***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: BACKGROUND : The objective of the present study was to evaluate the effect of the two methods of delivery , “ h and s-on ” vs. “ h and s poised ” , on perineal trauma and delivery outcome in primiparous women referred to Shariati Hospital of Isfahan during 2007 - 2008 . METHODS : In a clinical trial study , 100 low risk primiparous pregnant women were r and omly assigned to two h and s-on and h and -poised ( h and s-off ) groups . In the h and s-on group , this method was used to control fetal head in the second stage of labor . It means that the fingers of one h and supported fetal occiput and the other h and applied slight pressure on the head to control the delivery of the head during the crowning process . In the h and s-poised group , midwife observed the parturient woman and do not touch perineum during the second labor stage while fetal head was delivering . Then , the two groups were compared in terms of perineal trauma , as well as neonatal and delivery outcome . RESULTS : Demographic characteristics of all studied women were similar in two groups . The rate of episiotomy was higher in h and s-on group ( 84 % vs. 40 % , p = 0.001 ) . The rate of postpartum hemorrhage ( 4th stage ) was higher in h and s-on group ( 12 % vs. 4 % , p = 0.04 ) . The rate of mild and moderate postpartum pain in h and s-on group was higher than h and s-off group ( 70 % vs. 58 % and 29 % vs. 10 % , p < 0.001 ) but sever pain was not different in two groups . CONCLUSIONS : It seems that h and s-poised method is associated with less perineal trauma , particularly regarding the lower need for episiotomy and postpartum hemorrhage OBJECTIVE To investigate the influence of the traditional h and s-on versus the innovative h and s-poised method on the risk of perineal trauma during vaginal delivery and on neonatal outcomes . STUDY DESIGN In a prospect i ve , r and omized , multicenter study , 1,161 of 1,505 women giving birth at the Departments of Obstetrics and Gynecology of the University Hospital of Vienna and Semmelweis Women 's Hospital , Vienna , between February and September 1999 , were r and omized into the trial . In the h and s-on method , the left h and of the midwife puts pressure on the infant 's head , and the right h and is placed against the perineum . In the h and s-poised method , the midwife guides the parturient through the birth without touching the perineum , prepared to apply light pressure on the infant 's head . RESULTS One hundred eighty-seven of 574 women ( 32.5 % ) in the h and s-on group and 180 of 502 women ( 35.8 % ) in the h and s-poised group experienced perineal tears ( P = .5 ) . Sixteen women ( 2.7 % ) treated with the h and s-on method developed third-degree perineal tears as compared with five women ( 0.9 % ) treated with the h and s-poised method ( P < .05 ) . In the h and s-on group , 103 women ( 17.9 % ) underwent episiotomy as compared with 51 cases ( 10.1 % ) in the h and s-poised group ( P < .01 ) . No significant differences in neonatal outcomes were observed between the two groups . CONCLUSION Our data suggest that a policy of h and s-poised care is more suitable for preserving the perineum during birth and is a safe and effective birthing alternative for women Summary Background The purpose of this study was to compare the obstetric outcome of low-risk maternity patients attended by certified midwives  with that of  low-risk maternity patients attended by obstetricians .  Patients and methods Obstetric outcome of 1352 midwife patients was compared with that of 1352 age- and parity-matched physician patients with normal spontaneous vaginal delivery at the Department of Obstetrics and Gynecology of the University Hospital Vienna during the period from January 1997 to July 2002 . Our analysis was restricted to a sample of low-risk pregnant women . Women with medical or obstetric risk factors were excluded . Results A significant decrease in the use of oxytocin  ( p=0.0001 ) was observed in women who selected a midwife as their primary birth attendant compared with women in the physician group . In both groups most women gave birth in a supine position ; however , significantly more alternative birth positions were used by midwife patients ( p=0.0001 ) . Concerning perineal trauma , a significantly lower rate of episiotomies ( p=0.0001 ) and perineal tears of all degrees ( p=0.006 ) were found in midwife patients . When analyzing severe postpartum hemorrhage and postpartum infections , there were no significant differences between the two groups ( p>0.05 ) . Concerning neonatal outcome , there were no significant differences in APGAR score < 7 at 5 minutes (p>0.05).Our data clearly show the ability of certified midwives to successfully provide prenatal care and delivery to lowrisk maternity patients , with neonatal outcomes comparable to those of physician patients . The use of certified midwives supervised by obstetricians may provide the optimum model for perinatal care , particularly for those women who are low-risk maternity patients , leaving physicians free to attend to the high-risk elements of care Background Whether certain birth positions are associated with perineal injuries and severe perineal trauma ( SPT ) is still unclear . The objective of this study was to describe the prevalence of perineal injuries of different severity in a low-risk population of women who planned to give birth at home and to compare the prevalence of perineal injuries , SPT and episiotomy in different birth positions in four Nordic countries . Methods A population -based prospect i ve cohort study of planned home births in four Nordic countries . To assess medical outcomes a question naire completed after birth by the attending midwife was used . Descriptive statistics , bivariate analysis and logistic regression were used to analyze the data . Results Two thous and nine hundred ninety-two women with planned home births , who birthed spontaneously at home or after transfer to hospital , between 2008 and 2013 were included . The prevalence of SPT was 0.7 % and the prevalence of episiotomy was 1.0 % . There were differences between the countries regarding all maternal characteristics . No association between flexible sacrum positions and sutured perineal injuries was found ( OR 1.02 ; 95 % CI 0.86–1.21 ) or SPT ( OR 0.68 ; CI 95 % 0.26–1.79 ) . Flexible sacrum positions were associated with fewer episiotomies ( OR 0.20 ; CI 95 % 0.10–0.54 ) . Conclusion A low prevalence of SPT and episiotomy was found among women opting for a home birth in four Nordic countries . Women used a variety of birth positions and a majority gave birth in flexible sacrum positions . No associations were found between flexible sacrum positions and SPT . Flexible sacrum positions were associated with fewer episiotomies Background : Many women suffer from perineal trauma during the normal vaginal delivery . Perineal trauma is mainly associated with pain and complications after the childbirth . Perineal management techniques can play a significant role in perineal trauma reduction . This study aim ed to compare the effects of perineal management techniques ( h and s-off technique , Ritgen maneuver and perineal massage using a lubricant during delivery ) on the labor complications . Material s and Methods : This quasi-experimental clinical trial was conducted on 99 primiparous women who referred to Daran Hospital , Isfahan , Iran for normal vaginal delivery in 2009 . The subjects were selected using a convenient method and r and omly assigned to three groups of Ritgen maneuver , h and s-off technique and perineal massage with lubricant . A question naire was used to determine the demographic characteristics of the participants and complications after birth . The short form of McGill Pain Question naire and the visual analogue scale for pain were also employed . The incidence and degree of perineal tears were evaluated immediately after delivery . Moreover , the incidence and severity of perineal pain were assessed 24 hours and also 6 weeks after delivery . Findings : In the Ritgen maneuver group , the frequency of tears , the relative frequency of tear degrees , the severity of perineal pain 24 hours after delivery and the frequency of pain and perineal pain severity 6 weeks after delivery were significantly different from the other two methods . Conclusions : H and s-off technique during parturition of the neonate 's head was associated with fewer complications after delivery . It was even better than perineal massage during the parturition OBJECTIVE The objective of the study was to determine whether bed delivery without stirrups reduces the incidence of perineal lacerations compared with delivery in stirrups . STUDY DESIGN In this r and omized trial , we compared bed delivery without stirrups with delivery in stirrups in nulliparous women . The primary outcome was any perineal laceration ( first through fourth degree ) . RESULTS One hundred eight women were r and omized to delivery without stirrups and 106 to stirrups .  A total of 82 women r and omized to no stirrups ( 76 % ) sustained perineal lacerations compared with 83 in women allocated to stirrups ( 78 % ) ( P = .8 ) . There was no significant difference in the severity of lacerations or in obstetric outcomes such as prolonged second stage of labor , forceps delivery , or cesarean birth . Similarly , infant outcomes were unaffected . CONCLUSION Our results do not incriminate stirrups as a cause of perineal lacerations . Alternatively , our findings of no difference in perineal lacerations suggest that delivering in bed without stirrups confers no advantages or disadvantages Abstract Objective : Dianatal ® is a bioadhesive gliding film which reduces the opposing force to vaginal childbirth . We aim ed to investigate the safety , applicability , and impact of Dianatal ® obstetric gel on second stage of labor and perineal integrity . Methods : Low-risk singleton pregnancies at term were prospect ively enrolled . Eligible women were r and omly assigned to either labor management without using obstetric gel , or labor management using intermittent application of obstetric gel into the birth canal during vaginal examinations , starting at active phase of labor ( ≥4 cm dilation ) . The primary measured outcome was the length of second stage of labor . Results : Overall , 200 cases were analyzed . Demographic , obstetrical , and labor characteristics were similar between the groups . Neither adverse events nor maternal or neonatal side effects were observed . The mean lengths of the active and second stages of labor were comparable between the obstetric gel-treated and the control groups ( 157 versus 219 min and 48 versus 56 min , respectively ) . None of the women had grade III/IV perineal tears . Maternal and neonatal outcomes were not negatively influenced by using obstetric gel . No difference was found after sub-group analysis for spontaneous vaginal delivery . Conclusion : Dianatal ® obstetric gel is safe in terms of maternal or neonatal use . Albeit a trend toward shorter labor stages using Dianatal ® obstetric gel , no significant differences were noted among the groups . In order to further investigate the influence of the obstetric gel on labor stage interval , perineal integrity and maternal and neonatal outcomes , larger r and omized clinical trials are needed to be carried out BACKGROUND Trauma to the perineum is a serious and frequent problem after childbirth , with about 350000 women each year in the UK needing sutures for perineal injury after spontaneous vaginal delivery , and many millions more worldwide . We compared the continuous technique of perineal repair with the interrupted method , and the more rapidly absorbed polyglactin 910 suture material with the st and ard polyglactin 910 material . METHODS 1542 women who had a spontaneous vaginal delivery with a second-degree perineal tear or episiotomy were r and omly allocated to either the continuous ( n=771 ) or interrupted ( 771 ) suturing method , and to either the more rapidly absorbed polyglactin 910 suture material ( 772 ) or st and ard polyglactin 910 material ( 770 ) . Primary outcomes were pain 10 days after delivery and superficial dyspareunia 3 months postpartum . Analysis was by intention to treat . FINDINGS At day 10 , three women had dropped out of the study . Significantly fewer women reported pain at 10 days with the continuous technique than with the interrupted method ( 204/770 [ 26.5 % ] vs 338/769 [ 44.0 % ] , odds ratio 0.47 , 95 % CI 0.38 - 0.58 , p<0.0001 ) . Occurrence of pain did not differ significantly between groups assigned the more rapidly absorbed material or st and ard material ( 256/769 [ 33.3 % ] vs 286/770 [ 37.1 % ] , 0.84 , 0.68 - 1.04 , p=0.10 ) . Women reported no difference in superficial dyspareunia at 3 months for the continuous vs the interrupted method ( 98/581 [ 16.9 % ] vs 102/593 [ 17.2 % ] , 0.98 , 0.72 - 1.33 , p=0.88 ) or the more rapidly absorbed versus st and ard material ( 1 
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Episiotomy was more frequent in the h and s-on group ( average RR 0.58 , 95 % CI 0.43 to 0.79 , Tau² 0.07 , I² 74 % , four studies , 7247 women ; low- quality evidence ) , but there was considerable heterogeneity between the four included studies .There were no data for perineal trauma requiring suturing .
Other comparisonsThe delivery of posterior versus anterior shoulder first , use of a perineal protection device , different oils/wax , and cold compresses did not show any effects on perineal outcomes .
Moderate- quality evidence suggests that warm compresses , and massage , may reduce third- and fourth-degree tears but the impact of these techniques on other outcomes was unclear or inconsistent .
Poor- quality evidence suggests h and s-off techniques may reduce episiotomy , but this technique had no clear impact on other outcomes .