perineal trauma guideline (gl836) - royal berkshire hospital protocols and... · perineal trauma...

Perineal Trauma guideline (GL836)

Approval Approval Group Job Title, Chair of Committee Date Maternity & Children’s Services Clinical Governance Committee

Chair, Maternity Clinical Governance Committee

3rd May 2019

Change History Version Date Author, job title Reason 8.0 Jan 2019 H Inkster, Practice Dev MW,

T Haxton Snr Midwife, C Harding, Consultant MW

Amalgamation of existing guideline with those listed below

8.1 June 2019 T Haxton, C Harding, S Phillip

Appendix 4 added pg 17 MDT wound assessment & care plan

8.2 August 2019

C Harding, Consultant MW H Inkster, Practice Devt MW

Appendix 5 added pg 18 OASI risk assessment poster

Now includes information from the following which have now been withdrawn

• Third & Fourth degree tears_(GL926) V8.0

• Perineal wounds Assessment & Management (GL885) V5.0 Please also refer to:

• Local Safety Standard for Invasive procedures (GL1041) FBS

• Local Safety Standard for Invasive procedures (GL1042) Repair of vaginal and/or perineal trauma in the birthing environment

Author: H Inkster, T Haxton, C Harding Date: August 2019 Job Title: Practice Devt. MW, Snr MW, Consultant MW Review Date: May 2021 Policy Lead: Group Director Urgent Care Version: 8.2 August 2019

8.0 ratified 3/5/19 Location: Policy hub/ Clinical/ Maternity/ Intrapartum/ GL836 This document is valid only on date last printed of 20

Perineal Trauma guideline (GL836) August 2019 CONTENTS

1.0 Aims ............................................................................................................... 4

2.0 Intrapartum risk Assessment ....................................................................... 4

2.1 Intrapartum Care in labour to reduce perineal trauma ............................... 4

3.0 Assessment of degree of trauma both in hospital and community settings 5

4.0 First and Second degree tears: Suturing Technique ................................. 6

4.1 Management and suturing of OASI.............................................................. 7

5.0 First, Second and Labial tears ..................................................................... 9

6.0 Follow-up and prognosis of OASI ............................................................. 10

7.0 Record keeping ........................................................................................... 10

8.0 Guidance for possible problems that may occur ..................................... 11

Appendix 1 - Wound swabbing - The Levine quantitative swab technique ..... 13

Appendix 2 - How to use Flaminal – information for users ............................... 14

Appendix 3 – Wexner score sheet (Physio use) .................................................. 16

Appendix 4 – MDT Perineal Wound assessment & care plan…………………….17

Appendix 5 – OASI risk assessment poster ........................................................ 18

9.0 References ................................................................................................... 19



Perineal Trauma guideline (GL836) August 2019 Overview: Perineal trauma is one of the most common complications related to birth. It can occur spontaneously in the form of a perineal tear or secondary to an intervention such as an episiotomy or an assisted vaginal delivery,

The overall incidence of OASI (Obstetric Anal Sphincter Injury i.e. 3rd and 4th degree tears is 2.9% in the UK with an incidence of 6.1% in primiparae compared with 1.7% in multiparae. An appropriately trained Obstetrician must identify and repair this serious complication of vaginal delivery to reduce maternal morbidity, especially subsequent anal incontinence. Episiotomy and 1st / 2nd degree repairs can be performed by midwives. All repairs should ideally be completed within an hour of the delivery of the placenta, or as soon as possible. The relevant healthcare professionals should attend training in perineal/genital assessment and repair, and ensure that they maintain these skills as required in the Maternity Training Needs Analysis (CG360).

Definitions:

First degree tear – damage to the perineal/ vaginal skin only with intact underlying perineal muscles

Second degree tear – posterior vaginal wall, perineal skin and underlying muscle damaged

Third degree tear: partial or complete disruption of the anal sphincter muscles, which may involve either or both external (EAS) and internal (IAS) anal sphincter muscles. Classification: 3a: < 50% of EAS torn 3b: > 50% of EAS torn 3c: both EAS and IAS torn If there is any doubt about the grade of third degree tear, it is advisable to classify it to the higher degree rather than lower degree.

Fourth degree tear: disruption of the anal sphincter muscles with a breach or damage of the rectal mucosa.

‘Button hole’ tear: This tear involves the anal mucosa with intact anal sphincter muscles. It should be documented separately. Non recognition may cause recto-vaginal fistulae.



Perineal Trauma guideline (GL836) August 2019

1.0 Aims • To reduce the morbidity associated with perineal trauma.

• To improve the information given to those women who sustain perineal trauma

• To identify and treat at an early stage any complications.

• To provide a consistent level of care by all members of the multi-disciplinary team.

2.0 Intrapartum risk Assessment Risk factors for OASI • Women who birth their babies vaginally for the first time

• Ethnicity (South Asia women)

• (Short perineum < 3cms)

• Prolonged second stage --- O/P position

• Birthing stools/upright position/lithotomy for delivery

• Birth -weight > than 4kg

• Instrumental Birth

• Previous OASI 2.1 Intrapartum Care in labour to reduce perineal trauma

Intrapartum Clinical Measures Risks and benefits Maternal position • Upright positions reduce the incidence of

assisted birth or severe pain. They have no effect on the rate of OASI but may increase the incidence of 2nd degree tears (Gupta JK, et al., 2004).

• Birthing stools and lithotomy position should be avoided for birth as these can increase the incidence of OASI

Pushing techniques

A longer period of active pushing is linked to increased perineal pain in those with minor injuries

(Leeman L, 2009(11)). • Encourage women to commence active pushing in

response to their own urges. • Slowing the birth of the fetal head at the time of

crowning may reduce the risk of perineal trauma (Albers L, 2007)




Intrapartum Clinical Measures Risks and benefits Hands on and Hands Poised Techniques

• Hands on is thought to reduce “mild” perineal pain in the first 10 days. (Aasheim V, 2011)

• Manual Perineal Protection at crowning can be protective in the reduction of OASI (RCOG 2015)

• Good communication with the women as the head is crowning aids slow delivery of head and shoulders and can have a protective effect on perineal trauma

Warm Compresses

• Warm compresses applied to the perineum during the second stage of labour reduces the risk of OASI. (WHO 2018, RCOG 2015)

• Warm compresses should be offered to All women when the head is crowning

Episiotomy at 60 degrees • Clinicians should explain to women that the evidence for the protective effect of episiotomy is conflicting.

• Mediolateral episiotomy should be considered in instrumental deliveries.

• Where episiotomy is indicated, the mediolateral technique is recommended, with careful attention to ensure that the angle is 60 degrees away from the midline when the perineum is distended. (RCOG 2015)

2ND Person in the room for delivery (MSW or student midwife)

• Enable the midwife facilitating women birthing baby to focus on slow delivery of head and body of baby

• Baby to be delivered slowly using axial traction • 2nd person to assist lead midwife with task

orientated work i.e. record keeping etc. All measures taken during labour to reduce the incidence of perineal trauma must be discussed with the mother and documented clearly on K2 or the Intrapartum pathway

3.0 Assessment of degree of trauma both in hospital and community settings • Examination of the degree of trauma should be carefully assessed with a good light

source and adequate analgesia to identify the extent of any trauma, to include the structures involved, the apex of the wound and an assessment of bleeding

• If genital trauma is identified a rectal examination should be recommended to exclude concealed trauma (NICE 2014).




• Gain verbal consent to undertake the repair and record on the perineal repair sheet or electronic records (K2).

• Ensure adequate pain relief (Kettle C, 2011;) prior to and during the procedure (e.g. Local anaesthetic nitrous gas, epidural. NB infiltrate with local anaesthetic even if epidural in situ)

• If the suturing is delayed for any reason, inform the woman and record the reason on the perineal repair sheet or electronic record.

• In the home setting if it is not possible to adequately assess the trauma, transfer the woman (with her baby) to obstetric-led care (NICE 2014)

• If the woman decides against suturing, advise on the healing process and document in the maternal health record. The evidence on leaving second-degree tears is currently inconclusive. Therefore, second degree tears and unopposed vaginal edges should be sutured to improve healing and prevent mal-alignment. Minor tears can be left un-sutured

• The woman should be referred to a more experienced healthcare professional if uncertainty exists as to the nature or extent of trauma sustained.

• The systematic assessment and its results should be fully documented, possibly pictorially. (Gordon et al 1998, Lundquist M et al 2000, Fleming VE et al 2003, Leeman et al 2009).

4.0 First and Second degree tears: Suturing Technique

• Aseptic technique: the suturing should be carried out as soon as possible after delivery and ideally within 1 hour of delivery of placenta, to minimise risk of infection and blood loss. Prior to commencing procedure remove the pack and gloves used at delivery, wash your hands and use a new suturing pack and new pair of gloves.

• Analgesia: Ensure the woman has adequate analgesia (up to 20ml Lignocaine 1%. This includes 5mls which may have been used to infiltrated the perineum for episiotomy) can be administered by a midwife. If more analgesia is required, a medical practitioner must prescribe it. When teaching a student midwife the teaching midwife maintains responsibility for the administration of the Lignocaine under midwives administrations. Inhalational analgesia should be available and offered as appropriate

• Position for Suturing: the mother must be positioned appropriately for the repair. When using lithotomy poles the woman’s legs should be placed into and taken down from the lithotomy poles by two people in order to prevent musculo-skeletal injury to the woman and staff. A good light source is essential to visualise genital structures.




Count: A formal pause to count swabs, instruments and needles should be taken prior to commencing and again on completion of any procedure that has required the opening of any packs containing said items. It is the responsibly of the clinician undertaking the procedure to ensure that the counts are done, correct and are performed with a nominated second checker. The nominated second checker within the hospital setting should not be any individual who is present in a learning capacity. If another practitioner takes over during the procedure, then a recount must take place. The count should be documented and include the name of the second checker – see GL1042 NB Insertion of swabs in the vagina is not advised. However, if necessary the tape should be secured by a clamp to the sterile drape and the swab removed at the end of the procedure – See GL1042

• Suturing technique: The apex of the episiotomy or tear must be visualised and secured firmly to achieve haemostasis. Correct anatomical alignment of the vagina, perineal body and skin must be achieved and the sutures should not be too small or too tight. Locked or non-locked continuous sutures may be used in opposing vaginal skin. The perineal skin may be left un-sutured, as in a two-stage technique (when using this technique, the aim is to leave the skin edges no more than 0.5cm apart with the woman in the lithotomy position) or the edges opposed using sub-cuticular technique (Kettle et al 2007).

• A vaginal examination & rectal examination should be performed on completion of the repair to exclude sutures in the rectal mucosa; which can cause a fistula and retained swabs. To ensure it is not too tight, the vagina should accept 2 fingers easily.

• Following suturing blood loss from both delivery and suturing should be totalled For Labial tears using smaller suture and orange needle for infiltration is recommended

4.1 Management and suturing of OASI • The consultant on-call MUST be informed about every OASI tear. This should be

documented in the woman’s health care record.

• Repair must be carried out in theatre with adequate assistance and illumination under regional or general anaesthesia.

• The birth partner and baby may accompany the mother to theatre in order to keep mother and baby together however the appropriateness of this must be assessed on an individual basis and involve a discussion with the theatre team, anaesthetist and obstetrician. The partner must be made aware that their role is to support the mother and care for the baby. Only an appropriately trained obstetrician should undertake this level of repair. If necessary a referral should be made to a colorectal surgeon. (Please refer to Maternity Training Needs Analysis - CG360).

• The woman should be informed of the extent of the trauma.




• Appropriate consent for repair must be obtained- (Hyperlink to RCOG (2010) Consent advice no. 9)

• The rectal mucosa if damaged is sutured with fine, interrupted Vicryl sutures taking care to approximate the mucosal edge and tying the knot in the rectal lumen.

• The anal sphincter is repaired with at least two interrupted Vicryl sutures (the retracted end may need a temporary traction suture), using an overlapping technique or end-to-end.

• A urinary catheter should be inserted until full bladder sensation has returned if regional anaesthesia is used

• Detail of the procedure must be documented both in writing and pictorially on the perineal repair sheet in the woman’s health care record or K2.

• Post-operative laxatives should be prescribed. Bulking agents should be avoided

• Broad spectrum antibiotics ARE recommended.



http://www.rcog.org.uk/repair-third-and-fourth-degree-perineal-tears-following-childbirth


Perineal Trauma guideline (GL836) August 2019 5.0 First, Second and Labial tears Postpartum perineal care Aim; Minimising pain and the risk of infection • Visually assess perineum at each

postnatal visit to detect early signs of breakdown and infection,

• Educate the mother on what to look out for.

• Recorded in the postnatal health record.

Reduce Pain • Apply cold packs for 10-20 minute intervals

for 24-72 hours , (Leventhal L, 2011) , placing an ice pack or ice cubes wrapped in a towel on the incision – avoid placing ice directly on to your skin as this could cause damage

• Offer regular analgesia, o Oral paracetamol one gram 4-6 hourly

no more than 12 in 24 hours. o Oral non-steroidal anti-inflammatory

drugs (Hadwen G., 2010) in the absence of any contraindications.

o Rectal Diclofenac 100mg followed by Ibuprofen 200-400mg up to 4 times daily, no sooner than 16hrs

o Dihydrocodeine 30mg orally 4-6 hourly. Wound care - what to look out for and good practices Normal wound healing • Slight redness along wound. • Possibly some swelling. • Possibly some pain.

Advise women to; • Support the perineal wound when

defecating or coughing. • Advise positions that reduce perineal

oedema, especially in the first 24-72 hours; - Lying on side in recovery position with leg supported on pillow, avoiding long sitting positions.

• Avoid activities to increase intra-abdominal pressure for 6 weeks or more i.e. straining and lifting.

• Wash and pat dry using plain water and disposable kitchen towel, from front to back (i.e. ureter to anal area) after each toileting (Hadwen G., 2010)

• Change perineal pad frequently at least 3 hourly, wash hands before and after changing and to shower at least daily to keep the perineum clean (Bick D., 2009)

• To try wear breathable materials e.g. cotton, or disposable briefs with loose trousers.

• Report concerns to their midwife or GP.



Perineal Trauma guideline (GL836) August 2019 Give Tears and Stitches leaflet for advice to ALL women who have sustained perineal trauma including OASI

6.0 Follow-up and prognosis of OASI Follow Up: • Will be seen by physiotherapist prior to discharge from hospital, if women are not

seen by physio on the ward, a physiotherapy referral form with the patient’s details should be done and sent to the physiotherapy department. The women will then be sent an appointment for outpatient physiotherapy if they are not seen on the ward

• An EPR order can be requested for inpatient physiotherapy by the midwives whilst the patient is on the ward All women with OASI will get a 6 weeks follow up appointment with the physiotherapist

• All women should receive a 16 week appointment in consultant clinic

• Following external anal sphincter repair approximately 60-80% of women are asymptomatic at 12 months

• Symptomatic women mostly report experiencing incontinence of flatus or faecal urgency

• Primary care givers in subsequent pregnancies need to be informed of anal sphincter repair and of any continuing urinary or faecal symptoms

• If symptomatic after repair and/or abnormal ultrasound or manometry findings are present elective caesarean section in subsequent pregnancies may be offered: N.B the clinical relevance of asymptomatic defects demonstrated by ultrasound is currently unclear Inform women that best practice is unknown and discuss birth options

• Vaginal birth in subsequent pregnancies is associated with a 17-24% chance of developing worsening symptoms afterwards

• The risk of repeat severe perineal trauma is not increased in subsequent birth, compared with women having their first baby (RCOG 2015)

• The role of prophylactic episiotomy in subsequent pregnancies is not known and therefore an episiotomy should only be performed if clinically indicated. (RCOG 2015)

7.0 Record keeping • All measures taken to prevent perineal trauma must be discussed with the

mother and documented within K2 or the labour care pathway

• The use of warm compresses and position for birth must be evidenced within the labour records




• Enter all discussions and procedure notes in ‘Repair of Perineal Trauma’ sheet in hospital notes or on electronic records (NMC 2018).

• A Datix incident form should be completed by the professional conducting the delivery

• Postnatal checks including visualisation of the wound must be recorded in the postnatal health record.

• Whenever there is a deviation from the normal, (see chart) a care plan must be written in women’s records and evaluated at regular intervals.

8.0 Guidance for possible problems that may occur

Problem Action Follow up

Signs of vulva haematoma; Presentation depends on site, volume .and rate of formation • Persistent Pain; - varies

according to site of haematoma.

• Signs of Hypervolemia • Urinary retention. • An unexplained Pyrexia

• MOW’s (including temperature)

• Check FBC • Assess Haemodynamic

resuscitation • Refer to PPH guidelines for

treatment of hypervolemia. • Undertake a thorough

exam by experienced doctor/Midwife

• Imagining may be required to confirm diagnosis (Mawhinney S, 2007)

• Preventing further blood loss; - treat anaemia

• Minimising tissue damage;- • If packing remove 12-24 hours • Managing pain • Reducing the risk of infection • Providing women with

information and counselling and refer to Physio.

Early signs of localised infection • New or increasing pain. • Erythema. • Local warmth • Swelling around the suture

line. • In some cases there may be

an usual smell

• If early signs of localised wound infection, take a swab for MC&S using Levine technique.

• MOW’s assessment • Advise regular analgesia

and educate woman on promoting healing. Commence and educate woman on use of Flaminal gel 2/3 x daily. Follow up prescription can be prescribed by the GP.

• See GP in 1-2/52 for review in. • If no improvement chase

wound swab and consider adding oral antibiotics.

• If signs of sepsis, wound abscess or new haematoma refer to DAU for obstetric review.




Problem Action Follow up

Signs of localised infection spreading +/- Gape in perineum;- • Discharge – viscous,

discoloured and purulent. • Delayed or poor healing. • Perineal gaping/ to complete

wound break down. • Discolouration of tissue, or

friable bleeding tissue

• As above • This will normally heal by

secondary intention.

• If signs of infection, wound abscess or new haematoma refer to DAU for obstetric review.

• If referred into the unit assess Wound using Multi-Disciplinary Wound Assessment and Care Plan

• Review frequently and if no improvement, refer to GP sooner for assessment and antibiotics.

Signs and Symptoms of systemic infection to Completely broken down perineum. • Further deterioration of

wound- completely broken down perineum.

• Signs of pyrexia or hypothermia.

• As above • Commence Flaminal as

above after taking swap of wound.

• Urgent review by GP within 24hours, to commence oral antibiotics earlier.

• This will normally heal by secondary intention.

• If signs of infection, wound abscess or new haematoma refer to DAU for obstetric review.

• If referred into the unit assess Wound using Multi-Disciplinary Wound Assessment and Care Plan

Signs of sepsis. • Fever, rigors (persistent

spiking temperature, or low temperature <36 degrees suggests abscess). Beware: normal temperature may be attributable to antipyretics or NSAIDs

• Diarrhoea or vomiting – may indicate exotoxin production (early toxic shock)

• Abdominal /pelvic pain and tenderness Wound infection – spreading cellulitis or discharge Offensive vaginal discharge

• Urinary symptoms • Delay in uterine involution,

heavy lochia • General – non-specific signs

such as lethargy, reduced appetite

• MOW’s > 3 • Refer to and follow the

maternal Sepsis Tool, • All women who are unwell

during the puerperium require regular and frequent observation.

• Escalate concerns and insure multidisciplinary team involvement.

• The speed of onset or deterioration in symptoms and signs is important.

• Follow AMBER and RED Flag criteria on Sepsis 6 Pathway

(See Sepsis Guidelines GL872)



Perineal Trauma guideline (GL836) August 2019 Appendix 1 - Wound swabbing - The Levine quantitative swab technique

− Only swab if evidence of wound infection

− Usually identifies the bacterial species of the infection, and help steer antibiotic therapy

− Surface swabs will only unveil the colonising organism –may not reflect deeper tissue infection

The Levine quantitative swab technique

− Clean wound with normal saline

− Pat dry wound bed with sterile gauze

− Culture healthiest looking tissue, exclude exudate, purulent or devitalized tissue

− Spin end of sterile applicator over a 1cm x 1cm area for at least 5 seconds

− Apply sufficient pressure to swab, causing tissue fluid to be expressed



Perineal Trauma guideline (GL836) August 2019 Appendix 2 - How to use Flaminal – information for users

Antimicrobial

Please follow the instructions below a minimum of twice a day. Once in the morning and once before bedtime Wash and dry your hands thoroughly and collect everything you will need below • Tube of Flaminal • Clean sterilised syringe • 5-6 sheets of kitchen roll for drying hands and perineum

Instructions 1. Wash and dry your hands and dry with kitchen roll. 2. Pull the plunger out of the back of the syringe and fill with the Flaminal – see the picture

below.

3. Put the plunger back into the syringe so it is ready to use. 4. Clean the area with water- do not use shower gels or soap, using a shower head to

spray the area gently. 5. Pat the area dry with kitchen roll. 6. Wash your hands and dry with the kitchen roll 7. Pick up the prepared syringe and with one leg on the edge of the bath and using a

mirror to see the area you are treating, fill the area with Flaminal in a nice thick layer by pushing down on the plunger.




Please remember whilst you are having this treatment • To wash your hands BEFORE and AFTER using the toilet

• Try and keep the area as clean and dry as you can

• Use maternity sanitary pads only during this time, the thin plastic pads can cause the area to sweat which can cause infection.

• Change sanitary pads regularly and keep them in a clean bag (sandwich bag) so as not to get contaminated/dirty in handbags/nappy bags etc.

How to clean the syringe after use • Wash out the syringe using warm soapy water

• Sterilise using cold water sterilising fluid following the manufacturer’s instructions on the bottle- DO NOT use a steam steriliser.

Review The wound should be reviewed after 2 weeks by GP. Take the following actions in the following situations:

• If there are signs of wound improvement and a reduction in the signs and symptoms of infection, consider whether you need to discontinue the antimicrobial dressing. If the wound shows signs of improvement signs of infection remain, continue with the antimicrobial dressing for a further two weeks,

• If the wound deteriorates, fully reassess to exclude contributing causes (other than infection) that might indicate an alternative approach or the addition of systemic therapy



Perineal Trauma guideline (GL836) August 2019 Appendix 3 –Wexner score sheet (Physio use)



Appendix 4 – MDT Perineal Wound assessment & care plan




Appendix 5 – OASI risk assessment poster




9.0 References • Aasheim V, Nilsen ABVika, Lukasse M, Reinar L. Perineal techniques during the

second stage of labour for reducing perineal trauma. Cochrane Database of Systematic Reviews. 2011; Issue 3. Art. No.: CD006672. DOI:10.1002/14651858.CD006672.pub2.

• Albers L, 2007 Minimizing genital tract trauma and related pain following spontaneous vaginal birth. Albers LL, Borders N. J Midwifery Womens Health. 2007 May-Jun;52(3):246-53.

• Bick D. Postpartum management of the perineum. British Journal of Midwifery. 2009; 17(9):571-7.

• Fleming VE, Hagen S, Niven C 2003. Does perineal suturing make a difference? The SUNS Trial, British Journal of Obstetrics and Gynaecology: 110(7):684-9

• Gordon B et al. 1998 The Ipswich Childbirth Study: 1. A randomised evaluation of 2-stage postpartum perineal repair leaving the skin unsutured. British Journal of Obstetrics & Gynaecology 105 (4): 435-440

• Hadwen G. Perineal care: postnatal. The Joanna Briggs Institute. 2010.

• Kettle C, Hills RK, Ismail KMK. Continuous versus interrupted sutures for repair of episiotomy or second degree tears. Cochrane Database of Systematic Reviews. 2007; Issue 4 Art. No.: CD000947. DOI: 10.1002/14651858.CD000947.pub2.

• Leeman L, Fullilove A, Borders N, Manocchio R, Albers L, Rogers R. Postpartum perineal pain in a low episiotomy setting: Association with severity of genital trauma, labour care, and birth variables. Birth. 2009; 36(4):283-8.

• Leeman L, Fullilove A, Borders N, Manocchio R, Albers L, Rogers R. Postpartum perineal pain in a low episiotomy setting: Association with severity of genital trauma, labor care, and birth variables. Birth. 2009; 36(4):283-8.

• Leventhal L, de Oliveira S, Nobre M, da Silva F. Perineal analgesia with an ice pack after spontaneous vaginal birth: a randomised controlled trial. Journal of Midwifery and Women’s Health. 2011; 56:141-46.

• Lundquist M et al 2000. Is it necessary to suture all vaginal lacerations after a delivery? Birth 27(2):79-85.

• Mawhinney S, Holman R. Practice points puerperal genital haematoma: a commonly missed diagnosis. The Obstetrician and Gynaecologist. 2007; 9:195-200.

• National Institute for Health and Care Excellence. (2014). Intrapartum care for healthy women and babies (CG190) London: NICE



https://www.ncbi.nlm.nih.gov/pubmed/17467591



• Nursing and Midwifery Council (NMC) (2015) The Code. Professional standards of practice and behaviour for nurses and midwives Nursing and Midwifery Council: London

• Pairman S, e. a. (2010). Midwifery preparation for practice. . Sydney: Churchill r. Livingston Elsevie.

• Position in the second stage of labour for women without epidural anaesthesia. Gupta JK, Sood A, Hofmeyr GJ, Vogel JP. Cochrane Database Syst Rev. 2017 May 25;5:CD002006. doi: 10.1002/14651858.CD002006.pub4. Review. PMID:28539008

• RCOG Consent Advice No.9 June 2010. Repair of Third & Fourth Degree perineal Tears following Childbirth - hyperlink to RCOG

• Royal College of Obstetricians & Gynaecologists. (2015). The management of Third and Fourth Degree Perineal Tears. Green-top guideline No.29 London: RCOG.

• WHO Reproductive Health Library. WHO recommendation on techniques for preventing perineal trauma in second stage of labour (February 2018). The WHO Reproductive Health Library; Geneva: World Health Organization.






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