OBJECTIVE: to investigate the use of local anaesthetics, in the presence or absence of vasoconstrictors, for perineal repair during spontaneous delivery. DESIGN: double-blind, randomised-controlled trial. SETTING: a birth centre, in the city of Sao Paulo, Brazil. PARTICIPANTS: from June to December 2004, a total of 96 women were allocated into three groups (first-degree perineal lacerations, second-degree perineal lacerations or episiotomy), and treated with local anaesthesia (1% lidocaine or 1% lidocaine with epinephrine)(n=16 per treatment per group). INTERVENTIONS: an initial local infiltration of the anaesthetic solution was given so that episiotomy could be carried out (5ml) and to suture spontaneous lacerations (1ml), followed by repeated doses (1ml) until pain was completely inhibited. MEASUREMENTS AND FINDINGS: the main outcome measurement was the volume of anaesthetic used during episiotomy and perineal suture. Our data suggest that the concomitant use of the vasoconstrictor resulted in a significantly lower average volume used in the treatment of first-degree (1ml, 95% confidence interval (CI) 0.4-1.6) and second-degree (3.7ml, 95% CI 1.6-5.8) lacerations (p=0.002 and 0.001, respectively). A 0.3ml (95% CI 1.5-2.1) average decrease in anaesthetic volume was observed with episiotomy (p=0.724). The maximum volume of anaesthetic used with and without vasoconstrictor was 1-2ml in 95% and 3-4ml in 50% of first-degree lacerations, respectively, and 1-6ml in 88% and 7-15ml in 81% of second-degree lacerations, respectively. For episiotomy, the maximum dose was 15ml, regardless of anaesthetic solution used. KEY CONCLUSIONS: our data confirm the hypothesis that the use of anaesthetics in conjunction with vasoconstrictors is more effective than anaesthetics alone in the repair of perineal lacerations, but not for episiotomy.

OBJECTIVE: Australia finds itself in the grip of its worst drought on record. The surgical profession has a responsibility to conserve water where possible. We tried to show how much water we saved through the simple measure of turning taps off while not in use during the surgical scrub. DESIGN: We conducted a prospective analysis of two different scrub techniques at the Gold Coast Hospital in Queensland, Australia. Ten participants completed two 5-min scrubs using standard 'elbow on' taps. In the first, they left the taps running throughout the scrub; in the second, they turned the taps on and off so that water ran only when rinsing the hands. Water was collected and the amount of time the hands spent under running water was recorded. MAIN OUTCOME MEASURE: Amount of water used during the surgical scrub. RESULTS: A mean of 15.5 L was used during the 'taps on' scrub, with participants spending a mean of 47 s rinsing the hands. During the 'taps on/off' scrub, participants used a mean of 4.5 L, spending 40 s rinsing the hands. This represents a water saving of 11 L or 71% for each scrub (P < 0.001). There was a difference of 7 s in time rinsing the hands (P = 0.16). CONCLUSION: A taps on/off technique is a simple and effective way of conserving large amounts of water during the surgical scrub. The technique should be adopted as standard practice.

BACKGROUND: Women frequently suffer perineal trauma while giving birth. Interventions to increase the possibility for an intact perineum are needed. OBJECTIVES: To evaluate the effectiveness of antenatal perineal massage in increasing the likelihood of delivering with an intact perineum. METHODS: This single blinded prospective controlled trial included 234 nulliparous women with a singleton fetus. Women allocated to the study group were instructed to practice a 10 minute perineal massage daily from the 34th week of gestation until delivery. Primary outcome measures included the episiotomy rate; first, second, third and fourth-degree perineal tear rates; and intact perineum. Secondary outcomes were related to specific tear locations and the amount of suture material required for repair. RESULTS: Episiotomy rates, overall spontaneous tears and intact perineum rates were similar in the study and control groups. Women in the massage group had slightly lower rates of first-degree tears (73.3% vs. 78.9%, P = 0.39) and slightly higher rates of second-degree tears (26.7% vs. 19.3%, P= 0.39), although both of these outcomes did not reach statistical significance. The rates of anterior perineal tears were significantly higher in the massage group (9.5% vs. 3%, P = 0.05), whereas internal lateral tears rates were slightly lower but without statistical significance (11.5% vs.13.1%, P=0.44). CONCLUSIONS: The practice of antenatal perineal massage showed neither a protective nor a detrimental significant effect on the occurrence of perineal trauma.

OBJECTIVES: To determine the statistical association, in nulliparous patients, between maternal and fetal morbidity and the length of the second stage of labour. To precise whether a prolongation of this period of more than 2h may results in a dramatic increase of this morbidity. MATERIALS AND METHODS: Retrospective cohort study conducted in a level III referral centre between 1 April 2004 and 30 April 2005, including all nulliparous, term, cephalic, live singleton birth without fetal malformation in patients reaching the second stage of labour (n=1191). All deliveries were performed without restrictions in the length of the second stage of labour in the absence of fetal heart rate abnormalities. Maternal and neonatal morbidity were examined according to the duration of the second stage of labour with univariate analysis and after statistical adjustment with multivariate logistic regression for potential confounding variables. RESULTS: Global maternal morbidity ranged from 5.7% after 1h to 20.4% after more than 3h of full cervical dilatation. After a second stage duration of 2h, each additional completed hour resulted in a significant increase in global maternal morbidity (OR 1.78; IC 95%[1.59-1.97]), postpartum haemorrhage (OR 1.72; IC 95%[1.21-2.23]) and level three or four perineal lacerations (OR 1.24; IC 95%[1.7-1.41]). In the same time, caesarean section rate (OR 2.09; IC 95%[1.84-2.34]) and operative vaginal deliveries (OR 1.82; IC 95%[1.59-2.05]) increased significantly. Conversely, our study didn't demonstrate any significant association between neonatal morbidity and the length of the second stage of labour. CONCLUSION: Our study confirmed the association between the duration of the second stage of labour and the increase of maternal but not neonatal morbidity. Such an association, predominantly after 3h spend at full cervical dilatation, needs to be taken into account and, according to our experience, may justify caesarean section.