Hand on or Hands Off the Perineum?

Reflection can be defined as “a process of reviewing an experience of practice in order to describe, analyse and evaluate and so inform learning from practice.”(Reid, 1993) It is an important factor when working within any health profession and midwifery is certainly no exception. Schon (1991) defines a reflective practitioner as “someone who learns by reflecting on current experience and applies that learning to future practice.” Reflection allows midwives to grow and develop professionally as well as personally (Kirkham, 1994) and can guide her into moulding her sphere practice in a positive way to benefit the women she is caring for (Church & Raynor, 2000). It also allows midwives to continue with lifelong learning and put theory to practise (mayes pp 1201-1202).

However being a reflective practitioner is learned skill and Rayner (2005, p.154) states that developing reflective skills is not easy but once mastered have a lot of benefits on the midwives ability to make informed decisions. The Nursing and Midwifery Council (NMC, 2004) state that all midwives need to provide evidence on their continuous learning, which includes reflecting on their practice so that they can link theory with experience to create better care towards women.

The NMC code (2008) states that “you must deliver care based on the best available evidence or best practice.” Which suggests that midwife’s need to find a balance in using the best available evidence as well reflective learning to gain the best possible outcome for the women (Raynor D., Marshall E. & Sullivan A. 2005). Schon (1991, p.12) uses a metaphor to describe how professionals take into account professional issues: “High ground” uses manageable issues which can be solved by applying evidence based research and theory. For example when administering an injection, a midwife could read the most up to date evidence on what different areas are available on the body for administration for that individual women. “Swampy lowland” is used to describe confusing problems which usually are the crucially important problems.

They tend to defy technical solutions and therefore rely on trial and error and intuition to solve them. Evidence based practice (EBP) is widely used in health care, because government policies have incorporated EBP into the structure of the National Health Service to improve the quality of care, making treatments cost effective and to create rational decision making (DoH, 1997). Sackett et al (1996, p.169) defines evidence based practice as; “The conscientious, explicit and judicious use of current best evidence in making decisions about care of individual patients.” EBP prevents health professionals from basing their practice on tradition and belief, but information which is found in research and scientific development which means the information is constantly changing and updated. (DoH, 1995).

Adults learn at different rates and in different ways, depending on their education, ability and their personalities. What skill level you are at can also affect what learning style a midwife has. Patricia Benner published the “Novice to Expert Theory” in 1982 which has 5 levels of experience, novice, advanced beginner, competent, proficient and expert. Each level of experience had 3 different levels of skills within it and as the midwife moves through the level of experience she will then stop using abstract principles and use past experiences as well as moving from just being an observer to becoming actively involved (Current Nursing, 2010). Reflection is a means of learning and these learners tend to think things through before acting, they enjoy observing and tend to look at a situation from a different perspective and collect relevant evidence before coming to a conclusion (Hills, 2001. p.154).

In this essay I will be writing a reflection from practice regarding whether or not a midwife should have her hands on or off the perineum in the second stage of labour. I will be discussing the mechanisms of labour and looking at different pieces of research and connecting them with my experience to come to a conclusion on how I will change my practice in the future. I have considered and looked at a number of reflective models to use such as Johns (2000), De Bono (1990) and Kolb (1984), but I have decided to use Gibbs (1988) as I found it easier to use for this particular reflection than the others and it is laid out in a simple structure that I can understand. All persons involved in this experience have been given a pseudonym name, to maintain confidentiality and protect the parents and the midwife involved in accordance with the NMC guidelines (2008).

Louise was a nulliparous woman in her thirties who had no pregnancy complications and nothing sinister in her medical history, so she was classed as “low risk” and she was 7 days over her estimated due date. Louise came on to the delivery suite and my mentor and I were looking after her throughout her labour, her partner was away at work so Louise only had us for support.

Before Louise went into established labour, the fetus would have descended into the pelvis and turned slightly to get into the widest space within the pelvis (Downe, 2003. pp.492-493). The widest diameter of the brim of the pelvis is the transverse diameter and within the pelvic outlet the biggest space is the anteroposterior diameter. In nulliparous women, the fetal head descends into the pelvis during the last couple of weeks of pregnancy and stays there, however in multigravid women; the muscle tone is a lot more lax and stretchy, causing the head to bob in and out of the pelvis. Therefore the head will usually engage into the pelvis when labour starts (Downe, 2003. pp.492-493). Turning of the fetus occurs due to the contraction and retraction of the uterine muscles which exerts pressure on the fetus causing it to descend. The most common position for the fetus to be in at this stage is either the right or left occiputoanterior and the presentation would be vertex (Military Obstetrics and Gynaecology, 2009).

Once Louise progressed into the second stage of labour she often mentioned that she felt her body was automatically pushing the baby down, so both my mentor and I encouraged her to push and go with what her body was telling her. During the second stage, greater descent occurs as well as flexion of the head. This is due to pressure being exerted down the fetal axis, which is increased on the occiput more than sinciput. At the beginning of labour the suboccipitofrontal diameter presents and as greater flexion occurs it is the suboccipitobregmatic diameter that presents (Downe, 2003. pp.492-493). Flexion occurs so that there are smaller presenting diameters which makes the passage through the pelvis easier. Internal rotation of the head occurs due to the descent of the head hitting the pelvic floor. It is because of the pelvic floor that rotation occurs because it has resistance (Coad & Dunstall, 2005). It is when the contraction fades that the pelvic floor rebounds and allows the occiput to go forwards and rotate anteriorly one eighth of a circle which causes the neck to twist slightly.

The occiput then goes under the subpubic arch and will begin to crown once the head stops receding back into the vagina (Rankin, 2010 pp.510-513). Once the vertex was visible my mentor told me to put pressure on the perineum with my hand to help the head flex and to prevent it from trauma. Once the head is crowning the fetal head then extends by pivoting on the suboccipital region around the pubic bone. This allows the chin, sinciput and face to sweep across the perineum and is born via extension (Downe, 2003 pp. 492-493). Neither my mentor nor I gained consent from Louise to perform this act and as I put pressure on the perineum she flinched. As the head began to crown we told Louise to pant and give gentle pushes to allow the perineum to stretch slowly (Johnson & Taylor, 2010. p.217).

The perineum and the pelvic floor are made up of 6 layers of tissue including the outer skin, subcutaneous fat, superficial and deep muscles, pelvic ligaments and peritoneum. The superficial layer consists of five muscles which are the external anal sphincter, these circles around the anus and attaches to the coccyx by fibres. Then there are the transverse perineal muscles that go through the centre of the perineum from the ischial tuberosities. The bulbocavernosus muscles go from the perineum then round the vagina to the clitoris, just under the pubic arch. The fourth muscles is the ischiocavernosus which passes from the ischial tuberosities to the pubic arch and then to the corpora cavernosa. Finally there are the membranous sphincters of the urethra which is made up from muscle fibres which go below and above the urethra and attach to the pubic bone (Bennett and Brown. 2003. pp.107-108).

The deep layer is made up of 3 muscles, the pubococcygeus muscle which goes from the pubis to the coccyx. The illiococcygeus which passes from the fascia cover to the coccyx and the ischiococcygeus muscle which goes from the ischial spine to the coccyx (Stables and Rankin, 2005. pp.340-341). The perineal body is made up of muscle and fibrous tissue that sits between the rectum and vagina. The deepest part of the perineum is the apex which is created from the fibres of the pubococcygeus muscle. The base of the apex is made from the transverse perineal muscles and the bulbocavernosus. The measurements of the perineal body are 4cm in each direction (Downe, 2003. p.108).

During the second stage of labour the perineal tissues are compressed, dilated and elongated to allow the perineum to stretch as the head comes through (Downe, 2003 p. 502). I kept my hand on the perineum until the head and shoulders were out, just as my mentor had advised me, but even though I had done this, Louise still ended up with a 3rd degree tear which involves the deep muscle layer and extending to the anal sphincter (Rankin, 2005. p.516).

This event stuck my mind as I felt a range of emotions. As a student I did as I was told by my mentor, and as soon as I felt Louise flinch, I felt a lot of guilt because it was clearly uncomfortable and painful for her to have my hand there Midwives must follow rules and codes set by the Nursing and Midwifery Council (NMC) to ensure good practice, so that the women that are under their care receive the best possible care. One of these codes is to act as an advocate for women and inform and educate them so that they can make a choice which suits them, but I feel this code was not being followed as Louise was not informed that I was going to put my hand on her perineum or why I was going to put my hand there and I also gave no evidence as to how this technique would benefit her (NMC, 2008 p.2).

I felt cross with myself and my mentor because it was the only procedure we had done without consent and the National Institute for Health and Clinical Excellence (NICE, 2007. p.6) states that midwives should not invade a women’s intermit space or undertake any procedure without consent. Once the baby was delivered and we had diagnosed that she had a 3rd degree tear, I questioned in my head, what was the point in being hands on when it made no difference to the outcome? However I thought that if I hadn’t of put my hands on the perineum and she had tore; I would have felt guilty about that as well, so in either situation I would have felt guilty because as a midwife I am accountable for my actions. I was disappointed in myself because I did not have the courage to ask my mentor what reasoning she had behind being hands on rather than hands off.

The experience unfortunately was a negative one, because as mentioned above the NMC codes or the NICE guidelines were not taken into consideration for this particular situation, especially for that split second that Louise had flinched when I touched her. However every other component that happened during that labour was a very positive experience. We did the initial observations and assessment with consent which includes listening to Louise about her thoughts and expectations about her delivery, checking Louise’s temperature, urine, blood pressure, pulse and performed an abdominal palpation and auscultation to give a baseline so we can spot deviations from the norm (NICE, 2007. p.7).

We also performed a vaginal examination with consent to check the position of the fetus and made sure we explained why we were doing and maintained Louise’s dignity throughout, as per the NICE guidelines (2007, p.7). We made sure we kept accurate records throughout which is in accordance to rule 9 in the NMC rules and standards (2004). As midwives are the experts in normality, we made sure that we ensured normality throughout Louise’s delivery by not intervening or performing any unnecessary procedures. We also listened to what she wanted to gain the best experience for her (Royal College of Midwives (RCM), 2010). According to the NICE guidelines (2007 p.167) putting your hands off or on the perineum are both classed as normal and can both be facilitated during labour. So it will vary between midwives depending on what they learnt during their midwifery training and experiences (Da Costa and Riesco, 2006. pp.106-111).

There have been many studies on whether or not a midwife should have her hands on or off the perineum, but they have all come to similar conclusions that there is not much difference between either technique and that it is the midwifes preference. In 1998 McCandlish et al (1998) conducted a random controlled trial study, which compared both the “hands on or poised method” (HOOP Trial). It took 2 years to complete and they found that 3% of women in the hands poised group experienced more pain 24 hours after delivery. However they concluded that there was no significant difference between the two techniques. Wickham states that the HOOP Trial is valuable to knowledge because it has generated debate and discussion within the profession, which suggests midwives are thinking about this subject area. Wickham also reveals that the midwives that took part in this trial were using knowledge based on reflection and past experience rather than scientific evidence (Wickham, 2002).

Mayerhofer et al (2002) also conducted a study on perineal care which came to a similar conclusion as the HOOP Trial. 33% of women in the hands on group experienced perineal tears compared to 36% in the hands poised group. However they found that 3% of women in the hands on group experienced 3rd degree tears compared to just 1% in the hands poised group. Mayerhofer decided that this occurred because the amount pressure put on the perineum by a midwives hand can make it thinner and more vulnerable. He suggests this may cause ischemia and therefore facilitates more tears.

Da Costa and Riesco’s (2006) study backed up the HOOP Trial and Mayerhofer’s study because they also came to the conclusion that the hands off and hands on technique did not affect the frequency or severity of perineal trauma in nulliparous or multiparous women. They stated that there was no solid scientific evidence to clarify the use of either technique. As mentioned earlier in the essay, they suggested that the techniques came through clinical practice and a midwife’s personal preference and what they were taught during their training. One student midwife has expressed that all she has ever seen is midwives using the hands on technique, whilst other students say that they have seen the hands poised technique and prefer using that in their own practice (Student Midwife 2010). This suggests that neither technique is preferable, so the technique you use in practice can depend on which midwife you work with during your training and your personal experiences.

A midwife forum has shown that the vast majority of current midwives prefer using the hands on technique and their reasoning behind this is to prevent the head from crowning too fast (Midwifery Matters, 2010). A fetal skull is not fused; it has separate bones that can move independently. The bones of the skull are kept together by sutures, which allow the bones to move and overlap because they are made from soft fibrous tissue. When three or more sutures meet large areas of soft tissue are formed which are called fontanelles (Wylie, 2005. p 199). As the head descends into the pelvis during labour, the bones of the skull overlap at the sutures, this is called moulding. This occurs because it reduces the size of the diameter of the presenting part by as much as 1.25cm, which makes it easier for the head to descend. Moulding also protects the fetal brain from being compressed as long as it is not excessive or rapid which can occur from prolonged or quick labour.

Preterm babies have softer, wider sutures which mean they may have excessive moulding at birth which can cause intracranial damage (Bennett and Brown, 2003 pp 160-161). This could be one reason as to why midwives feel they need to use the hands on approach to slow that specific part of the labour down. However if the labour is prolonged the fetus is at risk of getting caput succedaneum, which is swelling on the presenting part of the fetal skull, this occurs because of prolonged pressure on the cervix as it dilates (Wylie, 2005. p.200).

Although the studies and guidelines suggest that either technique is suitable, Sara Wickham (2002) states that the term perineal care implies that action and interventions must be taken by the midwife, rather than discussing positions with the women to make the delivery of the fetus easier. Wickham states that “If babies needed hands to guide them out, wouldn’t women be born with an extra pair attached to their inner thighs?” This statement suggests that she believes that the midwife does not need to undertake the hands on position.

One of the main points that I have focused on from this experience, as mentioned above was that I did not gain consent from Louise when I used the hands on technique. As mentioned above from the studies, there is no significant scientific evidence that a particular technique is better than the other. However there is very little research on the woman’s thoughts and experiences of the hands on technique, this could be because it is one of the few techniques that we do not gain consent for (Reed, 2010). Reed (2010) also states that women should be informed of the perineum and techniques during her antenatal care so that she can make a choice. Kitzinger (2008, p.55) states that women feel empowered when they have a say and are in control of their labour, which gives them a better experience. Not gaining consent and giving couched breathing as the head crowns can take away a women’s control over her labour (Reed, 2010).

Women can gain control by preparing their perineum through perineal massage. A trial conducted by Labrecque et al (2001) suggests that women have had a positive response to perineal massage during their pregnancy. The aim of perineal massage is to train the tissue of the perineum to stretch to help lower the risk of tearing during labour (Muennich, 2010). Labrecque et al (1999) suggests that antenatal perineal massage is an effective method in increasing the chances of an intact perineum at the end of the intrapartum period. Shipman et al (1997) also suggests that it can reduce the risk of having an instrumental delivery. NICE (2007, p 165) states that “Perineal massage should not be performed by healthcare professionals in the second stage of labour.” So it is a technique that the women can have full control over during her pregnancy. However 52% of maternity units in the UK undertake perineal massage in the 2nd stage of labour, 21% put cold packs on the perineum and 33% use hot packs, this could possibly take away a women’s control (Sanders et al, 2005).

Many women do not know that the perineum exists, as it is not part of the routine antenatal care that is in the NICE guidelines (2008). On reflection, parent craft sessions also did not describe the mechanism of labour and how it affects the perineum, which suggests that information about antenatal perineal care needs to be included. This will prepare and educate women of what can happen to the perineum during labour and give them a choice on whether they would like hands on or hands poised.

From the evidence I have gathered above, I feel that this experience with Louise was a negative one. My mentor’s behaviour was unprofessional in this particular part of the labour because she failed to comply with the NMC codes and conducts as mentioned above. Because of her practice, I then behaved in the same way and did not gain consent from Louise and did not explain what I was doing which goes against the NMC code (2008, p4). Even though our actions did not affect her physically, because as shown above, the hands on technique has little significance as to whether Louise would tear or not, I feel that it would have affected her emotionally which was displayed when I put my hands on and she flinched away.

With the experience I have gained and the literature I have read, if I came across this situation again I will educate and inform women of what happens to the perineum during labour and postnatally. I will give women the choice of whether they would like me to have my hands on or off the perineum and give them evidence based information to help them choose which technique they would like. I will listen to her choices and not override her decision so that she does not feel that she has lost control of her labour. The main problem I came across was that no consent was given, so I in the future I will make sure that I gain the women’s full consent before acting.

From the research I have read and the experience I have had, for future practice I would choose to use to be a hands off practitioner. The research above has shown that being a hands on practitioner makes no difference as to whether women will have trauma to the perineum or not. Having your hands poised will prevent the woman from enduring any unnecessary pain from touching her. Every woman is an individual, therefore they will have individual personalities and what works for one woman will certainly not work for another, so keeping your hands off will prevent the women from having a bad experience. The perineum is a private area of the women’s body and I feel that not gaining consent to touch that area or informing the women as to why we are touching the perineum is unacceptable. I feel that keeping your hands poised will also give the woman control and confidence, as we are not interfering in her labour, showing that she is the expert of her body, not the midwife.

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