***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 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    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 Background : Obstetric anal sphincter injuries ( OASIS ) can cause an adverse impact on women 's physical and mental health . There was lack of published data in Chinese population particularly on study ing the risk of OASIS for nonrotational outlet forceps . This study was to determine the incidence and risk factors of OASIS . Methods : This is a retrospective cohort study carried out in a tertiary referral hospital in Hong Kong . The control group was selected r and omly . Univariate and multivariate logistic regression analysis was performed to evaluate the influence of potential risk factors on OASIS . This study review ed the obstetric records of OASIS women and r and om control from January 2011 to June 2014 . Univariate and multivariate logistic regression analysis was performed to evaluate the influence of potential risk factors on OASIS . Results : Of 15,446 women delivered , 49 had OASIS . The percentage of OASIS increased from 0.3 % ( 2011 ) to 0.38 % ( 2014 ) . There was an increasing trend of OASIS in attempted spontaneous vaginal delivery without episiotomy ( P < 0.01 ) , but it did not increase the OASIS risk ( P = 0.46 ) . Univariate analysis of 49 cases and 438 control subjects showed that forceps delivery ( odds ratio [ OR ] = 8.73 , P < 0.01 ) , prolong second stage of labor ( OR = 1.43 , P < 0.01 ) increased the risk for OASIS . In multivariate regression models , only forceps delivery ( OR = 6.28 , P < 0.01 ) proved to be independent risk factor . Conclusions : The incidence of OASIS in Chinese women was increased after 2012 , but still lower than the reported figures in the literature . Outlet forceps delivery could be a possible associated risk factor Background Fetal and neonatal mortality rates in low-income countries are at least 10-fold greater than in high-income countries . These differences have been related to poor access to and poor quality of obstetric and neonatal care . Methods This trial tested the hypothesis that teams of health care providers , administrators and local residents can address the problem of limited access to quality obstetric and neonatal care and lead to a reduction in perinatal mortality in intervention compared to control locations . In seven geographic areas in five low-income and one middle-income country , most with high perinatal mortality rates and substantial numbers of home deliveries , we performed a cluster r and omized non-masked trial of a package of interventions that included community mobilization focusing on birth planning and hospital transport , community birth attendant training in problem recognition , and facility staff training in the management of obstetric and neonatal emergencies . The primary outcome was perinatal mortality at ≥28 weeks gestation or birth weight ≥1000 g. Results Despite extensive effort in all sites in each of the three intervention areas , no differences emerged in the primary or any secondary outcome between the intervention and control clusters . In both groups , the mean perinatal mortality was 40.1/1,000 births ( P = 0.9996 ) . Neither were there differences between the two groups in outcomes in the last six months of the project , in the year following intervention cessation , nor in the clusters that best implemented the intervention . Conclusions This cluster r and omized comprehensive , large-scale , multi-sector intervention did not result in detectable impact on the proposed outcomes . While this does not negate the importance of these interventions , we expect that achieving improvement in pregnancy outcomes in these setting s will require substantially more obstetric and neonatal care infrastructure than was available at the sites during this trial , and without them provider training and community mobilization will not be sufficient . Our results highlight the critical importance of evaluating outcomes in r and omized trials , as interventions that should be effective may not be . Trial registration Clinical Trials.gov OBJECTIVE To evaluate the prevalence of obstetrical anal sphincter injuries ( OASIS ) , which include third and fourth degree perineal tears in primigravida in routine versus selective mediolateral episiotomy . Secondly , to determine the rate of episiotomy in local setting s. METHODS This r and omized control trial was carried out in the labor ward of a tertiary hospital of the Universiti Kebangsaan Malaysia Medical Center , Kuala Lumpur , Malaysia between May and October 2009 . The trial included 171 primigravida beyond 38 weeks gestation who achieved vaginal delivery , and r and omly assigned to selective and routine episiotomy groups .  The  type of perineal injuries following childbirth among 171 women were evaluated . RESULTS The overall episiotomy rate from both groups was 76.6 % . The prevalence of third degree perineal tears was 3.7 % in the routine compared with selective mediolateral episiotomy at 1.1 % . There was no occurrence of fourth degree tears in both groups . However , selective mediolateral episiotomy was associated with an increased risk of periurethral and labial injury compared with the routine group ( 4.5 % versus 0 % ) . CONCLUSION Routine mediolateral episiotomy in primigravida is associated with a higher prevalence of obstetrical anal sphincter injuries . As anal sphincter injuries are known to have morbidities , selective mediolateral episiotomy in primigravida is therefore recommended in the implementation of new delivery practice , and in an attempt to reduce our high episiotomy rate OBJECTIVE To observe the frequency and severity of perineal tears during vaginal delivery . METHODS It was a prospect i ve observational study done at the Countess Lady Duffrin Fund Hospital , Hyderabad , Pakistan , from December 1 , 2009 to May 31 , 2010 . Women with full-term singleton pregnancy primigravida or multigravida , in active labour were included in the study . Patients with pre-term labour , breech presentation and antepartum haemorrhage were excluded , leaving the study population to be 147/1488 . A pre design ed structured proforma was used after informed verbal consent by the patient . All results were analysed on SPSS version 11 . Frequencies and percentages were calculated , while Spearman 's rho test ( two-tailed ) was applied for categorical variables . A p-value of less than or equal to 0.05 was considered significant . RESULTS The frequency of perineal tears in our study was 147/1488 ( 9.8 % ) . The mean age was 28.08 + /- 7.47 , ranging between 17 - 42 years . The vast majority , 100 ( 68 % ) delivered spontaneously , 45 ( 30.6 % ) were delivered with help of the forceps , and only 2 ( 1.4 % ) had vacuum delivery . Parity , oxytocin use , mediolateral episiotomy , forceps use , weight of babies > 3.6 kg were significantly associated with perineal tears . CONCLUSION Perineal tears cause considerable post-natal morbidity . Identification of risk factors , vigilant monitoring during labour and good perineal support is recommended for minimising the risk of perineal trauma as well as morbidity Objective . To evaluate the impact of Advanced Life Support in Obstetrics ( ALSO ) training on staff performance and the incidences of post‐partum hemorrhage ( PPH ) at a regional hospital in Tanzania . Design . Prospect i ve intervention study . Setting . A regional , referral hospital . Population . A total of 510 women delivered before and 505 after the intervention . Methods . All high‐ and mid‐level providers involved in childbirth at the hospital attended a two‐day ALSO provider course .  Staff management was observed and post‐partum bleeding assessed at all vaginal deliveries for seven weeks before and seven weeks after the training . Main Outcome Measures . PPH ( blood loss ≥500ml ) , severe PPH ( blood loss ≥1000ml ) and staff performance to prevent , detect and manage PPH . Results . The incidence of PPH was significantly reduced from 32.9 to 18.2%[RR 0.55 ( 95%CI : 0.44–0.69 ) ] , severe PPH from 9.2 to 4.3%[RR 0.47 ( 95%CI : 0.29–0.77 ) ] . The active management of the third stage of labor was also significantly improved . There was a significant decrease in episiotomies . By visual estimation , staff identified one in 25 of the PPH cases before the ALSO training and one in five after the training . A significantly higher proportion of women with PPH had continuous uterine massage , oxytocin infusion and bimanual compression of the uterus after the training . Conclusions . A two‐day ALSO training course can significantly improve staff performance and reduce the incidence of PPH , at least as evaluated by short‐term effects Background Our aim was to describe the range of perineal trauma in women with a singleton vaginal birth and estimate the effect of maternal and obstetric characteristics on the incidence of perineal tears . Methods We conducted a prospect i ve observational study on all women with a planned singleton vaginal delivery between May and September 2006 in one obstetric unit , three freest and ing midwifery-led units and home setting s in South East Engl and . Data on maternal and obstetric characteristics were collected prospect ively and analysed using univariable and multivariable logistic regression . The outcome measures were incidence of perineal trauma , type of perineal trauma and whether it was sutured or not . Results The proportion of women with an intact perineum at delivery was 9.6 % ( 125/1,302 ) in nulliparae , and 31.2 % ( 453/1,452 ) in multiparae , with a higher incidence in the community ( freest and ing midwifery-led units and home setting s ) . Multivariable analysis showed multiparity ( OR 0.52 ; 95 % CI : 0.30–0.90 ) was associated with reduced odds of obstetric anal sphincter injuries ( OASIS ) , whilst forceps ( OR 4.43 ; 95 % CI : 2.02–9.71 ) , longer duration of second stage of labour ( OR 1.49 ; 95 % CI : 1.13–1.98 ) , and heavier birthweight ( OR 1.001 ; 95 % CI : 1.001–1.001 ) , were associated with increased odds . Adjusted ORs for spontaneous perineal truama were : multiparity ( OR 0.42 ; 95 % CI : 0.32–0.56 ) ; hospital delivery ( OR 1.48 ; 95 % CI : 1.01–2.17 ) ; forceps delivery ( OR 2.61 ; 95 % CI : 1.22–5.56 ) ; longer duration of second stage labour ( OR 1.45 ; 95 % CI : 1.28–1.63 ) ; and heavier birthweight ( OR 1.001 ; 95 % CI : 1.000–1.001 ) . Conclusions This large prospect i ve study found no evidence for an association between many factors related to midwifery practice such as use of a birthing pool , digital perineal stretching in the second stage , h and s off delivery technique , or maternal birth position with incidence of OASIS or spontaneous perineal trauma . We also found a low overall incidence of OASIS , and fewer second degree tears were sutured in the community than in the hospital setting s. This study confirms previous findings of overall high incidence of perineal trauma following vaginal delivery , and a strong association between forceps delivery and perineal trauma Background Episiotomy is the surgical enlargement of the vaginal orifice by an incision of the perineum during the second stage of labor or just before delivery of the baby . During the 1970s , it was common to perform an episiotomy for almost all women having their first delivery , ostensibly for prevention of severe per 
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Discussion Compared to high-income setting s , episiotomy rates are high in LMIC medical facilities .