Routine perineal shaving on admission in labour

Vittorio Basevi; Tina Lavender

doi:10.1002/14651858.CD001236.pub2

Рутинное бритье промежности при поступлении в больницу во время родов

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Referencias

References to studies included in this review

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Johnston RA, Sidall RS. Is the usual method of preparing patients for delivery beneficial or necessary?. American Journal of Obstetrics and Gynecology 1922;4:645‐50.

Kantor HI, Rember R, Tabio P, Buchanon R. Value of shaving the pudendal‐perineal area in delivery preparation. Obstetrics & Gynecology 1965;25:509‐12.

Google Scholar

Kovavisarach E, Jirasettasiri P. Randomised controlled trial of perineal shaving versus hair cutting in parturients on admission in labor. Journal of the Medical Association of Thailand 2005;88:1167‐71.

Additional references

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estudios incluidos
otras versiones publicadas

Altaweli RF, McCourt C, Baron M. Childbirth care practices in public sector facilities in Jeddah, Saudi Arabia: a descriptive study. Midwifery 2014;30(7):899‐909.

Briggs M. Principles of closed surgical wound care. Journal of Wound Care 1997;6(6):288‐92.

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Colomar M, Belizán M, Cafferata ML, Labandera A, Tomasso G, Althabe F, et al. Practices of maternal and perinatal care performed in public hospitals of Uruguay [Prácticas en la atención maternal y perinatal realizadas en los hospitals públicos de Uruguay]. Ginecologia y Obstetricia de Mexico 2004;72:455‐65.

Conde‐Agudelo A, Rosas‐Bermudez A, Gülmezoglu AM. Evidence‐based intrapartum care in Cali, Colombia: a quantitative and qualitative study. BJOG: an international journal of obstetrics and gynaecology 2008;115(12):1547‐56.

d'Orsi E, Chor D, Giffin K, Angulo‐Tuesta A, Barbosa GP, Gama Ade S, et al. Quality of birth care in maternity hospitals of Rio de Janeiro, Brazil [Qualidade da atenção ao parto em maternidades do Rio de Janeiro]. Revista de Saúde Pública 2005;39(4):645‐54.

DeMaria AL, Flores M, Hirth JM, Berenson AB. Complications related to pubic hair removal. American Journal of Obstetrics and Gynecology 2014;210(6):528.e1‐5.

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The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.

Romney ML. Pre‐delivery shaving: an unjustified assault?. Journal of Obstetrics and Gynaecology 1980;1:33‐5.

Schunemann HJ. GRADE: from grading the evidence to developing recommendations. A description of the system and a proposal regarding the transferability of the results of clinical research to clinical practice [GRADE: Von der Evidenz zur Empfehlung. Beschreibung des Systems und Losungsbeitrag zur Ubertragbarkeit von Studienergebnissen]. Zeitschrift fur Evidenz, Fortbildung und Qualitat im Gesundheitswesen 2009;103(6):391‐400.

SEA‐ORCHID Study Group, Lumbiganon P, McDonald SJ, Laopaiboon M, Turner T, Green S, Crowther CA. Impact of increasing capacity for generating and using research on maternal and perinatal health practices in South East Asia (SEA‐ORCHID Project). PLoS One 2011;6(9):e23994.

Sweidan M, Mahfoud Z, DeJong J. Hospital policies and practices concerning normal childbirth in Jordan. Studies in Family Planning 2008;39(1):59‐68.

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References to other published versions of this review

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estudios incluidos
otras referencias

Basevi V, Lavender T. Routine perineal shaving on admission in labour. Cochrane Database of Systematic Reviews 2000, Issue 4. [DOI: 10.1002/14651858.CD001236]

Renfrew MJ. Routine perineal shaving on admission in labour. [revised 02 April 1992]. In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP, Crowther C (eds.) Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database [database on disk and CDROM]. The Cochrane Collaboration: Issue 2, Oxford: Update Software; 1995.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Johnston 1922

Methods	Alternate allocation.
Participants	389 women in labour. Exclusions criteria: caesarean section; previously identified infection; eclampsia; postpartum admissions. USA.
Interventions	Pubic shaving plus the usual skin preparation (scrubbing of the external genitalia and inner thighs with green soap and water and the pouring of sterile water, alcohol and a weak solution of bichloride of mercury over the vulva and adjoining area) (N = 196) versus clipping of long pubic hairs only (no skin preparation) (N = 193).
Outcomes	Febrile puerperia.
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	High risk	Women alternately allocated to experimental or control group. No information on the timing of allocation, the personnel involved, or the number of exclusions during this process.
Allocation concealment (selection bias)	High risk	No sufficient detail about allocation sequence concealment.
Blinding of participants and personnel (performance bias) All outcomes	High risk	Blinding not possible due to the nature of the intervention.
Blinding of outcome assessment (detection bias) All outcomes	High risk	No mention of blinding of outcome assessors.
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	Not possible to determine the completeness of data.
Selective reporting (reporting bias)	Unclear risk	Insufficient information to permit judgement.
Other bias	Low risk	No other sources of bias identified.

Kantor 1965

Methods	Method of allocation not specified.
Participants	150 labouring women pre delivery. USA.
Interventions	First comparison: shaving of the pudendal and perineal areas (N = 50) versus clipping of long pubic hairs (N = 50). In all women the pudendal and perineal region was washed with a diluted pHisoHex solution. Second comparison: shaving of the pudendal and perineal areas (N = 25) versus clipping of long pubic hairs (N = 25). All women received povidone‐iodine spray as skin preparation, after washing to remove pHisoHex.
Outcomes	Positive bacteriology cultures (gram positive and negative). Maternal pyrexia.
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Method for determining the randomisation sequence not mentioned; insufficient information about the sequence generation process.
Allocation concealment (selection bias)	High risk	Insufficient detail about allocation sequence concealment.
Blinding of participants and personnel (performance bias) All outcomes	High risk	Blinding not possible due to the nature of the intervention.
Blinding of outcome assessment (detection bias) All outcomes	High risk	No mention of blinding of outcome assessors.
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	Not possible to determine the completeness of data.
Selective reporting (reporting bias)	Unclear risk	Insufficient information to permit judgement.
Other bias	Low risk	No other sources of bias identified.

Kovavisarach 2005

Methods	Random allocation from a table of random numbers with sequentially numbered, sealed envelopes.
Participants	500 pregnant women recruited from 1 hospital. 42 women excluded after randomisation due to caesarean section. Study period: November 2001‐February 2002. Inclusion criteria: term pregnancy (gestational age 37‐42 weeks) true labour pain, singleton, cephalic presentation, living fetus. Exclusion criteria: women with medical or obstetric complications (e.g. premature rupture of membranes, HIV positive, treatment with antibiotics within 7 days of admission, birth canal or anal infection). Thailand.
Interventions	Perineal shaving (N = 231) versus cutting of perineal hair, down to 0.5 cm above the skin (N = 227). In all women the perineal region was scrubbed with 4% chlorhexidine scrub and rinsed with savlon solution (1:100).
Outcomes	Perineal wound infection; puerperal morbidity; puerperal infection; neonatal infection; satisfaction of the patients, accoucheurs and perineorrhaphy operators.
Notes	All women were attended by nurses, externs and obstetrics‐gynaecology residents. The episiotomy wounds were repaired either by externs or residents under the supervision of the senior residents. The satisfaction of parturients was evaluated immediately after perineal repair had finished. The definition of puerperal infection was based on histopathological and not clinical criteria.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Use of a published table of random sequence generation.
Allocation concealment (selection bias)	Low risk	Use of sealed sequentially numbered envelopes.
Blinding of participants and personnel (performance bias) All outcomes	High risk	Blinding not possible due to the nature of the intervention.
Blinding of outcome assessment (detection bias) All outcomes	High risk	No mention of blinding of outcome assessors.
Incomplete outcome data (attrition bias) All outcomes	Low risk	No missing outcome data.
Selective reporting (reporting bias)	Unclear risk	Insufficient information to permit judgement.
Other bias	Low risk	No other sources of bias identified.

Data and analyses

Open in table viewer

Comparison 1. Perineal shaving versus no perineal shaving

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Postpartum maternal febrile morbidity Show forest plot	3	997	Risk Ratio (M‐H, Fixed, 95% CI)	1.14 [0.73, 1.76]
Open in figure viewer Analysis 1.1 Comparison 1 Perineal shaving versus no perineal shaving, Outcome 1 Postpartum maternal febrile morbidity.
2 Colonisation Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.2 Comparison 1 Perineal shaving versus no perineal shaving, Outcome 2 Colonisation.
2.1 Gram‐positive	1	150	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.82, 1.64]
2.2 Gram‐negative	1	150	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.70, 0.98]
3 Neonatal infection Show forest plot	1	458	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
Open in figure viewer Analysis 1.3 Comparison 1 Perineal shaving versus no perineal shaving, Outcome 3 Neonatal infection.
4 Wound infection Show forest plot	1	458	Risk Ratio (M‐H, Fixed, 95% CI)	1.47 [0.80, 2.70]
Open in figure viewer Analysis 1.4 Comparison 1 Perineal shaving versus no perineal shaving, Outcome 4 Wound infection.
5 Wound dehiscence Show forest plot	1	458	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 8.00]
Open in figure viewer Analysis 1.5 Comparison 1 Perineal shaving versus no perineal shaving, Outcome 5 Wound dehiscence.
6 Need for wound resuturing	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Discomfort	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Pain	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 Maternal embarrassment	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10 Maternal satisfaction	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Maternal satisfaction continuous data Show forest plot	1	458	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐0.13, 0.13]
Open in figure viewer Analysis 1.11 Comparison 1 Perineal shaving versus no perineal shaving, Outcome 11 Maternal satisfaction continuous data.

Figure 1

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 2

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1 Perineal shaving versus no perineal shaving, Outcome 1 Postpartum maternal febrile morbidity.

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Analysis 1.2

Comparison 1 Perineal shaving versus no perineal shaving, Outcome 2 Colonisation.

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Analysis 1.3

Comparison 1 Perineal shaving versus no perineal shaving, Outcome 3 Neonatal infection.

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Analysis 1.4

Comparison 1 Perineal shaving versus no perineal shaving, Outcome 4 Wound infection.

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Analysis 1.5

Comparison 1 Perineal shaving versus no perineal shaving, Outcome 5 Wound dehiscence.

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Analysis 1.11

Comparison 1 Perineal shaving versus no perineal shaving, Outcome 11 Maternal satisfaction continuous data.

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Summary of findings for the main comparison. routine perineal shaving before childbirth for women in labour

Routine perineal shaving before childbirth for women in labour
Population: Women in labour Settings: Hospitals in US (Baltimore, Dallas) and Thailand (Bangkok) Intervention: Routine perineal shaving before childbirth versus clipping of long pubic hairs or cutting of perineal hairs
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	Routine perineal shaving before childbirth
Postpartum maternal febrile morbidity	Study population		RR 1.16 (0.74 to 1.80)	997 (3 studies)	⊕⊝⊝⊝ very low^1,2
	67 per 1000	77 per 1000 (48 to 119)
	Low
	18 per 1000	20 per 1000 (12 to 33)
	High
	124 per 1000	141 per 1000 (90 to 213)
Neonatal infection	Study population		Not estimable	458 (1 study)	see comment	The outcome was reported with no events.
	See comment	See comment
	Moderate

Wound infection	Study population		RR 1.47 (0.80 to 2.70)	458 (1 study)	⊕⊕⊝⊝ low³
	70 per 1000	103 per 1000 (57 to 180)
	Moderate
	70 per 1000	103 per 1000 (56 to 179)
Maternal satisfaction Scale from 1 to 5	The mean maternal satisfaction in the control groups was 3.8 (five degrees)⁴	The mean maternal satisfaction in the intervention groups was 0 higher (0.13 lower to 0.13 higher)	MD 0.00 (‐0.13, 0.13)	458 (1 study)	⊕⊕⊝⊝ low⁵
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio; MD: mean difference
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ Most studies contributing data had serious design limitations. ² Wide confidence interval crossing the line of no effect. ³The total cumulative study population is not very small (sample size 458) and the total number of events is 40, but the 95% confidence interval is very wide. ⁴Likert scales on five degrees to measure a women's intensity of satisfaction (5, excellent; 4, good; 3, average; 2, fair; and 1, poor). ⁵Wide confidence interval crossing the line of no effect and small sample size.

Summary of findings for the main comparison. routine perineal shaving before childbirth for women in labour

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Comparison 1. Perineal shaving versus no perineal shaving

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Postpartum maternal febrile morbidity Show forest plot	3	997	Risk Ratio (M‐H, Fixed, 95% CI)	1.14 [0.73, 1.76]

2 Colonisation Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.1 Gram‐positive	1	150	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.82, 1.64]
2.2 Gram‐negative	1	150	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.70, 0.98]
3 Neonatal infection Show forest plot	1	458	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

4 Wound infection Show forest plot	1	458	Risk Ratio (M‐H, Fixed, 95% CI)	1.47 [0.80, 2.70]

5 Wound dehiscence Show forest plot	1	458	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 8.00]

6 Need for wound resuturing	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Discomfort	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Pain	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 Maternal embarrassment	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10 Maternal satisfaction	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Maternal satisfaction continuous data Show forest plot	1	458	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐0.13, 0.13]

Comparison 1. Perineal shaving versus no perineal shaving

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Referencias

References to studies included in this review

Johnston 1922 {published data only}

Kantor 1965 {published data only}

Kovavisarach 2005 {published data only}

Additional references

Altaweli 2014

Briggs 1997

Charrier 2010

Chen 2006

Colomar 2004

Conde‐Agudelo 2008

d'Orsi 2005

DeMaria 2014

GRADE 2008 [Computer program]

Higgins 2011

Nagpal 2014

Oakley 1979

Qian 2001

RevMan 2014 [Computer program]

Romney 1980

Schunemann 2009

SEA‐ORCHID 2011

Sweidan 2008

Tanner 2011

References to other published versions of this review

Basevi 2000

Renfrew 1995

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Data and analyses

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