Literature Review
The effect of maternal position
at birth on perineal trauma:
A systematic review
Abstract
Perineal trauma is associated with short- and long-term maternal
morbidity. Research has found that maternal position at birth can
influence perineal trauma. However, there is a dearth of evidence
examining specific maternal positions, including waterbirth, and
how these can influence incidence and degree of perineal trauma.
Such evidence is important to help reduce trauma rates and improve
information for women and midwives. To address this gap in reliable
evidence, a systematic review was conducted. Seven studies met the
inclusion criteria. Compared to land birth, waterbirth was found to cause
an increase in perineal trauma. Kneeling and all-fours positions were
most protective of an intact perineum. Allowing for different variables,
sitting, squatting and using a birth-stool caused the greatest incidence
of trauma. The findings of this review demonstrate that further research
is required around perineal guarding in alternative birth positions and
how parity affects trauma rates with waterbirth, so that women may be
advised appropriately. It also suggests findings that midwives can use
when discussing alternative birth positions with women.
Keywords: Perineal trauma, Waterbirth, Labour, Childbirth
G
enital tract sepsis is now the leading cause
of direct maternal death in the UK, with
the incidence rising since 2006 (Cantwell
et al, 2011). Perineal trauma can increase the
risk of puerperal infection, potentially leading to
sepsis (Cantwell et al, 2011; Kettle, 2011). It is also
associated with long- and short-term morbidities
such as pain and dyspareunia, stress and urge
urinary incontinence, and flatus incontinence
(McCandlish et al, 1998; Barrett et al, 2000;
Williams et al, 2007). These morbidities can lead to
women experiencing complex psychological issues
such as social isolation, anxiety, embarrassment
and avoidance of intimate contact due to fear of
Fay Lodge, Community Midwife, Calderdale and Huddersfield NHS
Foundation Trust
Dr Melanie Haith-Cooper, Director of Post Graduate Research/Senior
Lecturer in Midwifery and Reproductive Health, University of Bradford
mcooper2@bradford.ac.uk
172
pain (Williams et al, 2005; OReilly et al, 2009;
Priddis et al, 2013). In addition, women may fear
and anticipate pain during the suturing process
(Priddis et al, 2013), an intervention which can
blight an otherwise satisfying birth experience.
Perineal trauma is classified on the severity
of the tear into first, second, 3a, 3b, 3c and
fourth degree, depending on the level to which
the surrounding tissues are involved. Anterior
perineal trauma can also occur to the labia, urethra
and clitoris, though this is usually associated
with little morbidity (Aasheim et al, 2012). The
degree of morbidity is directly related to the
degree of perineal injury sustained (Williams
et al, 2007; Rdestad et al, 2008; Aasheim et al,
2012). Consequently, it is essential that midwives
practise in such a way as to reduce perineal
trauma, where possible.
A great deal of research has been conducted
into what causes and increases the incidence
of perineal trauma (Mayerhofer et al, 2002;
Christianson et al, 2003; Albers et al, 2005;
da Silva et al, 2012) with many factors being
attributed, including primiparity, instrumental
birth, ethnicity, heavier babies, maternal age
and body mass index. In addition, controllable
factors have been found to affect perineal trauma,
including birthing techniques and different birth
positions (Dahlen et al, 2007; da Silva et al, 2012;
Meyvis et al, 2012).
There are published guidelines advising on
birth positions (Royal College of Midwives (RCM),
2012a; 2012b; National Institute for Health and
Care Excellence (NICE), 2014). However, these
identify a lack of robust evidence differentiating
between birth positions, including waterbirth
when compared with recumbent positions, and
the incidence and degree of perineal trauma
sustained (RCM, 2012a; 2012b; NICE, 2014). NICE
(2014) states that there is no difference in the
rate of intact perinea when a supine position is
2016 MA Healthcare Ltd
compared with upright positions. However, the
guidelines question the methodological quality
of the studies used to substantiate their evidence.
Consequently, the results should be interpreted
British Journal of Midwifery March 2016 Vol 24, No 3
 Literature Review

with caution. The guidelines also rely on studies

that included lateral and semi-recumbent as
upright positions, which are not recommended
by the RCM Better Births Initiative as neither of
these positions allow for the assistance of gravity
during birth (RCM, 2015).
A Cochrane review (Gupta et al, 2012) examined
duration of the second stage of labour, comparing
limited birth positions (upright, birth-stool/
squatting and birth chair/cushion) with supine/
lithotomy positions, excluding waterbirth.
However, different upright positions were not
compared and perineal trauma was only considered
as a secondary outcome. Trauma not requiring
suturing was also excluded.
With research demonstrating that birth
position affects the rate and degree of perineal
trauma (Cluett and Burns, 2009; Gupta et al, 2012;
Dahlen et al, 2013), it is important to consider
which birth positions midwives are best placed to
promote to reduce the degree of trauma women
experience. However, no evidence could be
found specifically examining data related to this.
Consequently, this article will discuss a systematic
review that was undertaken to address this, with
the following review question:
Do different maternal positions at
birth affect the incidence and degree
ofperineal trauma?
Methods
The review protocol was formulated using the
Centre for Reviews and Disseminations (CRDs)
guidance for undertaking systematic reviews
(CRD, 2009). An initial literature scoping
exercise revealed sufficient literature and no
Table 1. Final search terms used with PICOS framework
Population Intervention/Comparator Outcome
Labour Birth/birthing position(s) Perineal trauma
Women Delivery position(s) Perineal tear
Maternal Water birth/waterbirth Perineum
Second stage Pool birth Perineal injury/ies
Birth Position Tear
Genital tract trauma
Trauma
Laceration
PICOSpatient/problem/population, intervention, comparison/control/comparator,
outcomes, study type
previously conducted reviews with the same
review question. A combination of search terms
(Table 1) was collated and used in an extensive
search of 19databases and Department of Health
publications. Reference lists of relevant articles
were hand-searched and known experts in the
field contacted. The review was limited to English
language and published studies only, due to
feasibility constraints, but was not limited by
year of publication. Studies that were considered
to meet the eligibility criteria (Table 2) based on
the title, abstract and subject descriptors were
obtained for data synthesis.
The final search generated 114 citations, and
a further 13 studies were discovered through
contacting experts and searching reference lists
of identified studies. A total of 32 citations were
obtained and assessed for eligibility against the
inclusion and exclusion criteria, leaving 10studies
suitable to be included in the review (Figure 1).
These studies were then subject to quality
assessment using the validated checklist from
the Critical Appraisal Skills Programme (CASP,

Table 2. Inclusion and exclusion criteria

PICOS Inclusion criteria Exclusion criteria
P Women following a natural vaginal birth Women following instrumental birth or
caesarean section
I Natural/upright birth positionsstanding, all fours, on Legs in lithotomy, supine/dorsal position, lateral
knees, squatting, in water, birth-stool, semi-recumbent (Sims) position, Trendelenburg position (head lower
position (trunk tilted forwards up to 30 to the horizontal) than pelvis)
C Natural/upright birth positionsstanding, all fours, Legs in lithotomy, supine/dorsal position, lateral
on knees, squatting, in water, on a birth-stool, semi- (Sims) position, Trendelenburg position (head lower
recumbent position (trunk tilted forwards up to 30 to than pelvis)
thehorizontal)
O Intact perineum Episiotomies
2016 MA Healthcare Ltd

Perineal trauma (including grazes, anterior perineal

trauma, first-, second-, third- and fourth-degree tears)
S Quantitative studies Qualitative studies
PICOSpatient/problem/population, intervention, comparison/control/comparator, outcomes, study type

British Journal of Midwifery March 2016 Vol 24, No 3 173

Literature Review

of Bias (CCRB) tool (Higgins et al, 2011). Two

studies were excluded due to interventions and
Titles and abstracts outcomes not being reported separately. For
identified and screened transparency of the selection process, excluded
n=114 studies were recorded in a table, detailing the
reason for rejection.
Studies identified Excluded Data synthesis adopted a narrative approach
from contact with n=86 due to the heterogeneity of the included studies
experts n=3 (CRD, 2009). Tables were used to assist with
Studies identified the textual narrative, allowing visual exploration
Unable to obtain of their relationships. As narrative synthesis is
from searching in
n=9 inherently a more subjective process than meta-
reference lists n=10
analysis, the author followed the guidance and
Full copies obtained and framework produced by the Economic and Social
assessed for eligibility Research Council (ESRC) methods programme
Excluded n=22 n=32 (Popay et al, 2006; Rodgers et al, 2009). The
Not relevant design academic supervisor offered ongoing support to
n=7 reduce the risk of bias.
Fits exclusion
criteria n=13 Findings
Did not meet Summary of included studies
inclusion criteria Table 4 gives an overview of the included studies
n=2 Publications meeting and Table 5 shows a quality assessment, with the
inclusion criteria strongest-quality studies to the left and studies
n=10 with an increased risk of bias to the right of
Excluded n=3 the table. There was vast heterogeneity among
Excluded during the studies, with variability of study design,
quality assessment population, setting, interventions and outcomes.
n=1 Only one study (Cortes et al, 2011) was undertaken
Interventions not in the UK. The others were conducted in countries
reported separately across Europe and Australia, all of which have
n=1 Number of studies very different maternity systems and practices.
Outcomes not included in the Some studies were conducted in hospital labour
reported separately review n=7
wards, others in birth centres; the increased risk
for each treatment of intervention in a hospital setting (NICE, 2014)
n=1 is an important factor for consideration when
interpreting results. Some women were attended
by midwives, others by obstetricians. These
Figure 1. Flowchart of search strategy. Adapted from Moher et al (2009) variationssuch as episiotomies being standard
practice in Turkey, as is being attended by an
2013). The results from the CASP checklists were obstetrician rather than a midwife (Hotun ahin
presented in a table relating them to the PICOS et al, 2007; Midwifery Today, 2015)will have
(problem, intervention, comparison, outcomes, influenced results. It is acknowledged that these
study type) framework, to allow clear comparison variations may have influenced the findings of
of the findings (Table3). One citation was rejected this review.
during this process as the study did not address a There was only one randomised controlled
clearly focused issue. trial (RCT) included (Table 4), considered the
Data extraction was undertaken using the gold standard of research (Altman et al, 2007);
Cochrane Collaboration data collection the other six were cohort studies, all deemed to
(CCDC) form (Cochrane Collaboration, 2013), be weaker in relation to quality and risk of bias
a standardised form providing consistency and when assessed using the CCRB tool (Higgins et
improving reliability and validity for quantitative al, 2011; Lodge, unpublished). Authors justified
2016 MA Healthcare Ltd

studies (Higgins and Deeks, 2011). Risk of not selecting an RCT from an ethical perspective:
bias due to non-randomised studies and poor that restricting women to certain positions
methodology was considered within the CCDC and withholding choices could not be ethically
form using the Cochrane Collaborations Risk justified. Despite the perceived limitations of

174 British Journal of Midwifery March 2016 Vol 24, No 3

 Literature Review

Table 3. CASP Checklist/PICOS Comparison Table

S P I C
Study Did the trial/study Were study participants Was exposure Were the groups similar
address a clearly recruited in an acceptable measured accurately to at the start of the trial/
focused issue? way/randomised? minimise bias/ were confounding
did blinding occur? factors accounted for?
Altman et al (2007) Y Y N Y
Randomised
controlled trial (RCT)
Cortes et al (2011) Y Y Y Y
Cohort study
Da Silva et al (2012)* N Y
Cohort study
Dahlen et al (2013) Y Y Y Y
Cohort study
Gardosi et al (1989) Y Y N Y
RCT
Geissbuehler et al Y Y Y Y
(2004)
Cohort study
Golay et al (1993) Y Y Y Y
Cohort study
Mollamahmutoglu
Y Y Y Y
etal (2012)
Cohort study
Shorten et al (2002) Y Y Y Y
Cohort study
Soong and Barnes Y Y Y Y
(2005)
Cohort study
*Study excluded during quality assessment; Study excluded during data extraction
CASPCritical Appraisal Skills Programme; PICOSpatient/problem/population, intervention, comparison/control/comparator, outcomes, study type

cohort designs, the overall assessment of quality
was good, so the results can be considered
propitiously.
The findings from the systematic review suggest
that different maternal positions at birth affect the
degree and incidence of perineal trauma.
Waterbirth
This systematic review found more second-degree
tears compared to rates of intact perinea and
first-degree tears (Cortes et al, 2011; Dahlen et al,
2013), but with more intact perinea in multipara
women (Mollamahmutolu et al, 2012). Only one
study compared waterbirth with different land
birth positions (Dahlen et al, 2013), finding it to
be protective of perineal trauma in comparison
2016 MA Healthcare Ltd
trauma was found in waterbirth (Geissbuehler et
al, 2004; Cortes et al, 2011; Mollamahmutolu et al,
2012) contradicting previous research which found
no difference in trauma rates between land and
waterbirth (Cluett and Burns, 2009).
While Geissbuehler et al (2004) found
a reduction in third- and fourth-degree tears
with waterbirth in comparison to land birth for
primagravid and multigravid women combined,
Cortes et al (2011) found an increase. This study,
however, only considered nulliparous women and
cannot be compared to other included studies
considering waterbirth and third- and fourth-
degree tears, due to the possible inclusion of
episiotomies in their data (Mollamahmutolu et
al, 2012; Dahlen et al, 2013). Cortes et als (2011)

to using a birth-stool and squatting positions but findings were linked to the length of immersion
less protective than all-fours/kneeling positions in water during labour, and the study proposed
(Dahlen et al, 2013). Compared to land birth that water caused an increase in perineal elasticity,
in general, an increase in incidence of perineal shortening the second stage but giving less time

British Journal of Midwifery March 2016 Vol 24, No 3 175

176
Table 4. Overview of included studies
Study Study type Study Participants Study Interventions Outcomes
characteristics population
Altman et al Randomised Swedish hospital 271 Primiparous Kneeling and sitting Kneeling and sitting upright during labour
(2007) controlled delivery ward positions were not associated with significant
trial differences in third- and fourth-degree
lacerations in normal, healthy women
atterm
Cortes et al (2011) Retrospective UK home from 738 Primiparous Waterbirth and undefined Waterbirth was found to have a greater
Literature Review

cohort study home birth unit land birth position incidence of third-degree tears (2.5% vs
1.3%) but the overall incidence of intact
perineum and perineal trauma following
waterbirth and land birth was not
statistically significant
Dahlen et al Retrospective Australian 6018 Parity not Waterbirth, all-fours/ Women who gave birth in water compared
(2013) cohort study alongside birth defined keeling, semi-recumbent, to positions on land had better perineal
centre standing, birth-stool, outcomes and women who birthed on a
squatting birth-stool had a higher rate of perineal
trauma
Geissbuehler et al Cohort study Swiss hospital 9518 Primiparous Waterbirth and land birth Significantly higher rates of no injuries,
(2004) and positions (bed birth, Maia first- and second-degree perineal
multiparous stool birth, holding onto lacerations, vaginal and labial tears
rope, lying on a mat, were found in the waterbirth group, and
supported all-fours and significantly more third- and fourth-degree
Roma wheel) lacerations after spontaneous land births.
No difference was found between the two
groups for clitoral tears

Mollamahmutoglu Cohort study Turkish hospital 411 Primiparous Waterbirth and land birth Perineal laceration rates were higher
et al (2012) and (conventional vaginal in the waterbirth group than with
multiparous delivery) conventional vaginal delivery but the
authors state however most of these
lacerations were minimal
Shorten et al Retrospective Australian public 2891 Parity not Semi-recumbent, all-fours, Alternative birth positions did not perform
(2002) cohort study hospital defined kneeling, standing and better than the semi-recumbent position
squatting positions and the squatting position demonstrated
least favourable results
Soong and Barnes Prospective Australian public 3756 Parity not Sitting, semi-recumbent, Semi-recumbent position was significantly
(2005) cohort study hospital defined all-fours, kneeling, associated with more perineal trauma,
standing and squatting while women birthing in the all-fours
positions position were less likely to sustain trauma

British Journal of Midwifery March 2016 Vol 24, No 3

2016 MA Healthcare Ltd
 Literature Review

Table 5. Overall quality assessment including risk of bias

Types of bias Studies in order of overall quality assessment including risk of bias
Strongest < < < <
Altman et Dahlen et Shorten et
Mollamahmutoglu Geissbuehler Soong and Cortes et al
al (2007) al (2013) al (2002) et al (2012) et al (2004) Barnes (2011)
(2005)
Selection bias Low Low Unclear Low High Low Unclear
random sequence
generation
Selection bias Low Low Unclear Unclear Unclear Low Low
allocation
concealment
Performance bias Low Low Unclear Low Low Unclear Low
Detection bias Low Unclear Low Unclear Unclear Unclear Low
Attrition bias Unclear High* Low Low Low Low Low
Reporting bias Low High* Low Low Low Low Unclear
Other bias Low Low Low High Low Low Low
Overall risk Low High* Moderate Moderate High Low Low
assessment of bias
CASP quality Good Good Good Good Good Adequate Adequate
assessment
* Risk of attrition and reporting bias documented as high on Cochrane Collaboration data collection form, but original data supplied by author and used for
review, therefore although attrition and reporting bias high risk, overall assessment with original data improves overall quality rating of study
CASPCritical Appraisal Skills Programme

for the tissues to stretch. This contradicts Cluett
and Burns (2009), who suggested a potential
benefit of waterbirth is an increase in elasticity of
the birth canal and perineum which may reduce
the incidence and severity of tearing.
All-fours and kneeling positions
The greatest incidence of intact perinea was
found with all-fours position, with kneeling a
close second. Rates above 50% were found in the
majority of studies (Shorten et al, 2002; Soong and
Barnes, 2005; Altman et al, 2007).
However, Altman et al (2007) and Cortes et al
(2011) documented all degrees of perineal trauma
as one outcome, and others included anterior
trauma in addition (Geissbuehler et al, 2004;
Dahlen et al, 2013). Some studies included all tears
requiring suturing as one outcome (Shorten et al,
2002; Soong and Barnes, 2005; Mollamahmutolu
et al, 2012). Consequently, it cannot be examined
in any detail whether all-fours and kneeling
positions can be protective of different types of
perineal trauma.
2016 MA Healthcare Ltd
(Altman et al, 2007). The rate of second-degree
tear (or first and second combined) was around
50% (Shorten et al, 2002; Soong and Barnes,
2005; Altman et al, 2007; Dahlen et al, 2013).
Few studies considered anterior trauma but
interestingly rates of labial tear were found to be
lower with these positions than with waterbirth
and other land birth positions (Geissbuehler et al,
2004; Dahlen et al, 2013). This review contradicts
previous evidence (Thies-Lagergren et al, 2011)
which found no increase in perineal trauma when
women used a birth stool. However, this trial
restricted its use to 30 minutes. In this context,
it was suggested that the high rates of trauma
associated with the birth-stool may have been
linked to the way it was used in the second stage
of labour when progess was slow (Dahlen et al,
2013), assisting in an upright position but possibly
causing increased perineal oedema and therefore
increased rates of trauma.
Parity
This systematic review aimed to investigate
whether perineal trauma and birth position may

Sitting, squatting and using a birth-stool be influenced by parity. Despite parity being
These positions were found to have the highest regularly discussed, there were minimal studies
incidence and degree of perineal trauma, with included in the review where parity was recorded
rates being up to 85.7% for primiparous women in relation to birth position, with only one study

British Journal of Midwifery March 2016 Vol 24, No 3 177


Literature Review
Further research
is required into how
parity and the length
of immersion during
waterbirth affects
perineal trauma, as
well as the safety and
practicalities of providing
perineal support in active
birth positions, including
waterbirth
considering multiparity (Mollamahmutolu et
al, 2012) and birth positions being limited to
kneeling, sitting (Altman et al, 2007), waterbirth
(Cortes et al, 2011) and undefined land birth
(Mollamahmutolu et al, 2012). Without further
studies considering parity with birth position,
a strong conclusion cannot yet be drawn and
practice cannot be influenced.
Implications of findings
The RCM (2015) Better Births Initiative advocates
the use of active birth positions to take advantage
of gravity. Midwives are advised to encourage
women to adopt different positions during labour
and birth. Midwives could use the findings from
this review when considering which upright
position to encourage. Women could be advised
that all-fours and kneeling positions may reduce
the incidence and degree of perineal trauma. The
findings also provide a possible counter-argument
to the evidence that waterbirth reduces perineal
trauma for nulliparous women (Cluett and Burns,
2009). All-fours and kneeling positions are easily
achievable for most women and may particularly
benefit women who are reluctant to mobilise away
from the bed.
However, it is important to interpret the findings
only tentatively due to the other variables that can
influence the incidence and degree of perineal
trauma and the limitations of this review.
Birth attendants
Some birth attendants are known to have a
personal preference for certain birth positions
(Shorten et al, 2002; Bodner-Adler et al, 2004)
but it is difficult to quantify the influence of this
178
preference on the womans instinct and choice of
position. Although maternal choice was promoted
in some studies (Shorten et al, 2002; Geissbuehler
et al, 2004; Cortes et al, 2011) it is difficult to
say whether the incidence or severity of trauma
has been affected as a result of women adopting
non-instinctive positions.
Perineal guarding
Perineal guarding is recommended practice by the
Royal College of Obstetricians and Gynaecologists
(RCOG, 2015) to reduce the incidence of perineal
trauma. Only Cortes et al (2011) discussed perineal
guarding, suggesting an increase in third- and
fourth-degree tears in the waterbirth group may
be attributable to a lack of perineal guarding.
However, as no other study discussed this practice,
it is unclear as to whether not guarding the
perineum has affected the rates and degrees of
perineal trauma.
Review limitations
Owing to the multiple locations of the trials
included, some of the results may not be
generalisable to the UK population. One example
is the practice of routine episiotomies in the
Turkish study (Mollamahmutolu et al, 2012).
This will reduce the number of documented tears,
while the recommendation that episiotomies
are not performed in the water will increase
the rates of both intact perinea and trauma
requiring suturing in waterbirth compared to
land birth. Therefore, the findings from this
review are tentative and highlight the need for
further research to substantiate the implications
for practice. Although only one of the included
studies was an RCT, this demonstrates the positive
ethos of promoting maternal choice of birth
position in many countries and birth settings
across the world.
A further limitation is the lack of data presented
by some of the studies considering parity and
the differentiated degrees of perineal trauma.
Consequently the reviewer had to make some
assumptions about the missing data, though they
were not considered significant enough to have
affected the overall findings.
Conclusion
This systematic review provides evidence to
support midwives advising women antenatally
on the benefits of using kneeling and all-fours
2016 MA Healthcare Ltd
positions during birth, to increase their chances of
an intact perineum while having the gravitational
benefits of being upright. These positions would
be useful for women who are reluctant to leave
British Journal of Midwifery March 2016 Vol 24, No 3

the bed and require little physical support from
another party. Women should also be alerted
to the increased risk of perineal trauma when
birthing in a sitting/squatting position or using
a birth-stool, and midwives should be mindful
of the length of time a woman spends on a birth-
stool during the second stage. However, further
research is required into how parity and the length
of immersion during waterbirth affects perineal
trauma, as well as the safety and practicalities
of providing perineal support in active birth
positions, including waterbirth. In addition,
further research is needed into the length of time
women spend on birth-stools and/or in the water,
and how this affects perineal integrity.
Further research is required in this field,
though whether this research should take the
form of RCTs or cohort studies is an area for
ethical debate. Woodward and Kelly (2004)
demonstrated that women are accepting of the
idea of participating in RCTs, which may produce
the most reliable and unbiased form of research
(CRD, 2009). However, encouraging RCTs that
restrict womens childbirth choices opposes the
Nursing and Midwifery Council (2015) Code, which
promotes empowerment and shared decision-
making between the midwife and woman. In this
context, participating in an RCT would prevent
women from adopting instinctive birth positions,
a factor that may prove to be protective in itself.
Toinvestigate this area fullyincluding the power
of instincta majority of good-sized, multi-
centred cohort studies, alongside a minority of
RCTs, would be required. BJM
Aasheim V, Waldenstrm U, Hjelmstedt A, Rasmussen
S, Pettersson H, Schytt E (2012) Associations between
advanced maternal age and psychological distress
in primiparous women, from early pregnancy
to 18 months postpartum. BJOG 119(9):110816.
doi:10.1111/j.1471-0528.2012.03411.x
Albers LL, Sedler KD, Bedrick EJ, Teaf D, Peralta P (2005)
Midwifery care measures in the second stage of labor and
reduction of genital tract trauma at birth: a randomized
trial. J Midwifery Womens Health 50(5): 36572
Altman D, Ragnar I, Ekstrm A, Tydn T, Olsson SE
(2007) Anal sphincter lacerations and upright delivery
postures--a risk analysis from a randomized controlled
trial. Int Urogynecol J Pelvic Floor Dysfunct 18(2): 1416
Barrett G, Pendry E, Peacock J, Victor C, Thakar R,
Manyonda I (2000) Womens sexual health after
childbirth. BJOG 107(2): 18695
Bodner-Adler B, Bodner K, Kimberger O, Lozanov P,
2016 MA Healthcare Ltd
Husslein P, Mayerhofer K (2004) Influence of the birth
attendant on maternal and neonatal outcomes during
normal vaginal delivery: a comparison between midwife
and physician management. Wien Klin Wochenschr
116(1112): 37984
British Journal of Midwifery March 2016 Vol 24, No 3
Literature Review
Key points
ll There is a dearth of evidence examining different upright positions
and how they affect the incidence and degree of perineal trauma
ll This systematic review found that maternal position at birth affects
the incidence and degree of perineal trauma
ll In comparison to land birth in general, waterbirth was found to
increase the risk of perineal trauma but may be protective of an intact
perineum for multiparous women
ll Kneeling and all-fours positions are most likely to result in an intact
perineum
ll Sitting, squatting and using a birth-stool were found to cause the
highest rates and degrees of perineal trauma
ll Further research is required into the effects on perineal trauma of
birth attendant and perineal guarding in alternative birth positions
Centre for Reviews and Dissemination (2009) Systematic
Reviews: CRDs guidance for undertaking reviews in
health care. CRD, University of York, York
Christianson LM, Bovbjerg VE, McDavitt EC, Hullfish KL
(2003) Risk factors for perineal injury during delivery.
Am J Obstet Gynecol 189(1): 25560
Cluett ER, Burns E (2009) Immersion in water in labour
and birth. Cochrane Database Syst Rev (2):CD000111.
doi:10.1002/14651858.CD000111.pub3
Cantwell R, Clutton-Brock T, Cooper G et al (2011) Saving
Mothers Lives: Reviewing maternal deaths to make
motherhood safer: 2006-2008. The Eighth Report
of the Confidential Enquiries into Maternal Deaths
in the United Kingdom. BJOG 118(Suppl 1):1-203.
doi:10.1111/j.1471-0528.2010.02847.x
Cochrane Collaboration (2013) Data extraction. http://
tinyurl.com/js3mu2d (accessed 18February2016)
Cortes E, Basra R, Kelleher CJ (2011) Waterbirth and pelvic
floor injury: a retrospective study and postal survey
using ICIQ modular long form questionnaires. Eur J
Obstet Gynecol Reprod Biol 155(1):2730. doi:10.1016/j.
ejogrb.2010.11.012
Critical Appraisal Skills Programme (2013) CASP checklists.
http://tinyurl.com/psk3o2m (accessed 18February2016)
da Silva FM, de Oliveira SM, Bick D, Osava RH,
Tuesta EF, Riesco ML (2012) Risk factors for birth-
related perineal trauma: a cross-sectional study
in a birth centre. J Clin Nurs 21(1516):220918.
doi:10.1111/j.1365-2702.2012.04133.x
Dahlen HG, Dowling H, Tracy M, Schmied V, Tracy S
(2013) Maternal and perinatal outcomes amongst low
risk women giving birth in water compared to six birth
positions on land. A descriptive cross sectional study
in a birth centre over 12 years. Midwifery 29(7):75964.
doi:10.1016/j.midw.2012.07.002
Dahlen HG, Ryan M, Homer CS, Cooke M (2007) An
Australian prospective cohort study of risk factors for
severe perineal trauma during childbirth. Midwifery
23(2):196203
Gardosi J, Sylvester S, B-Lynch C (1989) Alternative
positions in the second stage of labour: a randomized
controlled trial. Br J Obstet Gynaecol 96(11): 12906
Geissbuehler V, Stein S, Eberhard J (2004) Waterbirths
compared with landbirths: an observational study of
nine years. J Perinat Med 32(4):30814
179
Literature Review
Golay J, Vedam S, Sorger L (1993) The squatting position
for the second stage of labor: effects on labor and on
maternal and fetal well-being. Birth 20(2): 738
Gupta JK, Hofmeyr GJ, Shehmar M (2012) Position in the
second stage of labour for women without epidural
anaesthesia. Cochrane Database Syst Rev 5:CD002006.
doi:10.1002/14651858.CD002006.pub3
Higgins JPT, Deeks JJ, eds. (2011) Selecting studies and
collecting data. In: Higgins JPT, Green S, eds. Cochrane
Handbook for Systematic Reviews of Interventions
Version 5.1.0. www.cochrane-handbook.org (accessed
18February2016)
Higgins JPT, Altman DG, Sterne JAC, eds. (2011) Assessing
Risk of Bias in Included Studies. In: Higgins JPT, Green
S, eds. Cochrane Handbook for Systematic Reviews of
Interventions Version 5.1.0. www.cochrane-handbook.
org (accessed 18February2016)
Hotun ahin N, Yildirim G, Aslan E (2007) Evaluating
the second stages of deliveries in a maternity hospital.
Turkiye Klinikleri. J Gynecol Obst 17(1):3743
Kettle C (2011) The Pelvic Floor. In: Henderson C,
Macdonald S, eds. Mayes Midwifery: A Textbook For
Midwives. 14th edn. Baillire Tindall, London : 55166
Mayerhofer K, Bodner-Adler B, Bodner K, Rabl M, Kaider
A, Wagenbichler P, Joura EA, Husslein P (2002)
Traditional care of the perineum during birth. A
prospective, randomized, multicenter study of 1,076
women. J Reprod Med 47(6): 47782
McCandlish R, Bowler U, van Asten H, Berridge G, Winter
C, Sames L, Garcia J, Renfrew M, Elbourne D (1998)
A randomised controlled trial of care of the perineum
during second stage of normal labour. Br J Obstet
Gynaecol 105(12): 126272
Meyvis I, Van Rompaey B, Goormans K, Truijen S, Lambers
S, Mestdagh E, Mistiaen W (2012) Maternal position and
other variables: effects on perineal outcomes in 557 births.
Birth 39(2): 11520. doi:10.1111/j.1523-536X.2012.00529.x
Midwifery Today (2015) Birth & Midwifery in Turkey.
www.midwiferytoday.com/international/Turkey.asp
(accessed 5February2016)
Moher D, Liberati A, Tetzlaff J, Altman DG (2009)
Preferred reporting items for systematic reviews and
meta-analyses: the PRISMA statement. PLoS Med
6(7):e1000097. doi: 10.1371/journal.pmed.1000097
Mollamahmutolu L, Moralolu O, Ozyer S, Su FA,
Karayaln R, Hanerliolu N, Uzunlar O, Dilmen U
(2012) The effects of immersion in water on labor, birth
and newborn and comparison with epidural analgesia
and conventional vaginal delivery. J Turk Ger Gynecol
Assoc 13(1): 459. doi:10.5152/jtgga.2012.03
National Institute for Health and Care Excellence (2014)
Intrapartum care for healthy women and babies. www.
nice.org.uk/guidance/cg190 (accessed 5February2016)
Nursing and Midwifery Council (2015) The Code:
Professional standards of practice and behaviour for
nurses and midwives. NMC, London
OReilly R, Peters K, Beale B, Jackson D (2009) Womens
experiences of recovery from childbirth: focus on pelvis
180
problems that extend beyond the puerperium. J Clin
Nurs 18(14): 20139. doi:10.1111/j.1365-2702.2008.02755.x
Popay J, Roberts H, Sowden A, Petticrew M, Arai L,
Rodgers M, Britten N, Roen K, Duffy S (2006) Guidance
on the conduct of narrative synthesis in systematic
reviews. http://tinyurl.com/oovelaq (accessed
18February2016)
Priddis H, Dahlen H, Schmied V (2013) Womens
experiences following severe perineal trauma: a meta-
ethnographic synthesis. J Adv Nurs 69(4): 74859.
doi:10.1111/jan.12005
Rdestad I, Olsson A, Nissen E, Rubertsson C (2008)
Tears in the vagina, perineum, sphincter ani, and
rectum and first sexual intercourse after childbirth:
a nationwide follow-up. Birth 35(2): 98106.
doi:10.1111/j.1523-536X.2008.00222.x
Rodgers M, Sowden A, Petticrew M, Arai L, Roberts H,
Britten N, Popay J (2009) Testing methodological
guidance on the conduct of narrative synthesis in
systematic reviews: effectiveness of interventions
to promote smoke alarm ownership and function.
Evaluation 15(1): 4771. doi:10.1177/1356389008097871
Royal College of Midwives (2012a) Evidence Based
Guidelines for Midwifery-Led Care in Labour. Care of the
Perineum. RCM, London
Royal College of Midwives (2012b) Evidence Based
Guidelines for Midwifery-Led Care in Labour. Immersion
in Water for Labour and Birth. RCM, London
Royal College of Midwives (2015) About the initiative.
http://betterbirths.rcm.org.uk/about-the-initiative
(accessed 5February2016)
Royal College of Obstetricians and Gynaecologists (2015)
The management of third- and fourth-degree perineal
tears. Green-top Guideline No. 29. www.rcog.org.uk/
globalassets/documents/guidelines/gtg2911022011.pdf
(accessed 5February2016)
Shorten A, Donsante J, Shorten B (2002) Birth position,
accoucheur, and perineal outcomes: informing women
about choices for vaginal birth. Birth 29(1):1827
Soong B, Barnes M (2005) Maternal position at midwife-
attended birth and perineal trauma: is there an
association? Birth 32(3): 1649
Thies-Lagergren L, Kvist LJ, Christensson K, Hildingsson
I (2011) No reduction in instrumental vaginal births
and no increased risk for adverse perineal outcome
in nulliparous women giving birth on a birth seat:
results of a Swedish randomized controlled trial. BMC
Pregnancy Childbirth 11:22. doi:10.1186/1471-2393-11-22
Williams A, Lavender T, Richmond DH, Tincello DG (2005)
Womens experiences after a third-degree obstetric anal
sphincter tear: a qualitative study. Birth 32(2): 12936
Williams A, Herron-Marx S, Carolyn H (2007) The
prevalence of enduring postnatal perineal morbidity
and its relationship to perineal trauma. Midwifery 23(4):
392403
Woodward J, Kelly SM (2004) A pilot study for a
randomised controlled trial of waterbirth versus land
birth. BJOG 111(6): 53745
2016 MA Healthcare Ltd
British Journal of Midwifery March 2016 Vol 24, No 3
Copyright of British Journal of Midwifery is the property of Mark Allen Publishing Ltd and
its content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email
articles for individual use.