The interesting thing about this trial was that all the women are in the reclining position - the training video used to show midwives taking part how they were to participate clearly showed this. When a woman is lying back in the semi sitting or lithotomy position, there is a lot of pressure on her perineal tissues as the baby's head sweeps up under the pubic arch, and the tissues become extended, thin and much more fragile as a result. When the woman is upright, this "ironing out of the perineum" doesn't happen and the tissues can slip behind the baby's chin much more readily. Of course, when the woman is upright and using gravity, the speed of the birth is also much faster and it is important that she is not encouraged to push at all.
Perhaps what the HOOP trial shows is that when women are forced into poor physiological positions, then an intervention is required: the perineum will need to be supported if it is to withstand the unnatural pressures caused by gravitational forces on the baby's head. I have been sayingf for years that the old techniques used by midwives of "supporting the perineum and easing the head out with manual pressure against it" probably derived from a midwife's instinct to try and keep the perineum intact when it is clearly under huge stress. It may have been a "handy midwifery hint" that developed into a standard habit that is still used today. Note that in the summary below, the significance fo the birth positon of the woman is not mentioned at all - probably because very few women deliver (not "give birth") off the bed and in upright positions in the UK at the present time. The fact that the relationship of the woman's position to perineal pressure was not even canvassed as a variable says a lot in itself.
Personally, I would like us to acknowledge that women choosing their own birthing positions (something upright) will not need perineal support and that this is an intervention only needed when we limit women's choices. As long as she is encouraged to take her time and is not rushed she will be better able to judge her own efforts to get the baby born gently and for her tissues to stretch. Some will tear (e.g. when there is a compound presentation) but this is a quirk of nature and must be accepted too.
I think these issues of protecting the perineum are much better understood and practised in Australia than they are in the UK and probably in the US as well. We've been talking about "hands off the perineum" for almost 20 years (since I started doing "Active Birth" workshops and others also began promoting these ideas) and I would hope that something has sunk in here and there by now!
Regards
Andrea (in the UK at present and still trying to change UK midwives' practices!!)
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).
----- Andrea Robertson Birth International * ACE Graphics * Associates in Childbirth Education
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