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

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