|
Hi
Here's the MIDIRS abstract which concludes by
recommending hands on.
Lesley
| A randomised controlled trial of care of
the perineum during second stage of normal
labour - British
Journal of Obstetrics and Gynaecology , vol 105, no 12, December
1998, pp 1262-1272 McCandlish R; Bowler U; van Asten H; et
al - (December 1998) |
| |
Objective: To compare the effect of two methods of
perineal management used by midwives at the end of second stage on the
prevalence of perineal pain reported by women at 10 days after birth. The
methods compared were: 1. 'hands on', in which the midwife's hands are
used to put pressure on the baby's head in the belief that flexion will be
increased, and to support ('guard') the perineum, and to exert lateral
flexion to facilitate the delivery of the shoulders. 2. 'hands poised', in
which the midwife keeps her hands poised, prepared to put light pressure
on the baby's head in case of rapid expulsion, but not otherwise to touch
the head or perineum; the shoulders are allowed to deliver spontaneously.
Design: Randomised controlled trial. Setting: Recruitment and data
collection: Southmead Health Services NHS Trust, Frenchay Healthcare NHS
Trust, Royal Berkshire and Battle Hospital NHS Trust, West Berkshire
Priority Care Service NHS Trust, Severn NHS Trust, United Bristol
Healthcare NHS Trust, Weston Area Health NHS Trust and Glan Hafren NHS
Trust. Randomisation: Southmead Health Services NHS Trust, Bristol; and
The Royal Berkshire and Battle Hospital NHS Trust, Reading; Sample: 5741
women who gave birth between December 1994 and December 1996 Eligibility
and recruitment. During routine antenatal care midwives gave written
information about the trial to pregnant women and discussed participation.
A woman was eligible to participate if she had a singleton pregnancy with
cephalic presentation, was expecting a normal birth and was not planning
delivery in water, had not been prescribed an elective episiotomy, and did
not plan to give her baby up for adoption. If all these criteria were
fulfilled she was asked to give oral consent to join the trial. Women were
assured of their right to withdraw from the trial at any time. Once a
midwife had discussed the trial with a woman she attached a specially
designed HOOP sticker to the woman's notes and if she was ineligible for
any reason crossed it through. When a woman who was >/=37 weeks
gestation and in established labour the midwife attending her re-checked
eligibility and consent to take part. Randomisation: At the end of second
stage, when the attending midwife was confident that a normal vagina]
birth was likely, she opened the next in a series of sequentially
numbered, sealed, opaque envelopes. This contained a card with details of
the woman's randomisation group. Data collection: Attending midwives
completed data collection forms for every woman who was randomised
immediately after birth, at 2 days and at 9-11 days postnatally; each
participating woman also self-completed a trial questionnaire at 2 days,
10 days and at 3 months after birth. Results: Questionnaires were
completed by 97% of women at 10 days after birth. 910 (34.1 %) women in
the 'hands poised' group reported pain in the previous 24 hours compared
with 823 (31.1%) in the 'hands on' group RR= 1.10 95% Cl 1.01 to 1.18:
absolute difference 3%, 0.5% to 5%, p=0.02). The rate of episiotomy was
significantly lower in the 'hands poised' group (RR 0.79, 99% Cl 0.65 to
0.96, p=0.008) and the rate of manual removal of placenta was
significantly higher in that group (RR 1.69, 99% Cl 1.02 to 2.78; p =
0.008). There were no other statistically significant differences detected
in any outcomes measured. Conclusion: Women in the 'hands on' group
reported significantly less perinea] pain than those in the 'hands poised'
group. Although this finding related mainly to mild pain at 10 days
afterbirth, it has the potential to affect large numbers of women. In the
light of this evidence, a policy of 'hands poised' care is not
recommended. If 'hands poised' care is used then audit of important
outcomes, for example relating to third stage, should be maintained; a
policy of 'hands on' care merits audit of episiotomy rates. The majority
of women who give birth in the UK experience a range of direct midwifery
interventions during normal labour. Such routine care affects huge numbers
of women and must be based on reliable assessment of risks and benefits.
In this trial thousands of women and hundreds of midwives committed
themselves to help answer questions about the effects of alternative
perineal management methods. Thanks to their efforts the results provide
reliable evidence to inform balanced decisions about which of the perineal
methods evaluated is best for women and midwives. (MIDIRS abstract written
by Rona McCandlish). |
----- Original Message -----
Sent: Friday, June 13, 2003 8:28 AM
Subject: Re: [ozmidwifery] Re
Episiotomy
I am confused by this discussion so hoping for
some clarification! My understanding of the results of the HOOP trial was that
it favoured the use of Hands On - a finding that the midwives in the UK were
surprised by. I had read summaries that clearer pointed out an improvement in
perineal outcomes with a hands on approach. Was there re-analysis carried out
that found the opposite to be true? It sounds from this discussion that the
HOOP trial is now being said to have favoured hands off. Can someone
help?
----- Original Message -----
Sent: Saturday, June 14, 2003 12:43
AM
Subject: Re: [ozmidwifery] Re
Episiotomy
Actually Mary, if you want to get your hands
on, the only position you can't is water birth (unless you are in the tub
too (joke)) and possibly a deep squat. We used the deBuy birth stool a
lot there and trust me, you can definetly get your hands on. By hands on i
am not meaning anything beyond perineal support (which as the article
discusses is favoured by US midwives), and a gentle hand on the baby's head
(not really doing much). Mum's (mom's) I attended in the USA truly expected
this, perineal support especially is promoted in birth literature there.
This means the midwife is also in many and varied positions. I know it
isn't usually done here, I don't know for how long it hasn't been done:
before or after the Hoop trial? It will be interesting to see what the
outcomes of this study are, especially to see if it leads to practice
change. By this I mean if the study supports "hands off", then will US
midwives change their practice? And if it supports "hands on" will
Australian and Uk midwives change theirs? Or will we have to do a
repeat study here? Possibly the result will be ambiguous and claim there is
no significant difference betweeen practices and so no change will happen
anywhere. Interesting that's all.
marilyn
----- Original Message -----
Sent: Thursday, June 12, 2003 5:30
AM
Subject: Re: [ozmidwifery] Re
Episiotomy
Marilyn Wrote. I must admit after my
training in the USA it has been hard to do and I am definetly more "hands
on" than "hands off".
I find discussions about hands on and off interesting, given that if
a woman is birthing in a pysiological position, (upright squat, hands and
knees or kneeling leaning forward), there is nowhere for a midwife's hands
to be except in the "catch" position, especially if a woman is birthing in
water. I wonder if all this discussion and trials would be
going on if birth was truly in the hands of women? MM
|
