Table.
Important outcomes | Adverse effects, Perineal trauma | ||||||||
Studies (Participants) | Outcome | Comparison | Type of evidence | Quality | Consistency | Directness | Effect size | GRADE | Comment |
What are the effects of intrapartum surgical interventions on rates of perineal trauma? | |||||||||
at least 8 (at least 5006) | Perineal trauma | Restrictive versus routine use of episiotomy | 4 | 0 | –1 | 0 | 0 | Moderate | Consistency point deducted for conflicting results |
1 (at least 407) | Perineal trauma | Midline versus mediolateral episiotomy incision | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for quasi-randomisation, incomplete reporting of results, and no intention-to-treat analysis. |
19 (at least 6162) | Perineal trauma | Epidural analgesia versus other forms of analgesia or no analgesia | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for weak methods and use of surrogate outcome (instrumental deliveries) |
1 (1912) | Adverse effects | Epidural analgesia versus other forms of analgesia or no analgesia | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for weak methods and unclear clinical relevance of outcome |
11 (3799) | Perineal trauma | Vacuum extraction versus forceps delivery | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for inclusion of quasi-randomised RCTs and lack of blinding |
at least 11 (at least 3431) | Adverse effects | Vacuum extraction versus forceps delivery | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for inclusion of quasi-randomised RCTs and lack of blinding |
What are the effects of intrapartum non-surgical interventions on rates of perineal trauma? | |||||||||
at least 15 (at least 13,357) | Perineal trauma | Continuous support during labour versus usual care | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for support intervention varying between trials and use of surrogate outcome (instrumental deliveries) |
18 (5506) | Perineal trauma | Upright position versus supine or lithotomy positions during delivery | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for exclusion of participants after randomisation, diversity of interventions, and crossover between groups |
11 (4542) | Adverse effects | Upright position versus supine or lithotomy positions during delivery | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for exclusion of participants after randomisation, diversity of interventions, and crossover between groups |
1 (252) | Perineal trauma | Passive descent versus active pushing in the second stage of labour | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for incomplete reporting of results and use of surrogate outcome (instrumental deliveries) |
3 (438) | Perineal trauma | Sustained breath holding (Valsalva) method of pushing versus exhalatory or spontaneous pushing | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for incomplete reporting, including unpublished trials, and inclusion of non-RCT data |
2 (6632) | Perineal trauma | "Hands-poised" versus "hands-on" method of delivery | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for quasi-randomisation and missing data |
1 (5471) | Adverse effects | "Hands-poised" versus "hands-on" method of delivery | 4 | 0 | 0 | 0 | 0 | High | |
at least 5 (at least 2401) | Perineal trauma | Water births versus no immersion in water | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for different interventions of water immersion in RCTs, crossover between groups, and poor methods |
What are the effects of different methods and materials for primary repair of first- and second-degree tears and episiotomies? | |||||||||
2 (2594) | Perineal trauma | Non-suturing of perineal skin versus conventional suturing in first- and second-degree tears and episiotomies | 4 | –1 | –1 | 0 | 0 | Low | Quality point deducted for no intention-to-treat analysis. Consistency point deducted for conflicting results |
2 (2594) | Adverse effects | Non-suturing of perineal skin versus conventional suturing in first- and second-degree tears and episiotomies | 4 | –1 | –1 | 0 | 0 | Low | Quality point deducted for no intention-to-treat analysis. Consistency point deducted for conflicting results |
2 (152) | Perineal trauma | Non-suturing of muscle and skin versus conventional suturing in first- and second-degree perineal tears | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and unclear outcome measurement |
2 (152) | Adverse effects | Non-suturing of muscle and skin versus conventional suturing in first- and second-degree perineal tears | 4 | –3 | –1 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and unclear outcome measurement. Consistency point deducted for conflicting results |
11 (at least 5172) | Perineal trauma | Absorbable synthetic sutures versus catgut sutures | 4 | –3 | –1 | 0 | 0 | Very low | Quality points deducted for incomplete reporting of results, no blinding in some RCTs, and incomplete recruiting in 1 RCT. Consistency point deducted for conflicting results |
2 (1811) | Perineal trauma | Different types of absorbable synthetic suture versus each other | 4 | 0 | 0 | –1 | 0 | Moderate | Directness point deducted for use of restrictive outcome measure |
at least 6 (at least 3527) | Perineal trauma | Continuous versus interrupted sutures for repair of all layers or only perineal skin (analysed as a group) | 4 | 0 | –1 | 0 | 0 | Moderate | Consistency point deducted for different results at different time points |
at least 7 (at least 3289) | Perineal trauma | Continuous versus interrupted sutures for repair of all layers | 4 | 0 | –1 | 0 | 0 | Moderate | Consistency point deducted for conflicting results |
What are the effects of different methods and materials for primary repair of obstetric anal sphincter injuries (third- and fourth-degree tears)? | |||||||||
3 (279) | Perineal trauma | Different methods for primary repair versus each other | 4 | –1 | –1 | 0 | 0 | Low | Quality point deducted for heterogeneity of outcome measurement. Consistency point deducted for different results for different outcomes |
1 (112) | Perineal trauma | Different materials for primary repair versus each other | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and methodological weakness. Directness point deducted for composite outcome |
We initially allocate 4 points to evidence from RCTs, and 2 points to evidence from observational studies. To attain the final GRADE score for a given comparison, points are deducted or added from this initial score based on preset criteria relating to the categories of quality, directness, consistency, and effect size. Quality: based on issues affecting methodological rigour (e.g., incomplete reporting of results, quasi-randomisation, sparse data [<200 people in the analysis]). Consistency: based on similarity of results across studies. Directness: based on generalisability of population or outcomes. Effect size: based on magnitude of effect as measured by statistics such as relative risk, odds ratio, or hazard ratio.