Save the Perineum! A Protocol to Reduce Perineal Trauma


Paper Presentation

Purpose for the Program

Perineal trauma, including a third-degree or fourth-degree laceration, is a serious adverse outcome of a vaginal delivery, which can lead to chronic pain, urinary or bowel disturbances, and sexual dysfunction. The third-degree and fourth-degree laceration rate at this large university hospital was noted to be in the high range based on the University Health System Consortium database. The Obstetric Quality and Safety Committee identified the rate of third-degree and fourth-degree lacerations and charged a multidisciplinary team composed of physicians, nurses, and nurse–midwives to investigate potential causes that could be addressed to make positive improvements on the issue.

Proposed Change

To implement a perineal safety bundle for management of the second stage of labor. There are practices with some evidence thought to decrease perineal trauma; however, the team was not confident that one particular change alone would affect the rate of third-degree and fourth-degree lacerations. Therefore, a bundle was created composed of the following: (a) “Labor down” for at least 1 hour or until the urge to push is felt (but no longer than 2 hours); (b) use of warm packs to the perineum applied every 30 minutes during the second stage of labor; (c) change position every 15 to 20 minutes to help facilitate fetal descent and rotation; (d) foot position should rest on the bed or in foot rests instead of being held by the nurse or support person (avoidance of McRobert position except for the shoulder dystocia maneuver); and (e) avoidance of manual perineal stretching during the second stage of labor.

Implementation, Outcomes, and Evaluation

Nurses, physicians, and residents were educated about the bundle protocol. Physicians were given the option to opt-in or opt-out of the bundle. The protocol used during this 6-month time frame concluded in January 2013. Data on differences between use of the bundle versus nonuse will be compared with third-degree and fourth-degree laceration rates.

Implications for Nursing Practice

The implementation of evidence-based practice related to the second stage of labor is a process. Varied techniques of leg holding positions, perineal massage and manipulation, and passive management of the “labor down” phase have been thought to add to the perineal trauma and use of operative vaginal delivery techniques. Introduction of the bundle has provided direction to the nursing and medical staff in use of evidence-based practice.