Knut Haadem, MD, PhD*
Department of Obstetrics & Gynaecology, Helsingborg Hospital, SE-251 87 Helsingborg, Sweden
*Corresponding author:
Knut Haadem, MD, PhD,
Department of Obstetrics & Gynaecology,
Helsingborg Hospital, SE-251 87 Helsingborg,
Sweden
Received: 09 Aug 2026, Accepted: 21 Aug 2026, Published: 23 Aug 2026, J Short Name: Ajsccr
Copyright: ©2026 Knut Haadem. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and build upon your work non-commercially
Citation: Knut Haadem, Reducing Perineal Trauma During Vaginal Birth: From Improved Diagnosis to Standardized Perineal Protection. Ame journal of Sur and Clin Case Rep® 2026; V11(1): 1-2
Perineal tears sustained during childbirth are associated with both short- and long-term morbidity [1]. In recent years, considerable attention has focused on third- and fourth-degree obstetric anal sphincter injuries (OASI) because of their potentially lasting impact on women’s health [1]. Improved management, including repair in the operating theatre by experienced surgeons assisted by skilled theatre nurses rather than in the delivery ward, has contributed to improved outcomes (Anna Albinsson, personal communication).
Attention has also increasingly turned to second-degree perineal tears, which may be extensive despite the absence of anal sphincter injury. Such injuries have been associated with sexual dysfunction, dyspareunia, pelvic organ prolapse, and urinary incontinence [1]. To improve documentation and facilitate follow-up, the Swedish ICD-10 coding system has introduced a subclassification of second-degree tears (grades 2a–2d) according to severity [2]. This classification was implemented at our hospital six months ago and may provide a useful basis for evaluating preventive interventions.
Clinical examination of the perineal body remains fundamental in the assessment of postpartum symptoms and in treatment planning. Measurement of perineal height, combined with digital palpation using one finger placed on the posterior vaginal wall and the other in the rectum to assess the rectovaginal fascia may help identify defects of the perineal body and assess the integrity of the perineal muscles. Assessment of anal sphincter function should include both resting and squeeze function.
Preventing perineal trauma during vaginal birth remains a major challenge. Although evidence comparing hands-on and hands-off techniques is inconsistent [1], limiting excessive distension of the posterior fourchette and perineum is biologically plausible as a means of reducing tissue rupture. Manual support of the perineum during crowning may stabilize the tissue and reduce excessive stretching, and several studies have reported favourable outcomes [3,4]. Good communication with the woman, avoidance of forceful pushing during crowning, controlled delivery of the fatal head, and continuous perineal support are regarded as important components of good obstetric practice [3]. The presence of two midwives during delivery has also been associated with a lower incidence of severe perineal tears [4].
One limitation of the hands-on technique is the lack of standardization. A Perineal Protection Device (PPD; Baby Slide®) has been developed to facilitate correct hand positioning throughout crowning (Figure 1). If the device remains securely in place, adequate perineal support is achieved, whereas displacement indicates incorrect positioning. The PPD may therefore improve the reproducibility of the technique and facilitate standardized training.
Two studies [5,6] have demonstrated a higher rate of intact perineum in women receiving the intervention than in controls. In the first, a multicentre randomized controlled trial (RCT), the rate of intact perineum increased from 26.6% in the control group to 34.9% in the intervention group (p = 0.034) in a mixed population of primiparous and multiparous women (n=1148) [5]. In a subsequent RCT involving only primiparous women (n = 92), use of an enlarged device, 4 mm wider and 5 mm longer, reduced the odds of more severe perineal injury by 64% compared with controls [6].
However, the available studies have been underpowered to determine whether the PPD reduces the incidence of OASI. In a study of vacuum-assisted deliveries comparing PPD use with standard care, no difference in OASI was observed, although the number of episiotomies was lower in the intervention group [7]. The study was subsequently criticized because the device was successfully handled in only 47% of cases [8]. This finding may indicate that adequate training is an important prerequisite for successful implementation of the technique.
A multicentre RCT is planned for autumn 2026 to investigate whether the PPD has a protective effect against perineal tears during childbirth and whether its use influences outcomes one year after delivery. The study will include approximately 4,000 primiparous women (PeriProtect.se). This trial may provide important evidence regarding the effectiveness of standardized perineal protection in preventing perineal trauma and reducing subsequent morbidity.
Accurate diagnosis and registration of perineal tears are essential for evaluating preventive strategies. Since implementation of the new classification system in autumn 2025, 79.6% of vaginal deliveries at our hospital have been classified as grade 0–1, 18.8% as grade 2, and 1.6% as grade 3–4. The overall caesarean section rate was 13,9%.
Reducing the frequency and severity of perineal tears is an important goal for women and should remain a central objective of obstetric care. Effective prevention has the potential to improve maternal health and reduce long-term pelvic floor morbidity. Our current strategy combines controlled delivery of the fatal head, manual stabilization of the perineum with or without the PPD, attendance by two midwives during delivery, and standardized diagnosis with continuous audit of outcomes.
Whether standardized perineal protection using a dedicated device can further reduce severe perineal trauma remains to be established. Ongoing multicentre randomized studies, together with standardized classification and continuous audit, should provide valuable evidence to guide future obstetric practice.
The author declares having received research grants from Baby slide International AB.
References
Org.nummer: 559345-6576
Copyright © Babyslide 2024
Förvaltas och vidareutvecklas av Dear Friends
Designad och utvecklad av Buildahome
info@babyslide.com