PREVENTION OF PERINEAL LACERATIONS AND EPISIOTOMY : EVIDENCE FOR CLINICAL PRACTICE

Objective: to analyze the scientific productions about the clinical practice in Obstetric Nursing in the prevention of perineal lacerations and reduction of routine episiotomy. Method: integrative review, carried out from March to April 2017, in Lilacs and PubMed / MEDLINE databases. The delimited temporal cut was five years, totaling 18 articles to constitute the corpus of the analysis, classified according to the level of scientific evidence. Data were analyzed using the Content Analysis Technique, in the Categorical Analysis modality. Results: three categories emerged: << Factors related to the practice of episiotomy and the occurrence of perineal lacerations and indications for performance >>; << Approach of the professional who provides assistance to normal childbirth >> and << Strategies for the prevention of perineal lacerations>>. Conclusion: the literature indicates the reduction of routine episiotomy practice and the increasingly frequent use of methods to prevent perineal lacerations. In addition, the studies demonstrate the importance of the care provided by obstetrical nurses, since these professionals use much more good practices of attention to childbirth and birth, in relation to the medical class. Descriptors: Obstetric Nursing; Evidence Based Nursing; Perineum; Episiotomy; Lacerations; Review.

The Brazilian obstetric model is in a continuous process of changes, to the detriment of high rates of obstetric interventions and, consequently, maternal and neonatal morbidity and mortality.In view of this, more and more effective and safe obstetric practices, are being stimulated, together with the scientific evidences.In this way, several movements are being carried out in favor of the training of professionals and the insertion of obstetricians and midwives, for the qualification and humanization of care. 1 In order to improve the standard of obstetric and perinatal care in the world in 1996, the World Health Organization (WHO) published a guide to clinical practice on what should and should not be done during labor and delivery.Entitled "Good Practices in Delivery and Childbirth Care", this paper proposes that obstetric care be backed by the best published scientific studies worldwide. 2 the scope of good practices, the stimulus for the reduction of the episiotomy procedure is highlighted.This intervention is still routinely practiced by health professionals in order to prevent severe perineal lacerations and to shorten the delivery period, especially in critical situations, such as instrumental delivery.However, studies point out that risks outweigh the benefits, and may increase the extent of perineal lacerations and blood loss, cause infections, impair women's sexual function, and other complications. 3cording to the National Guidelines for Assistance to Normal Labor published in 2016, episiotomy should not be performed routinely in spontaneous vaginal deliveries.In addition, if performed, its need should be duly justified, since there is no consistent scientific evidence to indicate actual indications for this procedure. 4This study is in line with what is advocated by WHO, which also suggested that rate should be around 10%. 2 Therefore, it has been increasingly invested in methodologically consistent research, in order to constitute a theoretical-procedural corpus, for the implementation of techniques, in order to prevent perineal lacerations and to promote perineal integrity and the practice of restrictive episiotomy.Thus, with the stimulus for entry of the obstetric nurse into the scenario of usual childbirth care, these techniques are increasingly being researched and implemented in health services.
• To analyze the scientific productions about clinical practice in Obstetric Nursing in the prevention of perineal lacerations and reduction of routine episiotomy.
For the elaboration of this integrative review, six stages were covered, namely: identification of the theme and construction of the research question; delimitation of inclusion and exclusion criteria; survey of publications in databases; categorization and analysis of information extracted from publications; interpretation and critical analysis of the findings and presentation / synthesis of the review. 5 view of the above, the guiding question was formulated: What are the scientific evidences in the national and international literature on the prevention of perineal lacerations at delivery and reduction of episiotomy rates?Included in this study were publications on the prevention of perineal lacerations and episiotomy, available online, free of charge, with original articles in Portuguese, English and Spanish, and with abstracts available, indexed in databases and published as of 2011, the year in which it was published The Stork Network strategy was established as a milestone in maternal and child health care in Brazil. 6Theses, dissertations, review, opinion and reflection articles were excluded as well as studies that did not meet the criteria for inclusion and did not respond to the guiding question of research.
The search of the publications was performed by two independent reviewers, in the Latin American and Caribbean Literature (Lilacs) and Medical Literature Analisys and Retriveal System Online (MEDLINE) databases by PubMed / MEDLINE, in the period of March and April of 2017.The analysis occurred from the direct research in the databases.Firstly, the title and summary of the publications found in the search were read, based on the objective of the study and the guiding question of research.Then, the articles were read in full, which were selected according to the inclusion and exclusion criteria delimited.A data collection instrument was developed by the author of the review, through which the main information about the selected studies was extracted: author, year of publication, study methodology, objectives and main results on methods of prevention of perineal lacerations .18 articles were selected to constitute the corpus of the analysis, eight of them from the Lilacs database and ten from PubMed / MEDLINE.In relation to the publication of the studies, there was a predominance of publications of the International Journal of Obstetrics and Ginecology (três) and, of the national ones, the Electronic Journal of Nursing (two) and UERJ Journal of Nursing (two).Regarding the year of publication, recent studies predominate, from 2015 (seven).
Regarding the methodological approach, cross-sectional descriptive studies (three), randomized clinical studies (three) and systematic reviews (three) prevail.The majority of studies (ten) have a level of evidence VI, therefore, with little relevance to decision making in clinical practice.It is justified the predominance of studies with low levels of evidence due to the lack of scientific productions with consistent methodologies.This demonstrates the importance of research with methodological rigor and the publication of scientific evidence relevant to clinical practice.Figure 2 was elaborated with the main data extracted from the review of the studies

 Factors related to the practice of episiotomy and the occurrence of perineal lacerations and indications for the performance
Of the articles selected for this category, three Brazilian studies show that episiotomy is still a recurring practice in the daily life of maternity wards.Some risk factors for the need for episiotomy and the occurrence of perineal lacerations are scored.Primiparous women with no prior vaginal birth history and with little perineal distensibility are three times more likely to undergo the procedure.Prematurity, weight and vitality of the newborn are also associated with the perineal outcome, increasing the occurrence of lacerations and episiotomy.However, multiparity increases the probability of an intact perineum, whereas nulliparous women have a greater perineal elasticity and, therefore, less chance that the procedure is performed due to the absence of a previous perineal scar. 13Obstetric interventions are also indicated as risk factors for carrying out this procedure, such as: epidural analgesia, instrumental delivery and use of synthetic oxytocin for the induction of labor and postterm deliveries (over 41 weeks). 27out the episiotomy and its association with maternal and neonatal alterations, in a study that evaluated 1,129 medical records, the results showed that there was also a predominance of the practice in primiparous women.In relation to the variables related to the vitality of the newborn, such as Apgar score, birth weight, prematurity, among other neonatal aspects, they did not influence this practice, concluding that it is performed without precise indications. 9me factors that may influence the occurrence of spontaneous perineal lacerations, including maternal-fetal conditions, are described.
From the knowledge of these factors, the professional can analyze the need for perineal trauma prevention techniques.The studies point to the use of episiotomy to prevent severe lacerations, but the results emphasize that this procedure does not prevent the occurrence of trauma, as well as, it poses more risks than benefits to the woman.
In Jamaica, it was evidenced that the prevalence of 3rd and 4th degree lacerations is mainly, related to fetal birth weight (<3.4 kg) and invasive procedures in instrumental delivery, such as forceps and extractor vacuum. 15factors related to the perineal outcome, there may be an association with parity, prematurity, weight and vitality of the newborn.According to a study that analyzed these factors, the probability of occurrence of lacerations of 2nd degree was higher in newborns weighing more than 3,300 grams. 13 Amapá, in a quasi-experimental study, nurses and physicians reported performing episiotomy and directed pulling to prevent lacerations, thus, exposing women to perineal trauma.After an educational intervention, there was an increase in reports of intact perineum and adherence to evidence-based practices by professionals, as well as a reduction in those practices that may increase the occurrence of lacerations. 30om the findings in the literature, it is synthesized that, interventional practices may contribute to perineal trauma, and should therefore be avoided or used restrictively.One can mention, for example, strategies to avoid perineal lacerations that exclude episiotomy as a form of prevention.Also, some maternal-fetal characteristics can be visualized prior to labor, such as fetal weight,

DISCUSSION
and should be individualized in order to minimize lacerations.Finally, in relation to directed pull, it is now recommended that the woman make the expulsive force only when she feels like doing it, without being commanded by the professional.From these reflections, it is reiterated the importance of more studies being carried out in the area, in favor of a qualified and humanized assistance, with the minimum of interventions and for the integrity of the female perineum.

 Approach of the professional that provides assistance to the normal birth
In the care provided by obstetrical nurses, a study shows the prevalence of episiotomy, especially in primiparous women, in line with previous studies.Of the 447 births attended by this professional class, the intervention was performed in 50 of them.Of the 134 primiparous women, 41 had an episiotomy.Nonetheless, when compared with medical care, there is a reduction in rates when obstetrical nurses take delivery, although practice is still predominant. 10en corroborating with the mentioned author, on the perceptions of women submitted to episiotomy, two studies show that they are generally unaware of the procedure and do not receive information about the need to perform it at the time of delivery.In addition, they said they preferred a vaginal delivery without the "cut", but did not feel safe to ask the doctor.Others also believe that the episiotomy should be performed, as it assists in the exit of the baby, accelerating the birth, preventing the vaginal distension and that it is the medical professional who must decide on its necessity or not. 11,16so, on the assistance provided by obstetric physicians and nurses, in a study performed in a maternity hospital in Rio de Janeiro, both professionals performed obstetric interventions.Thus, it is perceived that the technicist model of health care is still predominant.However, in relation to the episiotomy, there was a greater proportion of its performance by the medical professional. 12 a comparative study, 37% (n = 75) of the follow-up performed by an obstetrician nurse, and 10.2% (n = 98) of the medical follow-up were observed in the practice of medical professionals and obstetricians.In addition, primary care lacerations (59.3%), a lower proportion of lacerations in the 2nd degree (22.2%) predominated, and severe traumas (3rd and 4th grades) were not observed.The rate of intact perineum was higher, 45.2%, by obstetric nurses and only 21.4% for physicians.These results demonstrate that the obstetrical nurses tend to be less involved in the followup of usual risk pregnancies, and greater concern and care with the female perineum, restricting the practice of episiotomy. 12 a study conducted in Israel, there was a comparison of 168,077 deliveries with and without episiotomy and its association with critical situations.The research pointed to a significant association between the performance of mid-lateral episiotomy and the occurrence of severe lacerations (3rd and 4th degrees).Moreover, even in conditions such as fetal macrosomia, non-reassuring fetal heart rate, occiput-posterior position, instrumental delivery, and shoulder dystocia, the results showed an association, regardless of episiotomy, with severe lacerations. 24This demonstrates the need for a restrictive practice this intervention.
From the above, according to recent systematic review and with what is recommended by the national guidelines, there is no scientific evidence that routine episiotomy reduces perineal trauma rates, but adopt a restrictive practice in women who are not candidates for childbirth instrumental, for example, may contribute to the reduction of perineal trauma.  Thiactice has become a routine procedure for a long time, based only on the experience of medical professionals.Currently, the best scientific evidence supports the thesis that there are no indications for its realization, as well as benefits for its practice.However, it is perceived that, despite the surveys pointed out by the studies, many professionals still use this procedure in the daily life of the health services.Therefore, the importance of scientific evidence in modern obstetrics is emphasized in order to transform the obstetric model in favor of humanized and less interventionist assistance.

 Strategies for the prevention of perineal lacerations
The stimulation of natural and physiological childbirth, especially by obstetrical nurses, has been directing care to a performance in favor of perineal integrity.From this, it is noticed that studies are being carried out, mainly at an international level, on techniques to prevent lacerations and maintain the pelvic floor intact, at the time of delivery.
From the synthesis of the publications listed for this review, some techniques of perineal preservation that are being studied and increasingly used, such as: hands off, perineal massage, use of perineal protection device (EPI-NO), induction of labor and perineal injection of hyaluronidase.The studies point out the benefits / harms and the effectiveness or not of these techniques, also suggesting the elaboration of better delineated research.
The hands off technique is gaining more and more space in obstetrical care, being performed mainly by obstetricians and obstetricians, to the detriment of the hands on technique.Traditionally, the professionals performed active management of the perineum, that is, they held it during the expulsive period and pressure was applied with the fingers, down, in order to control the velocity of exit of the cephalic pole.Currently, the hands off technique proposes that the perineum of the woman does not suffer the stimulus from the hands of the professional and that this control is done, spontaneously, by the woman.In two studies, the majority of the obstetricians (63.0%) prefer to use the hands off technique in standard risk deliveries, but most use the hands on technique (83.4%) in high-risk deliveries , especially those with a high probability of severe perineal trauma involving the anal sphincter. 19 a systematic review of manual hands on routine support compared to hands off in terms of risk and degree of perineal trauma, the authors did not consensus on the hand-on perineal trauma protective factor , but suggest that there may be benefits in adopting this practice, mainly because of the potential reduction of anal sphincter traumas.On the hands off technique, there was a significant reduction in episiotomy rates when professionals adopted this method.Therefore, the authors suggest that efficient, welldelineated multicenter randomized clinical trials should be performed to evaluate complex interventions on the two methods, comparing them according to the rates of anal sphincter lesions. 20is conclusion was also found in a review of the literature on the current evidence related to these methods.It is not possible to conclude on the effectiveness of the reduction of severe lacerations using the hands-on technique, especially the limitations of the selected studies, such as the randomized clinical trials, mainly in relation to the concept of each method and the professionals' understanding of the classification of lacerations. 21ese results are in agreement with the evidence from a systematic review where, with a sample of 4,099 women, the hands on and hands off techniques were evaluated.The occurrence of perineal lacerations of any degree and the need for episiotomy were lower in women in whom the hands off technique was applied. 31From this, the two techniques can be applied during the period of delivery to facilitate normal delivery spontaneous.Attention should be paid only to the hands-on technique, controlling the fetal cephalic pole descent and not performing directed pulling. 28garding the effect of the Finnish intervention of perineal protection, which consists of active manual protection, Nordic studies applying this technique obtained a reduction of anal sphincter traumas, but lower Apgar scores and increased episiotomy.It was concluded, therefore, that the technique can not be considered in clinical practice due to the low level of evidence of the studies selected in the review, which present important methodological limitations. 18garding the techniques used at the time of delivery, in a randomized clinical study conducted in Sweden with 1,148 women in labor, the use of a perineal protection device in vaginal delivery was evaluated.The results showed some benefits, and the number of women with intact perineum was higher in the intervention group (184; 34.9%) than in the control group (142; 26.6%), and the incidence of lacerations second grades were statistically lower in the intervention group.No negative complaints were observed in the use of the device. 22garding the techniques that can be used during prenatal care, in the third trimester and also at the time of delivery, studies on the use of the EPI-NO device, which means "non-episiotomy", were listed.It is a kind of balloon, introduced into the vagina and inflated, which produces the distension of the perineal muscles.The use of the device was well tolerated by the patients.Primparous or multiparous women in labor were included in the sample.It was concluded that the rate of episiotomy and the degree of lacerations was lower in patients who used the device. 14 contrast, on this method, a recent randomized clinical trial in Australia with 660 pregnant women challenged the use of EPI-NO during prenatal care.The study evidenced great uncertainty regarding the benefits of the use of the device, in primiparas with term pregnancies and without obstetric complications, in the prevention of pelvic floor trauma and obstetric anal sphincter lesions (3rd and 4th degree lesions).Therefore, because this is a recent study, carried out using a methodology with a high level of scientific evidence, obstetrical professionals should be advised not to guide the use of the device by pregnant women, since it is not proven to be effective. 25me strategies can be used both in the prenatal period and during labor, such as perineal massage.In a survey conducted in Turkey, the technique was evaluated in the first and second stages of labor in a randomized clinical trial.There was no statistical difference in the occurrence of perineal lacerations, but the reduction of episiotomy rates in the group receiving liquid vaseline massage. 17From this, the guidelines of the Ministry of Health for normal birth do not advise the performance of this technique for not benefits in reducing perineal lacerations. 28o pharmacological techniques were also cited to prevent perineal lacerations: induction of labor with synthetic oxytocin and perineal injection of hyaluronidase.The first one is mainly used in non-diabetic pregnant women, with constitutionally large fetuses and gestational age of 37 to 38 weeks and six days.The results demonstrated that induction under these conditions does not reduce the occurrence of perineal lacerations and that the identification of fetal intrauterine macrosomia does not improve maternal outcomes. 23The second technique, compared to placebo injection and no intervention, did not present significant differences and more consistent studies are needed to prove its effectiveness. 26 summary, the importance of further research in the area on pelvic floor preservation techniques, mainly performed by obstetrician nurses, is reiterated.Some publications have been elaborated by this professional category, which demonstrates the advances of a class that prioritizes the practice based on evidence and that is gaining important space in the assistance to vaginal birth of habitual risk in Brazil and in the world.Considering the results presented in the categories, we can see an increase in scientific productions about the prevention of perineal traumas in vaginal deliveries.This is due to the increasing stimulation of vaginal delivery and the need to improve the experience of women in this process.However, professionals in the area, supported by some international studies, have been questioning whether 1st and 2nd degree lacerations would be a problem for women, since it is a physiological event with a high probability of occurrence in this process.Some evidence even casts doubt on the need to suture non-severe lacerations, mainly because of the quality of the sutures used and the increased risk of puerperal infections due to the suture technique and lack of intimate hygiene guidelines for women. 32Despite this, most of the studies are still focused on uncovering the risk factors and methods for the prevention of perineal lacerations in order to improve the quality of life of women and the repercussions on sexual health.
In view of the results, the literature refers to the reduction of routine episiotomy practice and the increasingly frequent use of methods for the prevention of perineal lacerations, as recommended by national and international guidelines.Moreover, it shows that the practice of episiotomy is performed, mainly, by medical professionals, in relation to obstetrical nurses.This information configures the insertion of this professional into the normal delivery scenario as a strategy to reduce this procedure and increase the rates of non-severe perineal lacerations.This is mainly because Obstetric Nursing uses more good practices of childbirth care, pain relief technologies, and other methods than the medical class.
This study presents relevant data, based on recent studies, which may guide obstetric practice, which is constantly changing over the years.However, there is a growing need for evidence-based research to guide care that has for a long time been based on the experience of health professionals, and recently instigates reflection on the best studies ever published.It is a relevant topic that can contribute to the progress of scientific knowledge.

Level of Evidence Objective of the study
The following search strategies were used, based on terms indexed Studies identified according to reference, year of publication, methodology, level of evidence and objective.Santa Maria (RS), Brazil, 2016.Prevention of perineal lacerations and...
To evaluate the effect of the 'Hands on' routine / manual perineal support (MPS) during childbirth x ad hoc / non-perineal support ('hands off / poised'), risk and degree of perineal trauma.