Save the Perineum! A Protocol to Reduce Perineal Trauma

Abstract: Save the Perineum! A Protocol to Reduce Perineal Trauma

Purpose for the program: Perineal trauma including a third 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 and fourth degree laceration rate at this large university hospital was noted to be in the higher range based on the University Health system Consortium database. The Obstetric quality and safety committee identified the rate concerning and charged a multidisciplinary team composed of physicians, nurses and nurse midwives to investigate potential causes which could be addressed to make positive improvements on the issue.

Proposed change: 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 would alone impact the rate of third and fourth degree lacerations. Therefore, a bundle was created composed of 1. Labor down for at least 1 hour or until the urge to push is felt (but no longer than 2 hours); 2. Use of warm packs to the perineum applied every 30 minutes during stage 2, 3. Change position every 15-20 minutes to help facilitate fetal descent and rotation; 4. Foot position resting on the bed or in foot rests instead of held by the nurse or support person (avoidance of McRobert's position except for shoulder dystocia maneuver) and 5. Avoidance of manual perineal stretching during stage 2.

Implementation, outcomes and evaluation: Nurses, physicians and residents were educated about the 'bundle' protocol. Physicians are given the option to 'opt in' or 'opt out' of the bundle. The protocol is currently in use during this 6 month time frame which will conclude in January of 2013. Data on differences between use of the bundle vs. non-use will be compared related to third and fourth degree laceration rates.

Implications for nursing practice: Implementation of evidence based practice related to second stage of labor is a process. Varied techniques of leg holding positions, perineal massage/ manipulation and passive management of the laboring 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.

Keywords: perineal trauma, third and fourth degree laceration, labor down, second stage management