In addition, the newborn was assessed using a modified tool (III), tool (I & III) was developed initially by Ismail
and Tayel & kaboudan and his colleagues (Ismail & Tayel, 2019; Kaboudan et al., 2021).
Tool (I): Socio-demographic and clinical data, were developed after an extensive review of the literature and discussion
with experts in the field of OB/GYN
Tool (I). Socio-demographic data: age, level of education, occupation, current residence, and age at marriage.
Part 2: Current obstetric data: gravidity, parity, weeks of gestation, fetal position, fetal presentation, height, weight, body
mass index, way of pushing, birth position, and baby weight.
Tool (II). A manual perineal support observational checklist was developed after a pilot study and literature review (King
et al., 2019; Kleprlikova et al., 2020). Including the three techniques: FMPP, VMPP, and MRM.
Tool (III). Maternal and fetal course of labour and its outcome assessment checklist:
Part 1: Maternal course of labour and its outcome assessment checklist: duration of the 1st stage, duration of the 2nd stage,
pushing time, type of perineal support, time of the beginning of oxytocin, perineal condition, postpartum hemorrhage, time
of beginning oxytocin after birth, perineal condition, perineal tear degree, and complications occurred during childbirth.
Part 2: fetal course of labour and its outcome assessment checklist: ABGAR scores at 1st and 5th minute, fetal problems at
1st and 5th minutes, and the need for resuscitation (Ismail & Tayel, 2019; Kaboudan et al., 2021).
Reliability and validity
Tool (III) reliability was tested using the Cronbach Alpha coefficient test in two studies, with internal consistency that
equals (0.89) & (0.91) for the Maternal course of labor and its outcome assessment checklist (Ismail & Tayel, 2019;
Kaboudan et al., 2021) For the perineal tear categories in the tool (III), Internal consistency equals (0.72) (Mackenzie et al.,
2018).
The three tools mentioned above were checked for content validity by three experts in the field of OB/GYN nursing to
ensure it is consistent and relevant.
Data management and analysis plan:Collected data were coded, entered, and analyzed using SPSS version 25 software.
Descriptive statistics including frequency, percentage and graphs were used for categorical variables. Means and SD were
calculated for quantitative variables. Inferential methods included a Chi-square test for association between the categorical
variables and a t-test for independent groups. A p-value of less than or equal to 0.05 was considered significant.
Ethical consideration: This study was conducted after approval by the College of Nursing Research Unit, King Abdullah
International Medical Research Center (KAIMRC) Jeddah, the Institutional Review Board (IRB) at King Abdulaziz Medical
City-Western Region, and the Ministry of Health with East Jeddah hospital approval.
In addition, the responsible personnel in the hospital were contacted and notified before the actual time for data collection.
Furthermore, the researcher explained the study's purpose and nature to each participant who meets the inclusion criteria.
Also, informed consent was offered to all participants, including the following points: participation in this study is voluntary,
maintaining the confidentiality of participants and parturient women can withdraw at any time without penalty or treatment
bias.Finally, their information was saved and kept anonymous for safety and confidentiality. Names were not used, and all
data was kept in a safe place; these data are only accessible to the research team.
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3. RESULT AND DATA ANALYSIS

Findings: Introduction
Table 1: Sociodemographic characteristics of participants:
The sociodemographic characteristics of 180 participants are presented in Table 1. The mean age was 31.8 ± 5.8 years and
the mean age at marriage was 25.1 ± 4.4. Almost a fifth of the participants (82.2%) had a university degree, and two-thirds
were housewives (65.0%). The vast majority (90.0%) were urban residents.
Table 2: Current obstetric data
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The current obstetric data presented in table 2 shows that 12.2% of women were primigravida, and about half of them were
gravida 2 to 3. The mean gestational age was 38.7± 2.6 weeks. The directed way of pushing was dominant with 95.0%, and
the most common birth position was lithotomy (79.9%). The majority of fetal position was anterior with cephalic
presentation. Moreover, about three-quarters (76.7%) of the participants were overweight. Most infants (80.6%) weighed
between 2.5 and 3.5 kg.
Figure 1: Manual Perineal Support Observational Checklist
Figure 1 shows types of manual perineal support used by birth attendants. Among the three types included in this study,
VMPP was the dominant manual perineal protection technique (84.4%). While no attendant used the MRN technique.
Table 3: Maternal course of labor and its outcome assessment checklist:
Table 3, the maternal course of labor and its outcome assessment shows that the mean duration of the first stage was 8.3
hours, and the second stages were 38.6 minutes. The pushing time mean was 27.5 minutes. The distribution of perineal
condition showed that 46.1% were intact, 43.3% were torn, and 10.6% had an episiotomy. The first degree of perineal tear
was dominant, and no complications occurred during childbirth.
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Table 4: The neonatal course of labor and its outcome:
Table 4 presents the Neonatal labor outcomes. All newborns had ABGAR scores of 7 to 10 after the first and fifth minutes.
No fetal problems or resuscitation were observed for all newborns.
Table 5: Sociodemographic characteristics by technique:
Table 5 present the association results between the sociodemographic characteristics and the type of perineal support
technique. The association showed statistically significant differences in variables of age (P = 0.009) and level of education
(P = 0.049). However, there were no significant differences between MPP and occupation, current residence, and age at
marriage (P > 0.05).
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Table 6: Current obstetric data by technique:
The current obstetric condition is presented in table 6. There was no significant association between gravidity, parity, and
weeks of gestation in regard to MPP. Moreover, there was no significant relationship between fetal position, presentation,
and weight. Body mass index, birth position, and way of pushing were not significantly related (P > 0.05).
Table 7: Maternal outcomes by technique:
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Regarding the maternal outcome and the use of different MPP techniques (Table 7), there was no significant relationship
between the variables, MPP and the duration of the first and second stages of labour, pushing time, and the time of the
beginning of oxytocin. There was also no significant association between the use of different MPP techniques perineal
condition, tear degree, and complications during childbirth (P value > 0.05).
Table 8: The neonatal course of labor and its outcome by technique:
No significant relationship was identified between neonatal outcome (APGAR scores after one & five minutes, fetal
problems, and the need for resuscitation) by the type of MPP in addition P-values cannot be obtained due to the absence of
variability, as all cases fall into one category of each variable.
Figure 2: Association between MPP and Perineal condition
Figure 2: shows the association between MPP and Perineal condition. The analysis revealed no significant association
between MPP techniques and perineal condition (p = 0.48).
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4. DISCUSSION OF FINDINGS, CONCLUSION, LIMITATIONS, AND RECOMMENDATIONS

Discussion
Discussion of the study results is presented under three main headings: manual perineal protection techniques checklist,
Maternal and fetal course of labor and its outcome assessment checklist, and degree of perineal injury.
Regarding the sociodemographic characteristics of the study subjects, the results of the current study revealed that the
average age of the women was 31.8 ± 5.8 years, and the majority of them were multigravida and multiparous women. The
study outcomes are partially consistent with (al Ghamdi, 2020) the study was conducted in Mirbat in Abha Hospital, to
assess incidence factors and predisposing factors for third- and fourth-degree perineal tear, which gives the same result for
the average age of the participants 31 years but the women in his study were prim gravidas.
Next, the current study revealed that there was no significant relationship between Manual Perineal Protection techniques
and course of the maternal labor and its outcomes in relation to its parity. This could be attributed to many reasons. First,
the vast majority of the study subjects were multi or grand multiparas with the normal course of labour. Second, the majority
of fetal positions were in Occipito-Anterior, and their weight was> 2.5 -3.5 kg. These findings are consistent with the
findings of (Dekker, 2022) The researcher found that Multiparous are less likely to experience third- and fourth-degree tear
than primiparous (Al Gamdi, 2020; Dekker, 2022). Moreover, fetal weight and position of presenting part may also increase
or decrease the chance of developing a perineal tear. (Al Gamdi, 2020; Dekker, 2022). A retrospective study she found that
primiparous was one of the leading causes of 3rd and 4th- degree tear.
The results of the current study indicated that there were no statistically significant differences between the MPP techniques
and the perineal condition. It is interesting to explain that, less than half of the study had a perineal condition that was either
intact or had a tear, while the rest underwent an episiotomy. These outcomes are consistent with those of (Downe et
al.,2004). They conducted a study entitled “A prospective randomized trial on the effect of an adverse second stage of
labour, on labor outcomes in women not delivering with epidural analgesia”). The results of the study showed that, by the
practical method, when the fetal head is extended in the vulva and perineum the introitus opens 5 cm or more (Downe et
al., 2004). This technique facilitates the dilation of the fetal head; thus, the fetal head passes the introitus in the perineum
with smaller diameters, and it is associated with less perineal trauma, especially in connection with the less need for an
episiotomy (Foroughipour et al., 2011).
However, the results of this study did not show significant differences between manual perineal protection techniques and
the degree of perineal tearing. About two-thirds of the subjects surveyed had a first-degree tear and no case was reported
for third and fourth-degree tear. In line with (Pasi, 2020) study where he studied the effect of a modified vinnise technique
(VMPP) on perineal protection during labor, Pasi found that the use of a modified VMPP showsa significant reduction in
the incidence of perineal injury, and neither third nor fourth-degree tear were reported. Another study (Naidu et al., 2017)
aimed to determine whether perineal support at the time of vaginal delivery could reduce the incidence and severity of
OASIS, reported that perineal support was associated with a significant decrease in OASI rates.
The results of this study did not show any significant differences between manual perineal protection techniques and the
duration of the second stage of labor. It is interesting to note that about half of the subjects in the study had intact perineum
and the duration of the second stage of labor stag was slightly shorter. The result of the current study is not consistent with
the results of (Aasheim et al., 2017) and ; Kleprlikova et al., 2020). They reported that Various perineal techniques (MPP)are
being used to slow down the birth of the baby's head and allow the perineum to stretch slowly to prevent injury. Hands-on
approach is believed to promote spontaneous vaginal delivery and reduce perineal trauma (Aasheim et al., 2017; Kleprlikova
et al., 2020; Trochez et al., 2011).
Although the results of the current study revealed that there was no significant relationship between manual perineal
protection techniques and neonatal outcomes. A positive result was noted as all of the newborns had (7-10) APGAR scores
after one and five minutes, without problems in the fetus, or the need for resuscitation. This consistent profile of the newborn
was helpful in reducing external factors, which could interfere with the occurrence of fetal distress or the need for
resuscitation. The findings are constant with (de Souza Caroci da Costa and Gonzalez Riesco, 2006) , who conduct a study
titled “Comparison of ‘hands-off’ versus ‘hands-on’ techniques for reducing perineal tear during childbirth”, their study
shows a higher rate of positive neonatal outcomes in the hands-on group.
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Limitations: Despite the fact that this study offered some insight into the connection between MPP and birth outcomes, the
small sample size, limits generalizability. Additionally, compared to other sample techniques, the convenience sampling
technique adopted here, has lower population representativeness.
Research Implications:
Education: Integrate and teach these techniques for nursing and midwifery in universities.
Practice and Administration: Continuous training of midwives and nurses to use MPP correctly. Stakeholders and
policymakers in hospitals can add mastery of these techniques in the annual evaluation attendees including OBYGN
clinicians and midwives and create competencies for them.
Research: Replicate the study and reducing or eliminating the limitations such as the sample size and choosing primigravida
population. Conduct using systematic reviews and meta-analysis to summarize the best evidence regarding MPP technique
practice.
Recommendation:
Based on the findings we recommend the following:
• Further studies are needed to assess birth attendants' performance. Focusing on primigravida participants, adding the head
circumference of the neonate, and excluding OP position fetuses for more specific results.
• Combine another approach in addition to the MPP techniques to preserve the perineum during childbirth.
• It is vital to include the MPP techniques in the midwifery/ nursing teaching curriculum
Conclusion
There was no significant relationship between the use of various Manual Perineal Protection techniques on birth outcomes,
in addition VMPP was the most preferred technique by birth attendants, while there was an equal effectiveness of (VMPP,
FMPP) techniques in relation to birth outcome. Worth mentioning, MPP techniques showed zero incidences of OASIs.
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International Journal of Novel Research in Healthcare and Nursing