Midwifery: Warm Compresses Minimizing Perineal Tear Dissertation

Introduction

Perineal pain, which is experienced in the second stage of labor, affects the overall outlook of birth experiences and is associated with perineal trauma. The use of warm compresses is extensively supported by midwives to minimize perineal soreness and enhance relief without using potentially injurious pharmacological pain respite (Ahmad & Turky, 2010). Recent advances in medicine have generated a large body of evidence concerning effective childbirth practices (Ibrahim, Elgzar, & Hassan, 2017). However, many countries have not implemented major beneficial practices. Instead, they uphold ineffective or deleterious practices (Altaweli, McCourt, & Baron, 2014).

An example is Saudi Arabia, where barriers such as inadequate training in evidence-based medicine, unavailability of facilities, and time constraints are blamed for the failure to adopt evidence-based practices (Al‐Almaie & Al‐Baghli, 2004). Altaweli et al. (2014) report that routine procedures such as shaving of the pubic hair, episiotomy, enemas, electronic fetal monitoring, and intravenous (IV) infusion are commonly observed in some areas of Saudi Arabia. Nevertheless, there are no studies reporting the adoption of warm compresses to minimize the occurrence of perineal tears during labor. This literature review provides a background of early nursing practices, complications of labor, the trauma of the genital areas, and strategies used to minimize the trauma.

History of Childbirth

In the years before the 1930s, women gave birth to children in home settings assisted by traditional midwives. During this time, childbirth was a dangerous affair because many pregnant women and newborns lost their lives during or following childbirth (Corretti & Desai, 2018). Organized medicine sought to lower mortalities associated with childbirth in the mid-1930s. Consequently, a new branch of medicine known as obstetrics was set up (Rosenberg & Trevathan, 2002). Uncompromising efforts were made to eliminate high-risk habits such as poor hygiene by preventing infections during childbirth. Medications were used to hasten labor and alleviate pain. The training of clinicians was also enhanced. Prenatal care was recognized as important in avoiding death. Therefore, childbirth attempts shifted from home settings to hospitals in the hope of providing effective and managed conditions for birth (Thomasson & Treber, 2008). These steps led to significant improvements in healthcare, for instance, enhanced working conditions, improved family nutrition and public hygiene, better-quality handling of longstanding illnesses, and fewer deaths during childbirth.

In the 1940s, progress in the use of antibiotics and blood transfusion services elevated the safety of childbearing (Allen, O’Connell, Liston, & Baskett, 2003; Campbell et al., 2008). However, by the 1950s, the standard maternity treatment that was meant to enhance safety was characterized by extreme rigidity. For instance, the fear of infection led to extreme practices such as confiscating women’s personal effects immediately after admission to a hospital, shaving of pubic hair (Chen & Wang, 2006), administering unpleasant enemas, and barring fathers and other family members from accessing the maternity area (Leavitt, 2003). Babies were kept in nurseries and mothers had limited access to them. Bottle feeding was preferred to breastfeeding because of its alleged superiority of breast milk (Van Esterik, 2002). Additionally, heavy doses of analgesics affected mothers’ capacity to manage their actions, comprehend, and recollect labor because the drugs caused drowsiness for hours or days following delivery (Tournaire & Theau-Yonneau, 2007).

Consequently, mothers voiced their protests against these hospital procedures and sought more agreeable ways to deliver their babies. This quest was supported by medics, who were also concerned about the well-being of mothers. Therefore, the natural childbirth movement was established in addition to a shift towards family-focused motherhood (Moscucci, 2003). State and international bodies were instituted to make these modifications in the 1960s. Books describing caring and satisfying ways of bringing forth life were published. Childbirth preparation classes were also introduced. There was increased involvement of loved ones during childbirth because mothers were encouraged to breastfeed their babies and allowed them to spend more time caring for them throughout their hospital stay (Brubaker & Dillaway, 2009). However, the wishes and preferences of childbirth care varied from one mother to another.

In the 1970s, the midwife was recognized as a trustworthy caregiver for women who wished to be involved in their own care during delivery (Berg, 2005). This role was attributed to the midwife’s understanding of the prevention of labor complications and women’s emotional needs. Women could give birth at home or in a birthing center. Consequently, hospitals started providing more accommodating, family-centered care and relaxing, homelike rooms for delivery. Physicians also loosened their stances to accommodate and respond to women’s needs during labor. In the recent years, additional changes have been made to childbirth, for instance, modifications in women’s outlooks towards childbearing, improvements in pain management options, and development of technologies to smooth pregnancy and delivery (Pandya, 2010; Tew, 2013; Ducloy-Bouthors et al., 2014).

Risk Factors for Pregnancy and Childbirth

A number of factors can endanger the life of a mother and her baby during pregnancy and childbirth. These factors fall into four categories: current health problems, age, lifestyle behaviors, and pregnancy conditions. Health problems that affect childbirth include hypertension, polycystic ovary syndrome, diabetes, renal dysfunction, autoimmune disease, obesity, and HIV/AIDS. Uncontrolled hypertension increases the likelihood of renal disease, low birth weight, and preeclampsia (Nakimuli et al., 2015). Polycystic ovary syndrome may cause miscarriages, gestational diabetes, and premature delivery (Palomba et al., 2015). Diabetes is associated with birth defects in the fetus during the first trimester (Cypryk et al., 2018). Renal dysfunction, conversely, complicates conception, and heightens the risk of miscarriage (Mbachu et. al., 2017). Autoimmune diseases may cause a mother’s body to reject the fetus, thus causing preterm births and stillbirths (Sato et al., 2015). Obesity increases the likelihood of gestational diabetes and contributes to difficult deliveries (Mark et al., 2017). Women can transmit HIV infections to their babies during labor, childbirth, or breastfeeding (Livingston & Huo, 2016).

The age of the mother during pregnancy determines the level of risk involved during childbirth. Teenage mothers are likely to experience early labor and hypertension (Ganchimeg et al., 2014; Garba, Adewale, Ayyuba, & Abubakar, 2016). Additionally, very few teenage mothers undergo antenatal care to facilitate the evaluation of risks early enough (Ahorlu, Pfeiffer, & Obrist, 2015; Cavazos-Rehg et al., 2015). In contrast, first-time pregnancies after the age of 35 elevate the chances of having cesarean deliveries (Heffner, Elkin, & Fretts, 2003). Other problems include too much bleeding during labor, protracted labor persisting for more than 20 hours, genetic disorders in infants, and labor that fails to progress (Tough et al., 2002).

Lifestyle factors such as alcohol use increase the likelihood of miscarriages or stillbirths apart from causing birth defects in the fetuses (O’Keeffe et al., 2015). Cigarette smoking may cause preterm deliveries, birth defects, and increase the risk of health problems such as sudden infant death syndrome (Ko et al., 2014; Ion & Bernal, 2015).

A common pregnancy condition is multiple gestations (having twins or triplets), which elevates the probability of premature births (Tucker & McGuire, 2004; Aarnoudse-Moens, Weisglas-Kuperus, van Goudoever, & Oosterlaan, 2009) and cesarean deliveries (Barber et al., 2011). Additionally, there is a high likelihood that twins and triplets will be smaller than babies of singleton births (Blickstein, 2004; Vasak et al., 2017). Gestational diabetes predisposes pregnant mothers to premature labor and delivery, preeclampsia, and hypertension (Oostdam et al., 2012). Preeclampsia, on the other hand, may have adverse effects on the mother’s kidneys, liver, and brain (Sibai, Dekker, & Kupferminc, 2005).

Complications during Stages of Labor

Labor is the process through which a fetus is delivered after 24 weeks of gestation. Labor begins when uterine contractions become consistent and cervical effacement and distention increase. The first stage of labor occurs in two phases: the latent stage, which is the time taken for the cervix to open to 3 centimeters, and the active phase, which is the time taken from 3 centimeters to the full opening of the cervix. The main problem experienced during this stage of labor is the failure to progress, which is diagnosed if there is less than 2 centimeters dilatation in 4 hours or decelerating progress in parous women. Labor that is slow from the beginning is known as p dysfunctional labor, whereas sudden complications in previously progressive labor are referred to as s arrest (Arulkumaran, Collins, Hayes, Impey, & Jackson, 2008). Causes of poor progress include inefficient uterine activity, malpresentation, or a big baby.

The second stage of labor encompasses the time between the full dilatation of the cervix and childbirth. The active part begins when the mother starts pushing using the abdominal muscles to ‘bear down’. Different positions may be used for this stage, for example, standing, squatting, supine, or on all fours (Pillitteri, 2010). The head expands the perineum and anus as it comes down. Therefore, a pad may be used to hold the perineum and shield the anus while the other hand conserves flexion, thereby regulating the rate of passage of the head, reducing perineal expansion, and minimizing tears (Geranmayeh et al., 2012). Delivery should occur within three hours of the beginning of the second stage of labor in nulliparous women and within two hours for multiparous women (Simkin, Whalley, Keppler, Durham, & Bolding, 2016). Complications at this stage of labor are suspected in nulliparous women if delivery has not happened following one hour of active pushing. Instrumental delivery or a cesarean section may be recommended if delivery does not take place in two hours. Fetal malposition or disproportion is often suspected in delayed second-stage labor. A duration of one hour is often permitted for passive descent in women who have had an epidural before active pushing is recommended.

The third stage of labor includes the duration following the delivery of the baby to the expulsion of the placenta and other membranes. The only adverse effects associated with this stage are queasiness and vomiting. However, the complications that may arise include hemorrhage and failure to deliver the placenta in one hour.

Mortality and Morbidity Rate during Childbirth

According to the World Health Organization [WHO] (2015), the number of women succumbing to childbirth-related complications was approximately 289,000 in 2013, which was a reduction from 523,000 in 1990. The leading causes of maternal deaths included direct obstetric causes such as hemorrhage, hypertensive disorders, and sepsis, accounting for 27%, 14%, and 11% of the deaths respectively (WHO, 2015). The maternal mortality ratio (the number of deaths per 100,000 live births) reduced by 45% between 1990 and 2015 (WHO, 2015). However, this number did not meet the projected target of lowering maternal deaths by 75% (WHO, 2015).

Anatomy of the Perineum Area

The perineum is the area between the anal opening and the vulva in females (Dudek & Louis, 2013). It is found between the pubic symphysis and the coccyx. The roof of the perineum is formed by the pelvic diaphragm, whereas the bottom consists of a fascia and skin. This area contains muscles, blood vessels, and nerves associated with urogenital constructions and the anus. Opening the legs wide causes the perineum to form a diamond-like shape that can be split into two triangles by connecting through the ischial tuberosities. The first triangle is the urogenital triangle, which comprises the front portion of the perineum and contains the vaginal opening, urethra, and clitoris. The posterior portion is the anal triangle that encompasses the anus and ischioanal fossae (Clemente, 2010).

Episiotomy

An episiotomy is a surgical incision made to enlarge the vaginal introitus (Friedman, Ananth, Prendergast, D’Alton, & Wright, 2015). The birth attendant makes the decision to perform an episiotomy. Two main forms of episiotomies are available: mediolateral and midline. In mediolateral episiotomy, the cut extends from the fourchette laterally, hence minimizing the likelihood of anal sphincter damage. On the other hand, a midline episiotomy runs from the fourchette in the direction of the anus (Menzies, Leung, Chandrasekaran, Lausman, & Geary, 2016). Performing an episiotomy entails infiltrating the perineum with lidocaine if no epidural has been administered. Two fingers are then placed between the perineum to safeguard the baby. Thereafter, a pair of sharp scissors is used to make a single cut approximately 3 to 4 centimeters long (van Bavel et al., 2018).

The World Health Organization recommends that midwives should only consider episiotomies in specific situations (Oladapo et al., 2018). Such situations include when there is complicated vaginal delivery, for instance, breech, forceps, shoulder dystocia, and ventouse deliveries (Oladapo et al., 2018). The presence of extensive lower genital tract scarring, such as that attributed to female genital mutilation and third- or fourth-degree tears that have not healed properly necessitates episiotomies. A midwife may also choose to perform an episiotomy when there are symptoms of fetal distress or when there are signs that massive perineal trauma may occur. The indications of extensive perineal trauma include numerous perineal tears and perineal button-holing.

Complications associated with episiotomies include bleeding, hematoma, pain, infections, and dyspareunia (Gün, Doğan, & Özdamar, 2016). Scars may form and interfere with the anatomy. In rare cases, episiotomies are associated with the formation of fistulas (Thapa, Acharya, Singh, & Baral, 2017). The global incidence of episiotomies varies significantly and is estimated at 50% in the USA, 8% in the Netherlands, and 14% in the USA (Arulkumaran et al., 2008).

Midwifery management of episiotomies entails anesthetizing the perineum early enough to allow adequate time for the anesthesia to take effect. Since the procedure causes bleeding, it is necessary to avoid doing it very early. The incision should also be repaired as soon as feasibly possible. Moreover, the midwife should also check for additional tears or extensions when repairing the episiotomy to ascertain that no trauma is caused to the anal sphincter.

According to Albers, Sedler, Bedrick, Teaf, and Peralta (2015), “the continued decline in the usage of episiotomies is supported by evidence from research, which shows that routine episiotomy confers more harm than benefit”(p. 365). There is substantial evidence to support the restricted use of episiotomies. For example, Ali, Malik, Iqbal, and Faruqi (2016) found that episiotomy did not reduce severe perineal trauma significantly. However, it led to anterior vaginal or paraurethral trauma and was not recommended as a routine procedure. Friedman et al. (2015) also reported that the American Congress of Obstetricians and Gynecologists recommended against routine episiotomy. Amorim, Coutinho, Melo, and Katz (2017) reported that a non-episiotomy procedure was relatively safe for mother and child as opposed to routine episiotomy.

Perineal Tears

A perineal tear is a slit of the skin as well as other soft tissue constructions that detach the vagina from the anal opening. Perineal tears usually happen in women following vaginal childbirth that exerts undue pressure on the perineum. Perineum tears are classified into four groups depending on the extent of tissue damage. First-degree tears affect the skin around the perineum only, whereas second-degree tears damage the perineum and its muscles. An episiotomy is an example of a second-degree tear. Third-degree perineal tears, on the other hand, involve damage to the anal sphincter complex. Three forms of third-degree tears exist 3a, 3b, and 3c. In 3a tears, less than half of the external anal sphincter is destroyed, whereas 3b tears involve the destruction of more than half of the same anatomical area. In 3c tears, the internal anal sphincter is destroyed. Fourth-degree tears entail the destruction of the perineum, including the anal sphincter complex (internal and external) as well as the anal or rectal epithelium (Goh, Goh, & Ellepola, 2018).

The risk factors for perineal tears include forceps delivery, shoulder dystocia, midline episiotomy, and epidural anesthesia (Groutz et al., 2011). Nulliparity, persistent occiput posterior fetal position and second-stage labor that exceeds one hour also increase a woman’s chance of having perineal tears, especially third and fourth-degree tears (Hsieh et al., 2014). Giving birth to children weighing four or more kilograms and induction of labor are other factors that predispose pregnant women to perineal tears. Vacuum-assisted delivery was also a significant risk factor in Africa and Asia (Hirayama, Koyanagi, Mori, Zhang, Souza, & Gülmezoglu, 2012). Groutz et al. (2011) reported that Asian ethnicity also increased the likelihood of having perineal tears during childbirth.

The incidence of perineal tears has reduced significantly with modern medicine. However, such occurrences continue to be reported in different practice areas. Hirayama et al. (2012) report that the incidence of third- and fourth-degree perineal tears vary significantly from country to country. For example, the prevalence was 0.1% in countries such as Cambodia, China, India, and Uganda, whereas the incidence rate was 15% in the Philippines and 1.4% in Japan (Hirayama et al., 2012). Smith, Price, Simonite, and Burns (2013) reported that only 9.6% of nulliparous women had intact perineum following delivery, which implied that the prevalence of perineal tears was 91.4% in nulliparous women. However, the incidence of these lacerations in multiparous women was 31.2% (Smith et al., 2013). Freestanding midwifery-led units in the community and home settings recorded higher incidences of perineal tears than well-established medical facilities. In contrast, a study conducted by Hsieh et al. (2014) showed that approximately 225 (10.9%) deliveries led to third- or fourth-degree tears.

Perineal tears are associated with complications such as distress and problems during bowel movements, fecal urgency, longstanding perineal pain, and dyspareunia. The exposed tissue is also predisposed to bacterial infections. However, these symptoms may disappear after a year. There may be excessive stitching when repairing tears, which could lead to painful intercourse. The most common long-term complication associated with perineal tears is anal incontinence, which may happen many years following the trauma. However, these problems are mostly observed in third- and fourth-degree lacerations.

Genital Trauma

Genital trauma may be described as injuries to the female genital regions and the reproductive tract (Ismail, 2017). It includes factors such as perineal tears, episiotomies, breaking of the uterus, and lacerations of the cervix. The short-term complications associated with genital trauma include bleeding, a requirement for suturing, and pain (Ismail, 2017). The long-term consequences of genital trauma include protracted perineal pain and weakening of the pelvic floor muscles, which may affect the bowel, urinary, and sexual functions (Albers et al., 2005).

Midwives use various approaches to minimize genital trauma. The two most common are warm compresses and massaging with lubricants. Details about these messages are discussed in the subsequent sub-sections.

Prevention Techniques to Reduce Perineal Tears

Antenatal Pelvic Floor Training

This method involves squeezing and lifting the pelvic muscles as if attempting to prevent urination (Salvesen & Mørkved, 2004). The muscles should be held for about eight to ten seconds and relaxed for a similar duration. This process should be repeated about ten times continuously three to four times a day. Pelvic exercises strengthen the muscles of the pelvis and perineum and minimize the chances of tears (Fritel et al., 2008; Freeman, 2013).

Perineal Support

Perineal management techniques known as guiding or support techniques are reported to reduce perineal trauma (Aasheim, Nilsen, Lukasse, & Reinar, 2011). The most common methods are Ritgen’s maneuver and flexion method (Poulsen, Madsen, Skriver-Møller, & Overgaard, 2015). These approaches minimize perineal trauma by decreasing the presenting diameter of the fetal head through the woman’s vaginal opening (Laine, Gissler, & Pirhonen, 2009). Support methods retard the delivery of the head, permitting the perineum to stretch slowly, thereby lessening perineal distress (Aasheim et al., 2011).

Hand-Off Versus Hands-On

The hands-on method entails applying forward pressure on the perineum during childbirth, whereas a hands-off approach involves supporting the fetal head without touching the perineum (Foroughipour, Ghahiri, Norbakhsh, & Heidari, 2011). Studies show that hands-on and hands-off procedures do not influence the frequency or extent of perineal lacerations during childbirth (Souza, Costa, & Riesco, 2006; Laine, Rotvold, & Staff, 2013). However, it was shown that the frequencies of third-degree lacerations, episiotomy, bleeding, and pain after delivery were higher in the hands-on group compared to the hands-off group (Rezaei, Saatsaz, Chan, & Nia, 2014).

Lubricant Massage

This approach entails using a water-based lubricant to massage and stretch the perineum with each spasm in the second stage of labor. The midwife inserts two fingers inside the vagina and stretches the perineum gently in a sweeping motion (Stamp, Kruzins, & Crowther, 2001). Lubricant messages are reported to protect against perineum trauma in nulliparous women and eliminate the need for suturing in one out of 13 women (Eason, Labrecque, Wells, & Feldman, 2000). However, in a follow-up investigation after three months, Labrecque, Eason, and Marcoux (2000) found no distinction between the perineal function of women who had received perineal massages and those who had not.

Warm Compresses

Midwives and birth attendants apply warm compresses to the perineum to reduce perineal tearing. A systematic review of the literature conducted by Aasheim et al. (2011) showed that warm compresses lower the incidence of third- and fourth-degree tears. However, there was inadequate data about the incidence of tears that required suturing.

Akbarzadeh et al. (2016) examined the impact of warm compress bi-stage intervention on the incidence of episiotomy, perineal trauma, and postpartum discomfort intensity in the primiparous woman with deferred Valsalva maneuver. 150 women were arbitrarily assigned to two groups the first of which received warm compress bi-stage intermediation at 7-cm and 10-cm dilatation as well as in the course of stage one and stage two labor for 15 to 20 minutes (Akbarzadeh et al., 2016). The control group received the hospitals’ conventional care. The occurrence of episiotomy, undamaged perineum, lacerations, and postnatal pain intensity was evaluated in the two groups. There was a significant difference between the incidence of intact perinea in the intervention and control groups. Additionally, more episiotomies and higher mean lengths of the incisions were noted in the control group than the intervention. However, more ruptures were observed in the intervention group. The authors concluded that warm compresses bi-stage interventions in first-stage and second-stage labor were effective in lowering the incidence of episiotomies and the average length of the cuts (Akbarzadeh et al., 2016).

Kopas (2014) reviewed second‐stage labor care procedures and described the risk factors for perineal trauma. A protracted second stage and procedures such as epidural analgesia, pushing styles, labor positions, and perineal support methods were evaluated. Kopas (2014) reported that perineal compresses served to minimize perineal trauma and provide comfort during childbirth.

Pregnancy and birth data were evaluated in a separate retrospective descriptive study by Hastings-Tolsma, Vincent, Emeis, and Francisco (2007). The findings showed that the use of warm compresses alongside manual support, massage, and delivering in the lateral position protected against perineal tears.

Warm Compresses or Packs

Definition

A warm compress is a form of a pain-relief method where moist heat is applied to painful areas. The mechanism of warm compresses is attributed to vasodilatation and increased blood supply, tissue stretching or extensibility, and muscle relaxation. This technique also causes altered pain perception.

Implementing Techniques of Warm Compresses

A warm compress is made by putting a clean washcloth in warm water and squeezing out the excess water. The warm compress is held continuously to a pregnant mother’s perineum and external genitalia by the midwife’s gloved hand throughout the second stage of labor (during and between pushes). The compress is changed as required to maintain warmth and hygiene.

Measurement of Pain Intensity

The quantification of individual pain intensity is valuable for clinicians and researchers. Several scales are used for this purpose. However, it is unclear which scale provides the most accurate, replicable, and valid measure. Five benchmarks are used to rate pain intensity scales: ease of dispensing and scoring, sensitivity based on the total response categories, average rates of erroneous responses, sensitivity based on statistical power, and the degree of the association between each scale and a linear blend of pain intensity guides (Lee et al., 2015).

Different Pain Scale Measurements

The visual analog scale (VAS) is a unidimensional gauge of the amount of pain that is commonly used in adult populations. This scale comprises a vertical or horizontal line that is 100 millimeters long. The scale has two verbal descriptors of pain intensity. The subject is asked to put a line at right angles with the scale at the point that appropriately describes their pain levels. Readings between 0 and 4 millimeters indicate no pain, whereas values between 5 and 44 millimeters show mild pain. Moderate pain is indicated by values between 45 and 74 millimeters while readings between 75 and 100 millimeters show extreme pain.

The Behavioral Pain Scale (BPS) is used to assess behavioral reaction to pain. Four aspects of behavioral reactions to pain are evaluated. They include muscle tension, restiveness, grimacing, and sound. Other pain scales that can be used to evaluate pain include pediatric pain scale, color scales for pain, McGill pain questionnaire (MPQ) global pain scale, and patient-created personalized pain scales among others.

Numerical Pain Scale

The numerical pain scale is a unidimensional measure of the intensity of pain in adults. Different variations exist, though the most commonly used scale has 11 items ranging from 0 to 10. Zero 0 denotes no pain while 10 indicates the highest level of pain (Lee et al., 2015). Respondents are often asked to recount the intensity of pain within the last 24 hours. This assessment takes one minute to complete.

Pain Satisfaction Following the Application of Warm Compresses during Stage Two Labor

Akbarzadeh et al. (2016) examined the impact of a warm compress bi-stage intervention on the level of discomfort following childbirth among other variables such as the incidence of episiotomy, length of incisions, and perineal trauma in primiparous women with deferred Valsalva maneuver. It was noted that the intervention led to lower postpartum pain levels as reported by the visual analog pain scale. The study concluded that the use of warm compresses on the perineum during labor increased pain satisfaction levels in women.

Dahlen et al. (2009) conducted a study to determine women’s and midwives’ perceptions concerning the use of perineal warm packs during the second stage of labor. The investigation involved a randomized controlled trial where women and midwives were required to complete questionnaires regarding the impact of warm packs on pain intensity, perineal trauma, well-being, impressions of control, contentment, and plans for use during upcoming births. About 717 nulliparous women in the final phases of the second stage of labor were arbitrarily assigned to two treatments: application of warm packs to the perineum (360 participants) and regular care (357 subjects). The findings showed that warm packs were highly accepted by the women and midwives as an effective way of easing pain during the late second stage of labor (Dahlen et al., 2009). Midwives and women were likely to use warm packs in the future or recommend them to friends. The study concluded that warm packs were effective non-pharmacological pain relievers in second-stage labor.

Dahlen (2012) also recommended that warm compresses be incorporated into standard care during second-stage labor. This recommendation was considered valid following the publication of the systematic review by Aasheim et al. (2011), which showed that warm compresses were effective in relieving pain and reducing perineal trauma.

Advantages and Disadvantages of Warm Compresses

The advantages of warm compresses during the second stage of labor include reducing the incidence of third- and fourth-degree tears, reducing the magnitude of lower perineal pain following childbirth, and reducing the likelihood of urinary incontinence (Dahlen et al., 2007; Edqvist, Hildingsson, Mollberg, Lundgren, & Lindgren, 2017). Applying warm compresses is also cheap and simple. One shortcoming of warm compresses is that it does not reduce the number of women who require suturing following childbirth.

Studies in various parts of the world involving the use of warm compresses during second-stage labor in nulliparous and primiparous women report that the intervention does not cause significant reductions in the rate of perineal tears and trauma (Ibrahim et al., 2017). However, it reduces the intensity of perineal pain. These findings were reported by Ibrahim et al. (2017) in Egypt, Baba et al. (2016) in Japan, and Ali et al. (2016) in Iran, among other countries. However, no studies involving the use of warm compresses during labor have been conducted in Saudi Arabia.

Recommendation

Applying warm compresses to the perineal area during the second stage of labor is effective at reducing the incidence of third- and fourth-degree tears. It also enhances patient comfort during and after birth by reducing pain. Therefore, midwives, obstetricians, and nurses working in maternity divisions should consider incorporating this procedure into the second stage of labor. This practice could enhance the well-being of women and have positive implications for the quality of services offered. This information could also guide the development of methodological information for health policymakers and healthcare specialists for normal childbirth care.

Summary

This review indicates that normal vaginal childbirth is associated with risks of perineal tears and genital damage. Episiotomies were previously thought to minimize the incidence of perineal trauma. However, there is sufficient evidence to show that the process leads to genital trauma instead of serving a protective role. Warm compresses offer relief and patient satisfaction as shown by various studies. Midwives need to consider incorporating this procedure into their regular routine.

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