Just a thought about the increase in mild pain experienced by women who had
"hands poised" care at birth: was the increased rate of manual removal of
placenta a confounding factor? It would be interesting to compare those who
had "hands poised" care at birth and did not have a manual removal with
those who did have a manual removal because
having the trauma from a manual removal could add to pain. I agree with
others about the position of birth, when women are upright and gently
breathe the baby's head out according to their instincts without directed
pushing they do it all themselves. I think midwives can cause harm by
directing pushing and making women lay on their backs and then give
themselves credit when women have intact perineums. The midwife is the one
'in control' with hands on and instructing the woman when women can give
birth under their own steam and our job is to support this natural process
not to control it. Unfortunately some women do tear & I think there is more
to perineal integrity than the midwife's hands. Just being in hospital in an
alien environment has a huge influence on the birth process.
>From jan Prider
----------
From: Marilyn Kleidon[SMTP:[EMAIL PROTECTED]
Sent: Sunday, 15 June 2003 00:28
To: [EMAIL PROTECTED]
Subject: Re: [ozmidwifery] Re Episiotomy
Dear Andrea: I think this issue (mother's birth position) as well as
a lot
of other information is intended to be included by the study being
undertaken by the nurse midwives in this study Mary posted:
Reducing Genital Tract Trauma at Birth: Launching a Clinical Trial
in
Midwifery
A midwifery practice offers an ideal setting to study hand
techniques to
prevent genital trauma.
J Midwifery Womens Health 48(2) 2003
It is really worth having a read. While I do acknowledge the hands
on
techniques probably arose from women being in the "stranded beetle"
position, at least in the USA they (the hands)are also applied to
just about
every other position too. There, as I said before it has come to be
expected: especially among homebirth women (who were my clientelle
(sp)), as
in at the first interview: "You will support my perineum at the
birth?" This
is also acknowledged in the introduction to the study as women will
have to
agree to be randomised to one group or the other. I had never caught
a baby
with the mother flat on her back ...until I came here. Many were
hands and
knees, others supported squats, birthstool, water, and if lying
down, side
lying on the floor with mum's leg on my shoulder... and my hands on.
We had
so few tears that required suturing (5/60 at home) I almost didn't
get
enough suturing experience to be signed off for graduation. But, I
am sure
anecdotally, we could all justify our practice, none of us want to
hurt
women, quite the contrary. These results will be interesting, at
least in
the USA where, the practice is mostly (again, it is such a bug
country, at
least in some parts of Washington and California) "hands on".
marilyn
----- Original Message -----
From: "Andrea Robertson" <[EMAIL PROTECTED]>
To: <[EMAIL PROTECTED]>
Sent: Friday, June 13, 2003 5:49 AM
Subject: Re: [ozmidwifery] Re Episiotomy
> Hi Marilyn, Mary et al,
>
> 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. 91
0
> > (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
>
> e-mail: [EMAIL PROTECTED]
> web: www.birthinternational.com
>
>
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