A Comparison of "Hands Off" Versus "Hands On" Techniques for Decreasing Perineal Lacerations During Birth

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.^[6,17,18,19]

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.

J Midwifery Womens Health. 2006;51(2):106-111. © 2006  Elsevier Science, Inc.

Cite this: A Comparison of "Hands Off" Versus "Hands On" Techniques for Decreasing Perineal Lacerations During Birth - Medscape - Mar 01, 2006.