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Table 1 The Clinical Questions and Evidence of ‘2012 Evidenced-based Guidelines for Midwifery Care’ developed by the Academy of Midwifery

From: A cross-sectional survey of policies guiding second stage labor in urban Japanese hospitals, clinics and midwifery birth centers

Clinical Questions Evidences
CQ15. Perineal cleansing. There is no evidence of using benzalkonium chloride or Chlorhexidine for vulva sterilization. One controlled study from the UK compared using cetrimide/chlorhexidine to using just tap water for perineal cleansing during labor. The study found no significance between the number of women who developed fever, used antibiotics, had perineal infection, and intention of perineal tear. Also, there was no significant difference in the outcomes of the babies. Therefore, this study’s evidence indicates that using cetrimide/chlorhexidine in no more effective than tap water for perineal cleansing.
CQ16. Position in the second stage of labor. There are benefits and risks of each position, but there is no specific evidence that the supine position is more beneficial for women. There is high-level evidence that, when compared to spine position, upright position significantly reduced labor duration; the occurrence of vaginal instrumental birth; and it decreased episiotomy, pain and the incidence of fetal heart rate abnormalities. On the other hand, a high percentage of women using the up-right position had second-degree perineal tear and blood loss of over 500ml. There is no significant difference in third or fourth degree perineal tear for women in the upright position compared to women in the supine position. A woman should be informed about both the benefits and risks of each position and she should be able to choose the position. There is no specific evidence for position other than spine position is beneficial. Also there is no evidence for safeness. If there is a possibility of an abnormal labor then the spine position was recommended.
CQ17. Effectiveness of fundal pressure during the second stage of labour. There is no evidence available on the effects of manual fundal pressure. Fundal pressure by an insufflatable belt during the second stage of labour does not appear to shorten the second stage of labor. Several reports suggest that fundal pressure is associated with maternal and neonatal complications such as uterine rupture, neonatal fractures and brain damage. Also anal sphincter damage has been reported. In the “Clinical Guidelines for Obstetrical Practice”, they recommended recommended complementary use of fundal pressure for vacuum extraction or forceps but with caution. Fundal pressure during the second stage of labor is not recommended for normal delivery.
CQ18. Effectiveness of perineal massage during the second stage of labor. There is no evidence that perineal massage is effective in reducing the incidence of perineal tears or episiotomies. The only significant difference was that third-degree tears occurred less frequently in the group using perineal massage. Another RCT compared using perineal massage to applying warm compresses to the perineum, massaging the perineum with oil, and not touching the perineal until the baby’s head crowns during second stage of labor. This RCT found no significant difference in the incidence of perineal tear or episiotomy between the study groups. In addition, the women in the group who used perineal massage were the most willing to stop the intervention, yet there was still no significant difference in the incidence of third-degree perineal tear in the massage group compared to the other groups. Since there was no evidence that perineal massage prevents perineal tears, perineal massage should not be performed by health care professionals during the second stage of labor.
CQ19. The effectiveness of applying warm compresses to the perineum in order to prevent perineal tear during the second stage of labor. There was no evidence that applying warm compresses to the perineum is effective for preventing perineal trauma. However, there was evidence that the group using the warm compresses experienced less perineal pain in post-delivery day one and two than the other group. NICE guideline indicates from a cohort study that perineal trauma occurs less frequently when a warm compress is applied to the perineum. In a RCT intended for nulliparas, the women in the warm compress group were less likely to have third-degree perineal tears compared to the women in the control group. However, NICE evaluated one US RCT and found that there was no significant difference in the incidence of perineal trauma between the groups applying warm compress to the perineum, perineal massage with oil, and the group not touching the baby’s head until it crowned during the second stage of labor. Since different studies show conflicting information there is no evidence that supports applying warm compresses to the perineum in order to prevent perineal tear. However, no outcomes of harm occurred and it was found to decrease pain during labor and post-delivery day one and two; warm compress to the perineum can be one option.
CQ20. Hand position during the birth of a baby. There was no evidence of the effectiveness of two different methods of perineal management used to prevent perineal tears during delivery in the lateral position. In the NICE guideline, there was limited high-level evidence that women allocated to a ‘hands on’ perineal management group reported less pain at ten days after delivery compared to those women allocated to a ‘hand poised’ group. Also, in the ‘hand poised’ group, a smaller percentage of episiotomies were conducted in the ‘hand poised’ group compared to the ‘hands on’ group. There was no difference in the incidence of perineal trauma between the two groups and both methods of perineal management could be useful. There was no significant difference in the other RCT. However, the three studies used for the NICE guideline did not take delivery position into consideration during analyses and the RCT only considered the lateral position. Not to mention, the incidence of perineal injury differed by race. Therefore, there is no significant difference between two groups who were in lateral position. However, further study is needed to take other factors into consideration such as labor positions, race, and delivery environment. Since no study has been conducted in Japan, further study is needed.
CQ21. Routine vs. restricted use of episiotomy. There is evidence that restrictive use of episiotomy is more beneficial to women when compared to those women in the routine episiotomy group. The results of one systematic review showed that 75 % of women had episiotomies in the routine group while 28 % of women in the restrictive group had episiotomies. Obviously there was lower incidence of episiepisiotomy in the restrictive group. There was a small percentage of women with severe perineal trauma who needed suturing or who experienced the complication of dysraphism in restrictive group. There was no significant difference in the outcomes of vaginoperineal trauma, dyspareunia, urinary incontinence, perineum pain, or asphyxia of newborn. Therefore, restrictive use of episiotomy is more beneficial to both women and babies. NICE guideline only recommends restrictive use of episiotomy when it is needed for an instrumental delivery or for fetal abnormality, but not for routine use. In conclusion, episiotomy is not needed for all women. Rather, restrictive use is recommended when it is medically necessary during low-risk delivery in Japan.
CQ22. Effectiveness of taking hands and knees position for correcting fetal abnormal rotation during progressing labor. There is no obvious evidence that the hands and knees position fixes the abnormal rotation of the fetus or that it is effective in relieving the back pain that comes from abnormal rotation. There have been a few research studies on the effectiveness of the hands and knees position for abnormal rotation, but only one study was used for NICE guideline and a Cochrane systematic review. According to this study, there was no significance in the number of babies fixed as occipitoposterior to position occipitoanterior presentation. However, there is a tendency to correct the fetal abnormal rotation. In addition, this position was effective for relieving back pain and many women wanted to use the hands and knees position in her next delivery. No harm to mother or fetus has been reported due to being in the hands and knees position.