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. 2011 Apr 11;2011:1401.

Table.

GRADE Evaluation of interventions for Perineal care.

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.