Introducing a novel technique to reduce severe perineal injuries during delivery: the "shoulder-up" maneuver

To investigate if introducing a novel technique to assist the delivery of the posterior shoulder (the “shoulder-up” maneuver) in a tertiary referral unit may positively impact on the rate of severe perineal injuries. Single-center retrospective interventional study including all vaginal deliveries between April 1st 2020 and March 31st 2022. On March 1st, 2021, a bundle to raise the awareness on the perineal wounds prevention at the delivery of posterior shoulder had been introduced. The “shoulder-up” maneuver, which consists in a slow, controlled delivery of the posterior shoulder under direct visualization of perineal plane after the disengagement of anterior shoulder (see the attached figure), had been included as a standard of care. All midwives and physicians completed a full theoretical and practical course to learn the maneuver at the moment of the bundle introduction. A propensity score matching analysis was performed to assess the effect of the “shoulder-up” maneuver on the risk of perineal tears adjusting for those variables that resulted to be independently associated to more severe perineal injury (nulliparity, gestational age at delivery, peridural analgesia, vacuum extraction and birthweight > 4Kg at delivery). We matched a total of 3652 patients (1826 per arm); the analysis showed a significant increase in intact perineum rate (59.5% vs 66.4%, p = 0.009) and a significant reduction in the incidence of 2nd (30.7% vs 25.8%, p = 0.006) and 3rd-4th degree perineal wounds (2.8% vs 1.2%, p < .001) after the introduction of the bundle. Episiotomy rate did not significantly change before and after the maneuver adoption (7.0 % vs 6.5%, p = 0.702). Our study showed that after the introduction of the “shoulder-up” maneuver as a standard of care in the assistance to vaginal delivery the rate of severe perineal wounds significantly decreased.View Large Image Figure ViewerDownload Hi-res image Download (PPT)