Some Techniques May Help Reduce Perineal Trauma. (Perineal Massage, Warm Compresses).

SAN FRANCISCO -- Episiotomy rates are down. Now what?

It's time to turn attention to other means of reducing perineal trauma during childbirth, certified nurse-midwife Judith Bishop said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The rate of primiparous women with intact perinea or first-degree lacerations has tripled at the university since 1979 as the episiotomy rate for term, spontaneous deliveries has decreased from 69% to 10%.

Restricting the use of episiotomy is the only intervention proven to help reduce perineal trauma; it's backed by six randomized, controlled trials and many retrospective reviews, said Ms. Bishop of the university. Although minimizing episiotomy use may increase the number of anterior and vaginal lacerations reported, these carry minimal morbidity compared with other lacerations that are more common with episiotomy.

The strongest predictor of episiotomy use is the patient's type of health care provider. Private obstetricians have the highest episiotomy rate, midwives have the lowest rate, and faculty obstetricians and family physicians have rates in between these two extremes.

Data suggest that minimizing instrumental deliveries--or choosing vacuum delivery over forceps--may reduce perineal trauma. The instruments can damage tissue and are more likely to be accompanied by episiotomy to make room for the devices.

Few delivery positions have been studied with regard to perineal injury. A review of 16 randomized, controlled trials found no difference in perineal trauma rates between women who delivered in an upright position or in a supine position.