A Comparison of "Hands Off" Versus "Hands On" Techniques for Decreasing
Perineal Lacerations During Birth
Adriana de Souza Caroci da Costa, CNM, MS; Maria Luiza Gonzalez Riesco, CNM,
PhD
J Midwifery Womens Health. 2006;51(2):106 -111. ©2006 Elsevier Science,
Inc.
Posted 03/24/2006
Abstract and Introduction
Abstract
Our goal was to determine the frequency, degree, and location of perineal
lacerations and the neonatal outcomes associated with the use of two
techniques of perineal protectionexpectant ("hands off") and
interventionist ("hands on")during childbirth. We conducted a randomized
controlled trial to compare the effectiveness of two techniques for perineum
protection during spontaneous delivery. Study participants included 70
nulliparous expectant mothers, who were divided equally between the "hands
off" and "hands on" groups (n = 35 per group). Perineal laceration occurred
in 81.4% of the women. Among these, first-degree lacerations were
predominant (82.5%). Lacerations in the anterior and posterior regions of
the perineum occurred with similar frequencies. Laceration rates did not
differ between the "hands off" and "hands on" groups (P > .05). Neonatal
outcomes were similar in both groups. The use of "hands off" technique of
perineal protection does not alter the frequency or degree of perineal
lacerations in childbirth, relative to a "hands on" technique.
Introduction
Different techniques have been proposed for reducing or eliminating perineal
trauma during childbirth; some are applied during the antenatal period, but
most are used during labor.[1] Techniques used to protect the perineum
during the expulsive phase of a vaginal birth with cephalic presentation can
be summarized in the following manner: the fingers of one hand support the
posterior region, while the other hand exerts a light pressure on the
fetus's head, to control the velocity of the crowning process. This
intervention is based on the view that pressure exerted on the fetal head
impedes the fetus's ability to extend and push away from the pubic arch
toward the perineum, which may increase the risk of perineal laceration.[2]
A systematic review of techniques used to prevent perineal trauma during
childbirth did not reveal an optimal maneuver for preventing perineal
trauma.[3] On the basis of the results of a meta-analysis, maneuvers
associated with perineal protection and management of the fetus at the
moment of birth have been classified as category C, which is defined as
"Practices with no sufficient evidence to support a clear recommendation and
that should be used with caution until further research clarifies the
issue."[2]
Various studies investigating management of perineal trauma during vaginal
delivery have suggested that an expectant posture ("hands poised") may be
preferable to an active posture ("hands on"). For example, the findings of a
prospective randomized study of 1076 women that compared these two methods
indicated that the "hands poised" approach may reduce the risk of severe
lacerations and may diminish the frequency of episiotomies. Primiparity,
absence of episiotomy, a large fetal head diameter, and supine position
increased the risk of perineal trauma, regardless of the method used.[4] A
retrospective randomized controlled study involving 5471 women with
spontaneous vaginal births also compared the hands on and hands poised
techniques. In this retrospective study, the hands poised technique was
associated with lower rates of episiotomy, and the hands on technique was
associated with less pain in the first 24 hours after delivery. These data
were collected by a questionnaire sent 10 days after childbirth.[5] In
addition, a cohort study of 1068 women indicated that manual support of the
perineum during delivery was associated with intact perineum among
nulliparous women. The logistic regression analyses in the cohort study
indicated that manual support was an effective intervention for perineum
protection in the homebirth setting.[6]
The hypothesis investigated in the present study was that maneuvers related
to the protection of the perineum are associated with a greater frequency
and degree of perineal laceration. The aim was to compare the frequency,
degree, and location of perineal lacerations and the neonatal outcomes by
the use of two different techniques of perineal protectionexpectant ("hands
off") and interventionist ("hands on")in childbirth.
Methods
Perineal Management Techniques
A randomized controlled study design was used to compare the effectiveness
of two techniques ("hands off" and "hands on") for perineal management
during childbirth. In both techniques, the women are allowed to push
spontaneously during labor, without being directed in bearing down efforts,
responding to involuntary contractions of the abdominal muscles. The two
techniques of perineal protection are described in detail below.
During the expulsive period, the nurse-midwife's conduct is exclusively
expectant, only observing the successive movements of restitution, external
rotation, delivery of shoulders, and the remainder of the body. During
delivery, the nurse-midwife should support the baby's head with one hand and
the baby's torso with the other hand. If external rotation of the head or
delivery of the shoulders does not occur spontaneously within 15 seconds of
the delivery of the head, or if the newborn appears hypoxic, the
professional must manually rotate the head by grasping it and applying
gentle downward traction. Once the anterior shoulder is delivered, gentle
upward traction is used to deliver the posterior shoulder. After the
shoulders have been delivered, the newborn's neck is held with one hand,
while the other hand follows along the infant's back, and the legs or feet
are grasped as they are delivered.
When the infant's head is crowning, the nurse-midwife places the index,
middle, ring, and little fingers of the left hand close together on the
infant's occiput, with the palm turned toward the anterior region of the
perineum. In this manner, expulsion is controlled, by maintaining the
flexion of the head, protecting the anterior region of the perineum and
bilaterally supporting the ischio-cavernous and bulbo-cavernous muscles, the
urethral introitus, and the labia majora and minora. Simultaneously, the
right hand is flattened out and placed on the posterior perineum, with the
index finger and the thumb, forming a "U" shape, exerting pressure on the
posterior region of the perineum during the crowning process. The
nurse-midwife leaves no area without protection, particularly the region of
the fourchette. During the delivery of the shoulders and the remainder of
the body, the right hand is kept in place, protecting the posterior region
of the perineum, while the left hand supports the infant's head, allowing
external rotation and the delivery of shoulders spontaneously. If this does
not occur, the professional continues with posterior perineal pressure, and
with the left hand, pulls gently downward to deliver the anterior shoulder.
Once the anterior shoulder is delivered, gentle traction is applied upward
to ease delivery of the posterior shoulder. After both shoulders have been
delivered, the practitioner removes the right hand from the posterior
perineum and supports the infant's neck with one hand, while supporting the
remainder of the body with the other hand.
Study Site
The research was undertaken in a hospital birth center, in Itapecerica da
Serra, Brazil. In this birth center, women remain in a single multipurpose
room during labor, delivery, and recovery, for 1 hour after placental
delivery. The hospital provides antenatal care for high-risk pregnancies,
whereas low-risk pregnancies receive antenatal care in the basic health care
units. An average of 403 deliveries per month (2001 data) is performed at
the birth center (71% vaginal births), and nurse-midwives attend 100% of the
births. A team of obstetricians is responsible for admitting women in labor,
caring for dystocias and performing cesarean deliveries. Episiotomies are
only performed according to conditions determined by protocol. All
parturients are accompanied by a support person of their choice. The
Research and Ethics Committee of the institution where data collection took
place approved the research project.
Subjects
Eligibility criteria limited the study to primiparous expectant mothers aged
15 to 35, with fullterm pregnancies and vertex fetal presentation. In
addition, on admission to the birth center, study participants had a uterine
height not more than 36 cm, cervical dilatation of 8 cm or less, and intact
amniotic membranes. Additional limiting criteria were a labor that did not
exceed 12 hours after hospital admission, no use of oxytocin during the
first or second stages of labor, no perineal preparation during pregnancy,
and absence of episiotomy. All study participants gave birth in the left
lateral position. Women were excluded if there was dystocia requiring any
other procedure not described above, following the birth center's protocol.
Parturients were also excluded if there were any abnormalities during labor
related to fetal distress, if they chose to deliver in the lithotomy
position, or if a cesarean delivery was indicated. The final sample
consisted of 70 women who were distributed equally between the two groups on
hospital admission (35 hands off and 35 hands on). Group designations were
determined by an electronically produced randomized table. A signed consent
was obtained from all voluntary participants, both expectant mothers and
nurse-midwives, who were assured the right to withdraw from the study at any
moment.
A previous study at our institution[7] determined that perineal lacerations
occur in 73% of nulliparous women without episiotomy (51% with first-degree
and 22% with second-degree lacerations). A power analysis indicated that a
sample size of 32 women per group would give 85% power to detect the
difference of 50% perineal lacerations between groups, with an α = .05.
Data Collection
The data were collected from June to October of 2001. The nurse-midwives
attended the births and filled out the data collection forms after each
birth. Data forms were developed for the study and pilot tested. During the
pilot phase, the perineal protection techniques and data forms were
validated, and the women's acceptance of the techniques was noted. The
researchers offered each nurse-midwife an individual 6-hour theoretical and
practical training seminar in the two techniques and followed up before
beginning the study to verify whether the procedure was being performed
correctly. From a total of 13 nurses-midwives assigned to the training
program, 12 participated in the research by collecting data in both groups.
The researchers supervised both allocation to groups and the delivery
techniques.
Study Variables
The technique used during delivery, hands off or hands on, was the
independent variable. The dependent variables were 1) perineal conditions
(frequency, degree, and location of perineal laceration) and 2) newborn
outcomes, as evaluated by the Apgar score. For assessment of frequency and
degree[8] of perineal laceration, the following definitions were adopted:
Without laceration: intact perineum (no abrasions or unsutured lacerations).
With laceration: some degree of laceration of the fourchette, the perineal
skin, or vaginal mucous membrane, may or may not affect the underlying
fascia and muscle.
First-degree: laceration involving the fourchette, the perineal skin, and
vaginal mucous membrane, but not the underlying fascia and muscle.
Second-degree: laceration involving, in addition to skin and mucous
membrane, the fascia and muscles of the perineal body but not the rectal
sphincter.
Third-degree: laceration extending through the skin, mucous membrane,
perineal body, and involving the anal sphincter.
Fourth-degree: laceration extending through the rectal mucosa to expose the
lumen of the rectum.
To identify the location of perineal laceration, a detailed figure showing
the perineal region was used and annexed to the data collection form.
Data Analysis
Data were stored in an Excel software data bank, and comparative and
descriptive statistical analysis was performed. All tests (Student t,
chi-square, and Fisher exact) performed were two-tailed, and the
significance level was set at .05.
Results
Eighty-six women were enrolled in the study after meeting eligibility
criteria. During labor, 16 were excluded. After exclusions, group
designations were automatically adjusted by following the randomization
table. The final sample consisted of 70 primiparous expectant mothers
distributed in two groups (35 hands off and 35 hands on). Of the 13
nurse-midwives who participated in the training program, only one did not
take part in the study. The researchers were present at 96% of the
deliveries and confirmed that the nurse-midwives correctly applied the two
techniques, according to the training received.
The average age of the mothers at delivery, the average duration of the
expulsive period, and the average weight of the newborns were similar in the
two groups ( Table 1 ). In each group, a support person chosen by the woman
was present during labor in 94.3% of the births. The fetal head was
delivered in the anterioposterior position in all cases. The neonatal
outcomes were good in both groups, with median Apgar scores of 9 and 10 at 1
and 5 minutes, respectively, in both groups.
One newborn received an Apgar score that was <7 at 5 minutes (Apgar = 3 at 5
minutes). This baby was delivered with the hands on technique, and the low
Apgar score was attributed to reflex bradycardia caused by vagal stimulation
during a gastric aspiration maneuver performed after delivery. The baby was
immediately administered oxygen and promptly recovered.
The frequency, degree, and location of perineal lacerations are summarized
in Table 2 . No significant differences between the two groups were observed
in any of these measures (P > .05).
Discussion
The majority of women who have a vaginal delivery suffer from some kind of
perineal trauma, spontaneous perineal lacerations, or episiotomies.[2,9] In
Brazil, there are few studies that have tracked the prevalence of perineal
lacerations during childbirth. One study of 3442 births over 1 year
indicated that the rate of episiotomy was 26.5% overall and 43.3% among
nulliparous women.[10] A study analyzing the influence of previous
episiotomy on subsequent perineal outcomes in spontaneous delivery indicated
that among 121 women who gave birth in a horizontal position, perineal
trauma occurred in 47.1% of them, and the rate was independent of parity.
Among the women who had previously undergone an episiotomy, the frequency of
a subsequent episiotomy was 71.2%.[11]
In a study of 63 women who delivered spontaneously, 47.6% did not have
routine episiotomies. Among these, 46.7% had an intact perineum after
delivery and 53.3% had perineal lacerations. Of those with lacerations,
68.7% were first-degree, and 31.3% were second-degree. There were no third-
or fourth-degree lacerations.[12] A larger study of 2118 spontaneous
deliveries of nulliparous women at the General Hospital of Itapecerica da
Serra reported the perineal outcomes of 1222 women who did not have
episiotomies. Of these, 71.4% had perineal lacerations: 69.9% first-degree
lacerations, 29.9% second-degree, and 0.2% third-degree.[13]
In the present study, we observed a greater frequency of perineal
lacerations than the former study at our institution (Itapecerica da Serra,
described above).[13] In this study, 81.4% of the parturients had perineal
lacerations, compared to 71.4% in the previous study; however, the severity
of trauma was reduced (17.5% second-degree laceration in this study versus
29.9% in the previous study). Our results were independent of the perineal
protection technique used (hands off 82.8% and hands on 80.0%). Note that in
the present study, minor abrasions and small superficial lacerations that
did not require suturing were considered in the "with laceration" group. We
observed no cases of third- or fourth-degree lacerations in our study group.
In a recent randomized study of 1211 parturients in midwifery care over a
38-month period, a lower level of obstetric trauma occurred in mothers
offered any of the three following techniques late in the second stage of
labor: 1) warm compresses to the perineal area, 2) massage with lubricant,
or 3) no touching of the perineum until crowning of the infant's head. The
frequency distribution of genital trauma was equal with all techniques. The
rate of intact perineum (defined as no tissue separation at any site) was
23%, with 40% of all study participants in that study being nulliparous.[14]
In the present study, by using the same definition of "intact perineum," the
frequency of intact perineum was 18.6%, with all of the women being
nulliparous.
Other authors have considered any first-degree laceration limited to the
vaginal mucosa and perineal skin not requiring suturing to be "intact
perineum." These authors then combine all other first-, second-, third-, and
fourth-degree lacerations under the category "laceration."[15] In such a
categorization, an "intact perineum" may include abrasions and unsutured
tears, but not first-degree lacerations; and second-degree lacerations may
include labial and vaginal tears.[6] If this definition had been used in the
study cited above,[14] the frequency of intact perineum would have been 73%,
a rate similar to that in the current study but high relative to other
studies (46.7% of intact perineum among primiparous and multiparous and 44%
among primiparous).[12,15]
A study that included 3049 women who received birth assistance from
nurse-midwives and students indicated that supporting the perineum with the
hands and maintaining the woman in a left lateral position reduces the
frequency and degree of perineal laceration compared with the lithotomy
position.[16] The results also indicated that the lithotomy position is
associated with a prolonged period of expulsion, use of oxytocin, and fetal
bradycardia, conditions that are associated with the use of episiotomies and
an increased risk of perineal lacerations. The authors concluded that the
use of mechanical maneuvers of perineal protection, position at delivery,
second-stage duration, use of oxytocin, and continuous fetal monitoring were
directly associated with perineal trauma among primiparous women.[16]
Predictors of perineal trauma in nulliparous expectant mothers include low
socioeconomic status, maternal position, perineal massage, and manual
support of the perineum during delivery. This finding suggests that
caregiver management during delivery may reduce the frequency of perineal
trauma. However, in a secondary analysis of a cohort of women having
homebirth, maternal age, compresses, lubricants and oils, directed pushing,
a prolonged second phase of labor, and high infant birth weight were not
associated with greater perineal trauma.[6] Given evidence that maternal
position and use of oxytocin might affect perineal outcomes, we controlled
for these factors in our study; all deliveries were completed in the lateral
position and without oxytocin infusion.[6,17-19]
In this study, perineal laceration associated with the hands off versus the
hands on techniques yielded results that are in contrast with those of a
1999 study done in Austria.[4] Independent of parity, that study indicated a
62.1% frequency of perineal trauma, with a higher prevalence of episiotomies
and third-degree lacerations in the hands on group. The authors considered
perineal ischemia caused by manual intervention an important risk factor for
severe perineal trauma.[4] The present study did not replicate these
findings, but rather, found that the severity of laceration was similar in
both groups of women who had either hands on or hands off (82.7% versus
82.2% first-degree and 17.3% versus 17.8% second-degree lacerations,
respectively).
We also found that the location of perineal laceration was similar between
the two groups. In the hands on group, there was a slight increase of
perineal trauma in the anterior region (71.4% versus 62.1% in the hands off
group); however, the hands off group had slightly more cases of perineal
trauma in the posterior region (65.5% versus 60.7% in the hands on group).
The anterior region of the perineum was considered the area surrounding the
clitoris, the vestibular and urethral region, labia majora and minora, and
vaginal mucosa. The posterior region of the perineum included the
fourchette. The tissues in the anterior perineum may be more vulnerable to
laceration due to pressure from the fetal occipital bone when the head is
extended. Conversely, it is possible that the pressure exerted by one of the
hands on the fetal head to protect the anterior region of the perineum
pushes the head away from the pubic arch toward the posterior region,
increasing the frequency of perineal lacerations in the posterior region.[2]
Although there was no significant statistical difference between the two
groups when considering the duration of the expulsive period, the fetal
expulsion was, on average, a little longer in the hands on group (21.3
minutes versus 17.4 minutes in the hands off). The high variability in the
duration of the expulsive period in both groups was confirmed by the large
standard deviations associated with the mean values. Women in the study
groups were administered a questionnaire 10 days after delivery. Responses
indicated that in the hands on group, the length of the second stage of
labor was slightly less and associated with less perineal pain in the first
24 hours after delivery.[5] Episiotomies were performed less frequently in
the hands off group. The study did not establish a relationship among the
degree of perineal laceration, episiotomy, and the level of pain.[5]
Some nurse-midwives who participated in the present study were initially
resistant to using the hands off technique. They believed the hands off
technique to be associated with a greater potential for harmful consequences
on the perineum. This belief may have been based on their educational
background and their professional experience, which was limited to the
exclusive use of the hands on technique. This reluctance was overcome by the
training program and by involving them in the study. In addition, compliance
with the group allocation and protocol was verified by the presence of the
researchers during data collection.
The favorable results observed in both groups may be attributed to the
following aspects of delivery care: left lateral position during labor,
spontaneous pushing, no use of oxytocin, the presence of a support person of
the laboring woman's choice, and the high degree of education and expertise
of the attending nurse-midwives. Education in obstetrics should prepare
health professionals for use of several techniques for perineal protection,
and women should be allowed to choose, after being informed, which technique
they prefer.[20]
An important aspect of reducing perineal trauma and its morbidity is to
minimize the severity of the lacerations that do occur. Even a small
decrease in the severity of lacerations may substantially improve recovery
in the postpartum period. In future studies examining perineal management,
it will be important to separately analyze the effects of delivery
techniques on laceration severity. However, with the observed 15% difference
between the groups in the rate of second-degree lacerations, a sample size
of >3000 women per group would be necessary to have 85% power to detect a
significant difference. To detect the 25% difference in first-degree
laceration found in this study, 261 women would be needed in each group.
Conclusion
The present study showed that the hands off and hands on techniques did not
affect the frequency or severity of perineal trauma in women undergoing
childbirth for the first time. There is not sufficient scientific evidence
to support or refute the use of either of these maneuvers for perineal
protection during delivery. Thus, it appears that these techniques have been
adopted in clinical practice before conclusive evidence supporting a
particular approach to reduce the perineal trauma was demonstrated. Our
findings are consistent with the view that perineal trauma may be associated
more with other factors, such as delivery position, use of oxytocin,
maternal expulsive efforts, and the presence of a support person, than with
the technique of perineal protection used.
Table 1. Maternal Age, Duration of the Expulsive Period, Weight of the
Newborn in "Hands Off" and "Hands On" Groups
Labor Outcomes Hands Off
(n = 35) Hands On
(n = 35) P*
Maternal age (y)
Mean (SD) (2.7) 20.1 (3.3) .05
Median 18 19
Duration of expulsive period (min)
Mean (SD) 17.4 (12.0) 21.3 (15.5) .25
Median 15 17
Birth weight (g)
Mean (SD) 2996.7 (334.6) 3017.7 (416.0) .82
Median 2970 3020
*Student t test.
Table 2. Perineal Outcomes in Relation to "Hands Off" Versus "Hands On"
Management of Perineum Prior to Birth
Perineal Outcome Total
(n = 70)
n (%) Hands off
(n = 35)
n (%) Hands on
(n = 35)
n (%) P
Perineal laceration 57 (81.4) 29 (82.8) 28 (80) .76*
Degree of laceration
First degree 47 (82.5) 24 (82.7) 23 (82.2) 1.0
Second degree 10 (17.5) 5 (17.3) 5 (17.8)
Location of laceration
Anterior region of the perineum 21 (36.9) 10 (34.5) 11 (39.3) .76*
Posterior region of the perineum 19 (33.3) 11 (37.9) 8 (28.6)
Anterior and posterior region of the perineum 17 (29.8) 8 (27.6) 9 (32.1)
*χ2 test.
Fisher exact test.
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Acknowledgements
The authors thank Dr. Jan Nick from Loma Linda University School of Nursing,
the General Hospital of Itapecerica da Serra, and all the participants of
the study.
Leanne Wynne
Midwife in charge of "Women's Business"
Mildura Aboriginal Health Service Mob 0418 371862
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