Critical Analysis of 'Hands On' Method for Perineal Tear Prevention

This article provides a critical analysis of the 'hands on' method for perineal tear prevention during normal vaginal birth. It discusses the different opinions and evidence surrounding this technique and its impact on perineal trauma. The article also explores the factors that contribute to severe perineal tears and the importance of women-centered practice in childbirth. Based on the analysis, a recommendation for practice is provided.

Introduction
Perineal tears are the trauma to the perineum. Perineal tears are regarded as the first degree when
they involve perineal skin. When along with the skin perineal muscles are involved, they are
considered as second degree. When the trauma involves anal sphincter complex, it is considered
as third degree. Lastly, the trauma is considered fourth degree when all the structures mentioned
in first three degrees are affected along with the anal epithelium or rectal mucosa. The third
degree tear and the fourth degree tears come under the category of severe perineal tear. The
overall rate of severe perineal tear differs in reports between 0.6–10.2percent (Frankman, et al.,
2009). This variation can be due to discrepancies in definitions and clinical practices. The anal
sphincter injury (ASI) contributes chiefly in short and long-term maternal morbidity. The
likelihood and extent of complications is related to the degree of the trauma. An increase in ASI
in several nations including Australia is seen. This increase has led to the revision of existing
evidence and clinical guidelines. Rate of ASI is also an indicator of quality of maternal care. An
‘interventionist bundle’ is developed by Women’s Healthcare Australasia (WHA) with the aim
of improving the health outcomes for women through preventable 3rd and 4th degree. It has five
recommendations for every women. Many Australian maternity hospitals have adopted this
bundle to reduce their incidence of 3rd and 4th degree tear. For the assignment second
recommendation is chosen and critically evaluated. The issue is discussed in context of women-
centered practice and its clinical relevance is presented. Based on this analysis, a
recommendation for practice is also provided.
Critical analysis of the evidence for 'hands on' method during normal vaginal birth
In spite of identifying and management, complications post-childbirth like perineal pain and
fecal incontinence have an increased incidence after ASI (Boyles, et al., 2009). These are related
to several physical, mental, and social difficulties. Therefore, primary prevention is significant.
Studies have identified a range of factors which are associated with risk of bearing perineal
injury during labor. Some of them can be ascertained before childbirth such as demographic
factors, nutritional status, ethnicity, physical activity level, parity, and fetal size (Voldner, et al.,
2009). Various intrapartum interventions are identified which can possibly the risk, like women’s

birthing position, instrument selection for surgical vaginal delivery, perineal massage, warm
compressions, episiotomy cutting policy, and manual perineal support (Gupta, et al., 2012).
Clinicians commonly refer manual perineal support as the ‘hands on’ method, with a broad range
of methods used across the globe. It is believed that these methods decrease the occurrence of
perineal trauma by decelerating the birth of the fetal head, and by lowering its presenting
diameter. However, ‘hands on’ technique is a topic of debate among the healthcare experts.
Some experts in this field advocate the ‘hands on’ while other section advocate ‘hands
off/poised’ methods (Trochez, et al., 2011). The absence of uniformity in the literature and
among the expert opinions may get confuse the clinicians. In addition, it is an unfavorable
scenario for women who want to make informed decisions regarding their labor. Increase in the
incidence of rates of severe perineal tear could be attributed to inadequate perineal support and
has brought out the age-old debate back. ASI during obstetric procedure is a critical complication
of vaginal delivery. The incidence of ASI has increased steadily in past years globally (Dillen, et
al., 2010). ASI, in turn, is a major risk factor of anal incontinence in the long run. A study found
that increasing incidence of ASI post normal vaginal deliveries can be linked with the adoption
of hands-off method or enhanced identification of tears (Revicky, et al., 2010). Various experts
have advocated the hands-off methods in which the midwife acts as a guide during childbirth and
only application of slight pressure on head of the fetus is placed, and the procedure of delivery is
carried out without touching the perineum.
Slowing down the delivery of the head of the fetus during crowning can decrease the likelihood
of perineal trauma. Various techniques can be used to regulate speed of birth in majority of the
birthing positions that women take. The bundle enumerates a range of techniques which can be
utilized for all births to decrease quick expulsive force and reassure occurrence of birth in a slow
regulated way. These techniques are supported through evidence of previous studies (Basu, et al.,
2016) (Jiang, et al., 2017). The second recommendation has various instructions. Women should
be encouraged to minimize active pushing by guiding her through verbal instructions. Regulated,
slowed or shallow breathing of women must be used to deliver the child slowly. Perineum must
be supported by the professional with the dominant hand. This recommendation has an exception
when the women is having a water birth. Professional will apply the counter pressure to the fetal
head though the use of non-dominant hand to handle the head of the fetus (Aasheim, et al.,
2011). This recommendation also has the exception of water birth. The obstetrician must assess

the speed of the progress of the head to facilitate the utilization of suitable pressure, that is, to
enable advancement of the procedure but prevent unregulated expulsion. After the head is
delivered, the clinician must wait for occurrence of restitution. The clinician will keep on
supporting the perineum and at the same time encouraging the women to push gently to deliver
the shoulders. If the shoulders are not delivered spontaneously, clinician will remove the
dominant hand and apply gentle downward pull or as suitable based on the women’s position.
Then, the clinician will enable the posterior shoulder to be issued following the curve of Carus,
safeguarding the perineum through this entire step. Lastly, support is given to the body of the
baby by moving both hands.
While reviewing literature it was found that there is a lack of clarity regarding the usage of
terminology, and consequently, ‘hands poised’ has become interchangeable with ‘hands off’, in
which the professional’s hands are ‘nowhere near the perineum’ (Ismail, et al., 2015). Royal
College of Midwives showed inadequate evidence regarding the use of guidance or flexion of the
presenting fetal part to decrease perineal injury (RCM, 2012). Another survey revealed that
midwives used mixed practice regarding the position of their hands at the time of birthing fetal
head, while majority of the respondents stated the use of ‘hands on’ methods (RCM, 2012). The
survey did not find any considerable relation between experience and midwives’ position of
hands, but a significant relationship was observed between the women’s position, birthing place,
and what the midwives did with their hands. But these findings were contrasted with another
study’s findings which revealed that less experienced midwives had enhanced chances to use the
‘hands off’ methods (Trochez, et al., 2011). A survey conducted in Australia found that 11.8%
doctors and 61% midwives used their hands on the fetal head/perineum to decrease the
likelihood of perineal injury during labor (East, et al., 2015). However, findings from a Cochrane
review found that with practice of ‘hands off’ methods, use of episiotomy can be reduced. It
showed questionable evidence on using the hands-on technique on the presenting part to lower
the perineal trauma at the time of labor (Aasheim & Nilsen ABV, 2011).
A study revealed similar rate of genital trauma during labor in women during maternal care who
were given certain techniques in the second stage of labor that are warm compression to the
perineum, perineal massage using a lubricant, and not touching the perineum until the head of
the fetus crowns. A study compared the hands-off and hands-on methods to reduce the

occurrence of perineal tear during childbirth and found that the rate of tear and neonatal
outcomes were similar in both the techniques. However, they inferred that since the hands-off
technique did not alter the frequency or severity of perineal tear in labor, it should not be
preferred over hands-on technique. Also, the site of the perineal tears in the both the methods
was similar. Overall, hands-off technique reported more incidences of anterior perineal tears as
compared to hands-on techniques. Trauma to the clitoris, vestibule, periurethral region, labia
major, labia minor and vaginal mucosa are defined as the anterior perineal tears. Application of
the pressure to head of the fetus to give support to the anterior perineum in hands-on technique
transfers the head pressure on pubis arch. An increased rate of posterior perineal tear was
reported in hands-on technique (Foroughipour, et al., 2011). Another study compared the two
methods and found that more than 60% of participants who received hands-on technique had
perineal trauma. They also reported an increased frequency of episiotomy in hands-on technique.
The investigators reasoned that perineal ischemia occurred due to manual intervention is a chief
risk factor for severe perineal trauma. Hands-off technique is linked with lesser frequency of
perineal trauma, specifically reduced requirement of episiotomy.
A study found substantial difference in the rates of episiotomy rate between hands-on and hands-
off methods. The rate of frequency of tear was lower in hands-off techniques. It can be
rationalized by the increased incidence of episiotomy in hands-on technique, which subsequently
resulted in lower incidence of tears. Likewise, more number of cases of first degree tears were
found in hands-off techniques which can be attributed to the lesser number of episiotomy.
Frequency of second degree tears were same for both types of techniques. Overall, low degree
tears which include minor lesions and injuries were more common in hands-off techniques.
Lastly, severe perineal trauma was missing or negligible in both types of techniques. The study
also observed the rate of hemorrhage in both types of techniques. Rate of hemorrhage was almost
similar in first three stages of labor however it was more in the forth stage in hands-on technique,
which can be attributed to higher frequency of episiotomy in this technique. The hemorrhage and
hematoma at the episiotomy site was similar in both the techniques. But, 82% participants on
which hands on technique was used did not demonstrate hemorrhage or hematoma at the site of
episiotomy, while with the sue of hands-off technique, the frequency was 74%. So, a small
increase in hemorrhage and hematoma was seen in the hands-off technique which can be
attributed to the tears occurring due to the absence of episiotomy. Therefore, overall this study

found the higher frequency of perineal tears by the use of hands-on methods. The study also
evaluated neonatal outcomes which include 1- and 5-minute APGAR scores, height, weight,
head circumference and oxygenation. They were similar in both types of techniques. The rate of
induction did not also show any significant difference both types of techniques (Foroughipour, et
al., 2011).
A study which conducted an NRS meta-analysis with a large sample of women found
considerable safeguarding impact of hands-on technique in decreasing the likelihood of severe
perineal tear (Bulchandani, et al., 2015). Our meta-analysis of the NRSs showed a considerably
increased likelihood of episiotomy with manual perineal support. The study included two large
studies in the NRS meta-analysis which evaluate an intervention programme. These programme
not only included hands-on methods, but also other factors of regulates birth, such as effective
communication between the midwife and the woman, a birthing position of women that enables
a good look of the perineum during the last phase of childbirth, and direction on the usage of
episiotomy on recommendation (Hals, et al., 2010) (Laine, et al., 2012).
Therefore, on analyzing the evidence from the literature, it was found that the evidence is not
sufficiently conclusive to make changes in practice. However, a strong possibility of substantial
benefit of using ‘hands on’ techniques is indicated. In addition, during clinical practice, hands-on
techniques must not be regarded also but as an aspect of a sequence of organized interventions
during the childbirth. Encouraging women to control their active pushing, enabling
implementation of the hands-on techniques in various birthing positions, and different kinds of
vaginal birth are significant factors which should be considered in training sessions for hands-on
techniques. An efficiently designed research is urgently required to assess the complex
techniques implemented as part of hands-on methods to confirm a controlled childbirth.
Conclusion
Among four degrees of perineal tear, third and fourth degree are referred as severe perineal tear.
A group of experts in this field advocate the ‘hands on’ while other group advocates ‘hands
off/poised’ methods. A range of demographic and intrapartum factors can affect the likelihood of
severe perineal tear in clinical practice. These confounding factors such as position of women
during childbirth, are significantly linked with the application, and usefulness of the hands-on

techniques. In addition, there are a range of hands-on techniques that may have different levels
of usefulness in giving support to the pelvic floor (Jansova, et al., 2014). The review recognizes
the moderately evidenced satisfactory impact of hands-on techniques to reduce perineal
complications during childbirth. Therefore, during the vaginal delivery hands-on methods could
be utilized for birthing the head of the fetus. Medical and midwifery students can be trained to
use this method effectively, so that this method can be used prominently as a technique for
carrying out normal vaginal birth. Moreover, by reducing the frequency of severe perineal tear
during labor, the financial load of treatment and diagnosis will also be lowered in the health
facilities and also on the families of the women. The recommendations in the interventionist
bundle is implemented by various hospitals in Australia. Its implementation can be supported by
a process of continuous data collection, evaluation and feedback among participating hospitals.
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