Ritgens Maneuver for the Prevention of Anal Sphincter Tears at Delivery: A Randomized Controlled Trial
Condition: Perineal Lacerations
MeSH terms: Lacerations
Study type: Interventional

Summary: 
      The aim of the investigation was to assess whether routine use of the modified Ritgen´s
      maneuver decreases the risk of anal sphincter injury at delivery, compared with simple manual
      protection of the perineum.Ritgen´s maneuver means that the fetal chin is reached for between
      the anus and the coccyx and pulled anteriorly, while using the fingers of the other hand on
      the fetal occiput to control speed of delivery and keep flexion of the fetal neck.
    

Detailed description: 
      This application is made retroactively - the study was performed during December 1st, 1999 to
      July 31st, 2001, at Lund University Hospital and Helsingborg Hospital. Primigravid women in
      the area were informed about the study at the maternity care centers, receiving written
      information in gestational week 36. Eligible for the study were women with singleton
      pregnancy and a fetus in cephalic presentation, admitted for labor, rupture of the membranes
      or induction after 37 completed gestational weeks. Primigravid women received written
      information about the study at the maternal health care centers, and eligible women were
      asked for consent at admission in labor.

      Randomization was done at the beginning of the second stage of labor (at full cervical
      dilatation), in each unit by a telephone call from the delivering midwife to the other
      department, where randomization lists with numbers for allocation were kept. In women
      allocated to Ritgen´s maneuver, the protocol stated that the delivery of the fetal head
      should be managed by this maneuver, i.e. lifting the fetal chin anteriorly, using the fingers
      of one hand placed between the anus and the coccyx, and thereby extending the fetal neck,
      whereas the other hand should be placed on the fetal occiput to control the pace of the
      expulsion of the fetal head. The technique for Ritgen´s maneuver was standardized, and
      midwives that were unfamiliar with the procedure were instructed by senior colleagues before
      the trial. In the other study group, the protocol entailed our standard care. The standard
      practice at delivery was using one hand to apply pressure against the perineum, and the other
      hand on the fetal occiput to control the expulsion of the fetal head, and only to use
      Ritgen´s maneuver in case of labor arrest or abnormal fetal heart rate pattern when the fetal
      head was at the pelvic floor.
    

Intervention name(s): Ritgens maneuver; Standard care (Manual support of the perineum)
Intervention type(s): Procedure; Procedure
Intervention description(s): Delivery of the fetal head should be managed by Ritgens maneuver, i.e. lifting the fetal chin anteriorly, using the fingers of one hand placed between the anus and the coccyx, and thereby extending the fetal neck, whereas the other hand should be placed on the fetal occiput to control the pace of the expulsion of the fetal head. The maneuver was used during a uterine contraction; The protocol entailed our standard care: using one hand to apply pressure against the perineum, and the other hand on the fetal occiput to control the expulsion of the fetal head, and only to use Ritgen´s maneuver in case of labor arrest or abnormal fetal heart rate pattern when the fetal head was at the pelvic floor.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Prevention
Keywords: sphincter tears; Ritgen maneuver; perineal tears; prevention; delivery