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Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
REVIEW ARTICLE
The effect of ‘‘hands on’’ techniques on obstetric perineal laceration: A structured review of the literature Haiying Wang a, Rasika Jayasekara b, Jane Warland b,* a b
Women’s & Children’s Hospital, South Australia, Australia School of Nursing & Midwifery, University of South Australia, Australia
A R T I C L E I N F O
Article history: Received 5 January 2015 Received in revised form 4 February 2015 Accepted 25 February 2015 Keywords: Hands on Hands off Hands poised Perineal laceration Birth
A B S T R A C T
Objective: The purpose of this structured review was to review current evidence of ‘‘hands on’’ and ‘‘hands off’’ techniques as it relates to rates of perineal laceration in order to provide direction for future research in this important area of midwifery practice. Method: A structured literature search using all identified keywords and index terms was undertaken in MEDLINE, EMBASE Joanna Briggs Institute, CINAHL, TRIP, and OVID nursing database. Findings: A total of 24 papers were identified from the initial searches as potentially relevant to the review questions. Of these a total of nine papers were considered relevant for this review. These nine included one systematic review with meta-analysis, four randomised controlled trials (RCTs), one quasiexperimental study and three cohort studies. Conclusion: ‘‘Hands on’’ techniques have been traditionally used but not been well defined in the literature, therefore it is currently unclear as to whether or not ‘‘hands on’’ technique can reduce perineal laceration. More studies are required to test the effectiveness of a standardised ‘‘hands on’’ technique and also to determine what part other factors such as maternal position, visualisation and use of water might play in perineal laceration rates. ß 2015 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives.
1. Introduction and background Perineal laceration is a common outcome following vaginal birth. Perineal laceration can occur in 50–85% women with an estimated one quarter to one third requiring suture repair.1 It is well established that perineal laceration may affect postpartum recovery and has been found to have short-term or long-term physical and psychological impact on women’s health.2,3 Additionally, a third and fourth degree perineal laceration can cause anal incontinence and sexual dysfunction4 as well as an increased risk of subsequent perineal laceration with the next vaginal birth.4,5 The incidence of third and fourth degree perineal laceration is estimated to be between 0.5% and 7% variously in developed countries.1,2 Risk factors associated with perineal laceration are primiparity, infant weight, instrumental birth6,7 Occipito-Posterior (OP) birth, prolonged second stage, gestational
* Corresponding author at: GPO Box 2471, Adelaide 5001, Australia. Tel.: +61 08 83021161; fax: +61 08 83022168. E-mail address: [email protected] (J. Warland).
diabetes8 and maternal age.2 Many studies focus on preventing perineal laceration, but to date there has been no consistent conclusion regarding which strategies are the best. Traditionally ‘‘hands on’’ or ‘‘guarding’’ the perineum was believed to have reduced the risk of perineal trauma. However, since the publication of the results of the hands on or poised study (HOOPS)9 and in keeping with current midwifery practice of minimising intervention there seems to be a current worldwide trend towards midwives choosing ‘‘hands off’’ or ‘‘poised’’ method rather than ‘‘hands on’’ method. Traditionally ‘‘hands on’’ generally means that during vaginal birth, the accoucher places their hands on the perineum and/or the foetal head as the head is crowning to ‘flex’ the head and support the perineum, this is thought to protect the perineum from laceration. Whereas, ‘‘hands off’’ or ‘‘hands poised’’ means that the accoucher does not routinely place their hands on the foetal head during birth but closely observes the progress of the head and perineum only placing hands on if they deem it necessary.10 ‘‘Hands off’’ or ‘‘hands poised’’ method has been reported as having significantly less risk for episiotomy compared with ‘‘hands on’’ method,9 but with an increased chance of incidence of obstetric anal sphincter injuries (OASIs).11–13
http://dx.doi.org/10.1016/j.wombi.2015.02.006 1871-5192/ß 2015 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives.
Please cite this article in press as: Wang H, et al. The effect of ‘‘hands on’’ techniques on obstetric perineal laceration: A structured review of the literature. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.02.006
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Whether the accoucher uses ‘‘hands on’’ or ‘‘hands off’’ can also depend on an individual health care institutions’ routine procedures, and both ‘‘hands on’’ and ‘‘hands off’’ techniques can be used across the same country, e.g. the United Kingdom (UK).9 It may be interesting to note a reported steady increase in incidence of third and fourth degree perineal laceration in some Nordic countries over the last decades.7 One hypothesis is that this increase may be due to the wide adoption of ‘‘hands off’’ technique during birth by midwives in these countries.7 The purpose of this structured review was to review current evidence of ‘‘hands on’’ and ‘‘hands off’’ techniques as it relates to rates of perineal laceration in order to provide direction for future research in this important area of midwifery practice. 2. Review method The review questions for this review were: Does ‘‘hands on’’ technique make any difference compared to ‘‘hands off’’ technique on perineal outcomes following vaginal birth? Which technique has better perineal outcomes, ‘‘hands on’’ or ‘‘hands off’’? 2.1. Inclusion criteria The review included studies which reported any ‘‘hands on’’ technique (manual protection perineum) or ‘‘hands off/poised’’ used by the attending accoucher during spontaneous vaginal birth. The outcome measures included were: incidence of perineal laceration or any damage to the perineal body during vaginal birth that occurred either spontaneously or intentionally by surgical incision (such as episiotomy). This review also considered all degrees of perineal tearing. All published randomised controlled trials (RCTs), quasi-experimental studies and cohort studies evaluating the effect of ‘‘hands on’’ and/or ‘‘hands off/poised’’ techniques on perineum outcomes after vaginal birth were considered. 2.2. Search method A literature search using all identified keywords and index terms was undertaken in MEDLINE, EMBASE Joanna Briggs Institute, CINAHL, TRIP, and OVID nursing database. The search terms were ‘‘birth’’, ‘‘deliver*’’, AND ‘‘Perine*’’, AND ‘‘hands on’’ hands off’’ ‘‘hands poised.’’ Reference lists of identified papers as well as Google scholar were searched for additional studies. The search was limited to papers published in English between 1st of January 2004 and 31st December 2014. 3. Results A total of 24 papers were identified from the initial searches as potentially relevant to the review questions. Of these a total of nine papers were considered relevant for this review. These nine included one systematic review with meta-analysis,14 four randomised controlled trials (RCTs),15–18 one quasi-experimental study19 and three cohort studies.11,20,21 Papers not included in this review because they did not meet inclusion criteria were: literature reviews, those studies that only evaluated hands on or hands of but made no comparison between perineal outcomes between the two techniques or described animal or experimental model set-up to determine the most effective way to place hands. All included studies are summarised in Table 1. 3.1. RCTs A Cochrane review which conducted a metasynthesis of data from two RCTs14 suggested that the hands-off technique reduces
the use of episiotomy without increasing incidence of third- and fourth-degree tears. However, four other randomised controlled studies comparing hands on and hands off/poised report conflicting results. The most recent of these indicated that third degree trauma and episiotomy was slightly more common in the ‘‘handson’’ group and periurethral tears that ‘‘did not need mending’’ were more common in the ‘‘hands off’’ group.15 Foroughipour and colleagues16 also used a RCT to evaluate the effect of ‘‘hands on’’ versus ‘‘hands poised’’ on perineal trauma and birth outcomes in 100 women having their first baby, deemed at low risk of complications. They also found the ‘‘hands poised’’ method resulted in lower episiotomy rates and perineal trauma as well as less post-partum haemorrhage. Jo¨nsson et al.17 compared use of ‘‘Ritgen’s maneuver’’ (sometimes known as ‘chinning’) versus standard ‘‘hands on’’ care in 1423 women having their first baby and found there was not a statistically significant difference in the rate of third and fourth degree tears between the two groups. Finally, de Souza Caroci da Costa’s group18 enrolled 70 women having their first baby into their RCT and found laceration rates did not differ between the ‘‘hands on’’ and ‘‘hands off’’ cohorts. It is noteworthy that all women in this trial birthed in the left lateral position. None of the other RCTs specifically mentioned the position the women birthed in so there can be no comparisons made regarding whether or not this position provides any additional benefit in reducing perineal laceration. Overall these RCTs show the incidence rate of episiotomy in ‘‘hands on’’ groups is likely higher than ‘‘hands off’’ groups, however the ‘‘hands on’’ technique seems to reduce rate of OASIs. 4. Quasi-experimental study Fahami and others19 compared hands off, hands on and perineal massage using lubricant during birth using a quasi-experimental approach. They recruited 99 women having their first baby using convenience sampling and then randomly assigned them to receive one of three interventions. Their outcomes measures were incidence and degree of perineal trauma and post birth pain assessed at 24 h and 6 weeks post-partum. They found that ‘‘hands-off’’ technique was associated with fewer tears and lower pain scores than the other two interventions. 4.1. Cohort studies Two cohort studies reported that introducing a ‘‘hands on’’ intervention reduced perineal laceration-OASIs (referred to third and fourth degree tear) by 50% compared with that before the intervention program.11,20 The intervention program aimed to reduce the incidence of OASIs, which consisted of four components: (1) good communication; (2) adequate perineal support; (3) visualisation of the perineum and (4) restricting episiotomy. Among these, manual support of the perineum was considered the core element of this intervention. These two studies were conducted in Norway and recruited 71,861 participants in total. In the Hals et al. study,20 the incidence of OASIs decreased from 4–5% to 1–2% in four participating hospitals from 2003 to 2009. They showed there was significant effectiveness in providing perineal support during birth (p < 0.001). In Laine et al.’s study,11 the incidence of third and fourth degree perineal laceration dropped from 4% to 1.9%. Therefore, both studies showed the effectiveness of ‘‘hands on’’ in reducing OASIs but it is also important to note that incidence of episiotomy in both studies increased compared with pre and post the intervention program, from 20.36% to 22.8% in Laine et al.’s study,11 and from 14.67% to 23.76% in Hals et al.’s study.20 The other cohort study21 set out to determine risk factors for perineal trauma. They prospectively recruited 2754 women to
Please cite this article in press as: Wang H, et al. The effect of ‘‘hands on’’ techniques on obstetric perineal laceration: A structured review of the literature. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.02.006
Outcome
Study design
Placement of hands on/off description
Sample/setting
Key findings
Reducing perineal trauma
Meta-analysis of 2 RCTs
N/A
Two studies, 6547 women
de Souza Caroci da Costa and Gonzalez Riesco18 Fahami et al.19
Frequency, degree, and location of perineal lacerations and the neonatal outcomes Incidence and degree of perineal tears. Incidence and severity of perineal pain 24 h and 6 weeks after delivery Perineal trauma, and pain
RCT
At crowning the accoucher places the index, middle, ring, and little fingers of the left hand close together on the foetal occiput, with the palm turned towards the anterior region of the perineum. When foetal head distends vagina, one hand places forward direction pressure onto foetal chin (Adjusted Ritgen maneuver). Hands off: perineum not touched during crowning but ‘‘left hand prevented sudden exit of baby’s head’’.
RCT
Fingers of one hand support foetal occiput and the other hand applies slight pressure on the head to control the delivery of the head during crowning.
70 nulliparas divided equally between the ‘‘hands off’’ and ‘‘hands on’’ groups (n = 35 per group) 99 primiparas Comparison of Ritgen maneuver (hands on), hands-off technique and perineal massage with lubricant 100 low risk primiparas randomly assigned to two hands-on and hand-poised (hands-off) groups
Hals et al.20
Assessment of an education interventional program designed to decrease the frequency of anal sphincter tears
Interventional cohort study
Jo¨nsson et al.17
Rate of 3rd and 4th degree tears
RCT
Laine et al.11
Pre- and posteducation intervention study
Populationbased cohort study
Rezaei et al.15
Reduction in perineal laceration
RCT
Smith et al.21
Incidence of and risk factors for perineal trauma
Observational cohort
The accoucher presses the foetal head with the left hand to control the speed of crowning whilst the right hand supports the perineum and tries to grip the foetal chin. When a good grip has been achieved, the woman is asked to stop pushing and to breathe rapidly until most of the head is out, then the perineal ring is pushed under the neonate’s chin. Ritgen’s maneuver during a uterine contraction using one hand to pull the foetal chin from between the maternal anus and the coccyx, and the other on the foetal occiput to control speed of delivery. Standard care: perineal support with one hand and control of the speed of crowning with the other. During crowning: slowing the delivery of the baby’s head with one hand, supporting perineum with the other hand and squeezing with fingers (first and second) from the perineum lateral parts towards the middle in order to lower the pressure in middle posterior perineum, and asking the delivering woman not to push. Hands-off: midwife. Observes and only places hands on if there is a delay after the delivery of head. Hands-on: during crowning midwife maintains flexion by places the index, ring, and little fingers of her left hand close together on the fetus’s occiput, with the palm turned towards the anterior region of the perineum. Simultaneously, the right hand is flattened, and placed on the posterior perineum, with the index finger, and the thumb forming a ‘‘U’’ shape, exerting pressure. Whether the hands were on or off the perineum and/or baby’s head.
Hands-off technique reduces the use of episiotomy without increasing incidence of third- and fourthdegree tears. Result based on meta-analysis of two studies (Mayerhofer10 and McCandlish9). Perineal laceration occurred in 81.4% of all the women. Laceration rates did not differ between the ‘‘hands off’’ and ‘‘hands on’’ groups (p > 0.05). Neonatal outcomes were similar in both groups. In the Ritgen maneuver group, the frequency of tears, the relative frequency of tear degrees, the severity of perineal pain 24 h after delivery and the frequency of pain and perineal pain severity 6 weeks after delivery were significantly different from the other two methods. The rate of episiotomy was higher in hands-on group (84% vs. 40%, p = 0.001). The rate of postpartum haemorrhage was higher in hands-on group (12% vs. 4%, p = 0.04). The rate of mild and moderate postpartum pain in hands-on group was higher than hands-off group (70% vs. 58% and 29% vs. 10%, p < 0.001) but severe pain was not statistically different in two groups. Anal sphincter tears decreased from 4–5% to 1–2% during the study period in all four hospitals (p < 0.001). The number of episiotomies increased in two hospitals but remained unchanged in the other two. The lowest proportion of tears at the end of the intervention (1.2% and 1.3%, respectively) was found in the two hospitals with an unchanged episiotomy rate. The rate of third- to fourth-degree tears was not statistically significant in those assigned to Ritgen’s maneuver and those assigned to simple perineal support (relative risk 1.24; 95% confidence interval 0.78–1.96).
Foroughipour et al.16
Quasiexperimental
40,152 vaginal deliveries
1423 nulliparous women in term labour, singleton pregnancy, and cephalic presentation
The OASIS incidence was significantly reduced by 50%, from 4% (591/14,787) in the first time period to 1.9% (316/16,922) in the second.
600 nulliparous women (n = 300 per group)
Non-Significant difference in overall perineal trauma between groups (p = 0.74). Third degree trauma slightly more common in ‘‘hands-on’’ group, 8:1 (p = 0.1). Episiotomy was performed more frequently in ‘‘Handson’’ 38:17 women (p = 0.003) groups. Periurethral tears that ‘‘did not need mending’’ were more common in the hands off group 47:28 (p = 0.01).
2754 women with a planned singleton vaginal birth
Using ‘‘hands on’’ as the reference group the ‘‘hands off’’ group were slightly less likely to tear however after adjustment this was not a statistically significant finding AOR 0.77 (0.39, 1.52).
3
907 women identified with obstetric anal sphincter injury
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Please cite this article in press as: Wang H, et al. The effect of ‘‘hands on’’ techniques on obstetric perineal laceration: A structured review of the literature. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.02.006
Table 1 Summary table of included studies.
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their study. One of their observations was whether or not the accoucher placed their hands on or off the perineum. No details were given about how hands were placed or what the accoucher did with their hands. Whilst they initially found a slight difference between perineal trauma rates in the ‘‘hands off ‘‘group (OR 0.48, 95% CI 0.27, 0.86), this association disappeared following adjustment (AOR 0.77, 95% CI 0.39, 1.52). It should be noted that in all of the studies we reviewed ‘‘hands on’’ and ‘‘hands off’’ are described variously or not at all. Table 1 includes a brief description of the hands on/off technique used to enable comparisons between the studies included in this review.
5. Discussion Traditionally accouchers have used ‘‘hands on’’ technique during vaginal birth.10 The evidence with respect to ‘‘hands on’’ or ‘‘hands off’’ techniques is probably largely based on one randomised controlled trial conducted in the UK, the ‘HOOP’ study.9 The HOOP study initially was designed to evaluate whether ‘‘hands poised’’ method would reduce perineal pain at 10 days after birth compared with the ‘‘hands on’’ method. This study recruited 5471 women in two hospitals of southern England. The authors concluded that pain was less in the ‘‘hands on’’ group compared with the ‘‘hands poised’’ group. The results of this study showed there were no differences in the location, frequency and severity of perineal trauma between two groups. They also found the likelihood of episiotomy in ‘‘hands poised’’ group was lower but the rate of manual removal of placenta was greater compared with ‘‘hands on’’ group. It is noteworthy that there has been no evaluation of the uptake of ‘‘hands off’’ or ‘‘hands poised’’ since the HOOP results were published nor has there been any evaluation of whether there has been a change in prevalence rates of perineal trauma. However, there has been wide uptake of ‘‘hands off’’ for example, a UK survey exploring 1000 midwives preferred perineal management ‘technique’ found the group to be almost evenly split (hands off 49.3%; hands on 50.7%).22 A more recent study, also a survey, indicated that a group of Australian midwives and doctors would use the hands on, hands off or episiotomy depending on the specific clinical situation.23 This suggests that this ongoing debate has resulted in clinicians using a range of techniques in order to try to minimise perineal trauma during birth. It is not yet known what the best technique is to place ‘‘hands on’’ however, some reports have indicated a theory for applying effective manual perineal protection. For example, one study by Zemcˇı´k et al.,24 in Czech Republic used stereophotogrammetry to analyse and quantify perineal deformation and strain at the final stages of birth. This study showed that the highest tissue strain occurred at the posterior fourchette in a transverse direction. To effectively reduce the tension, the authors suggested the approach of placing their right thumb and index finger alongside the forchette pulling towards to each other to reduce the tension in the midline at the time of pushing. Other fingers of the right hand might be placed on the median part of the perineum and provide gentle support as the head crowns. This study was the first to quantify the strain on the perineum that occurs during vaginal birth and thereby providing a scientific explanation for how the accoucher may place and use their hands during birth. Two other reported studies25,26 using biomedical models have also indicated that squeezing the perineum between the thumb and index finger of the accoucher’s dominant-posterior hand during birth significantly reduces tissue tension throughout the entire thickness of the perineum; thus, this kind of ‘‘hands on’’ intervention might help reduce obstetric perineal trauma. Manual perineal protection is therefore probably not as simple as whether the accoucher
places their ‘‘hands on’’ or leaves their ‘‘hands off’’ or ‘‘poised. It is a matter of how and when to put the hands on the perineum. Unfortunately all studies in this review provided different descriptions of the ‘‘hands on’’ technique making comparisons between reported outcomes difficult. Additionally, details are lacking as to exactly where fingers are placed, if both hands are used (one supporting, one squeezing), what time to put ‘‘hands on’’, i.e. between a contraction or during the contraction, during pushing or between pushing. There are also other factors in play as to whether or not hands are placed on or off. For example, clear visualisation of the perineum may be influenced by a number of factors including birth into water27 and woman’s position, especially if she is upright.28 Thus further research that occurs in this area should standardise exactly what is done with the accoucher’s hands but also report if the woman is birthing into water or land, and what position she was in. Much of this information is currently missing from these reports therefore, a conclusion cannot yet be drawn as to whether ‘‘hands on’’ is better than ‘‘hands off’’ or vice versa. 6. Conclusions ‘‘Hands on’’ techniques have been traditionally used but not been well defined in the literature, therefore it is currently unclear as to whether or not ‘‘hands on’’ technique can reduce perineal laceration. However, evidence indicates that ‘‘hands on’’ techniques which support (squeeze) the two sides of the posterior fourchette towards the midline may have a significant effect on reducing perineal laceration especially third and fourth degree tears. The effectiveness of this technique may be associated with other factors such as slowing down ‘‘flexing’’ the foetal head and supporting the perineum as the head ‘crowns’. More studies are required to test the effectiveness of this specific ‘‘hands on’’ technique and also to test if it is also effective in reducing first and second degree obstetric perineal laceration and what part other factors such as maternal position, visualisation and use of water might play. 7. Implications for research and practice The results of this review show there is a need for further investigation of effective ‘‘hands on’’ technique of reducing all degrees of perineal laceration associated with birth. Unified definition and detailed descriptions of an exact ‘‘hands on’’ technique such as where and when to place hands and fingers, and if the accoucher is applying pressure or squeezing, and in which direction, are required. Such details would then allow a standardised use of ‘‘hands on’’ and studies using such a standard to be replicable. More studies are also required to test if ‘‘hands on’’ techniques can decrease the incidence of first and second degree perineal lacerations. References 1. Li Z, Zeki R, Hilder L, Sullivan EA. Australia’s mothers and babies 2011. Perinatal statistics series. Canberra: AIHW National Perinatal Epidemiology and Statistics Unit; 2013. 2. Kettle C, Tohill S. Perineal care. Clin Evid (Online) 2011;2011(April). pii:1401. 3. McCandlish R. Perineal trauma: prevention and treatment. J Midwifery Womens Health 2001;46(6):396–401. 4. Nakai A, Yoshida A, Yamaguchi S, Kawabata I, Hayashi M, Yokota A, et al. Incidence and risk factors for severe perineal laceration after vaginal delivery in Japanese patients. Arch Gynecol Obstet 2006;274(4):222–6. 5. Harkin R, Fitzpatrick M, O’Connell PR, O’Herlihy C. Anal sphincter disruption at vaginal delivery: is recurrence predictable? Eur J Obstet Gynecol Reprod Biol 2003;109(2):149–52. 6. Hirayama F, Koyanagi A, Mori R, Zhang J, Souza JP, Gulmezoglu AM. Prevalence and risk factors for third- and fourth-degree perineal lacerations during vaginal delivery: a multi-country study. BJOG 2012;119(3):340–7.
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WOMBI-410; No. of Pages 5 H. Wang et al. / Women and Birth xxx (2015) xxx–xxx 7. Laine K, Gissler M, Pirhonen J. Changing incidence of anal sphincter tears in four Nordic countries through the last decades. Eur J Obstet Gynecol Reprod Biol 2009;146(1):71–5. 8. Hauck YL, Lewis L, Nathan EA, White C, Doherty DA. Risk factors for severe perineal trauma during vaginal childbirth: a Western Australian retrospective cohort study. Women Birth 2015;28(1):16–20. 9. McCandlish R, Bowler U, van Asten H, Berridge G, Winter C, Sames L, et al. A randomised controlled trial of care of the perineum during second stage of normal labour. BJOG 1998;105(12):1262–72. 10. Mayerhofer K, Bodner-Adler B, Bodner K, Rabl M, Kaider A, Wagenbichler P, et al. Traditional care of the perineum during birth. A prospective, randomized, multicenter study of 1,076 women. J Reprod Med 2002;47(6):477–82. 11. Laine K, Skjeldestad FE, Sandvik L, Staff AC. Incidence of obstetric anal sphincter injuries after training to protect the perineum: cohort study. BMJ Open 2012;2(5). 12. Revicky V, Nirmal D, Mukhopadhyay S, Morris EP, Nieto JJ. Could a mediolateral episiotomy prevent obstetric anal sphincter injury? Eur J Obstet Gynecol Reprod Biol 2010;150(2):142–6. 13. Raisanen S, Vehvilainen-Julkunen K, Gissler M, Heinonen S. The increased incidence of obstetric anal sphincter rupture – an emerging trend in Finland. Prev Med 2009;49(6):535–40. 14. Aasheim V, Nilsen AB, Lukasse M, Reinar LM. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev 2011;(December (12)). http://dx.doi.org/10.1002/14651858.CD006672.pub2. CD006672. 15. Rezaei R, Saatsaz S, Chan YH, Nia HS. A comparison of the ‘‘hands-off’’ and ‘‘hands-on’’ methods to reduce perineal lacerations: a randomised clinical trial. J Obstet Gynaecol India 2014;64(December (6)):425–9. 16. Foroughipour A, Firuzeh F, Ghahiri A, Norbakhsh V, Heidari T. The effect of perineal control with hands-on and hand-poised methods on perineal trauma and delivery outcome. J Res Med Sci 2011;16(August (8)):1040–6. 17. Jo¨nsson ER, Elfaghi I, Rydhstrom H, Herbst A. Modified Ritgen’s maneuver for anal sphincter injury at delivery: a randomized controlled trial. Obstet Gynecol 2008;112(2 Pt 1):212–7.
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18. de Souza Caroci da Costa A, Gonzalez Riesco ML. A comparison of ‘‘hands off’’ versus ‘‘hands on’’ techniques for decreasing perineal lacerations during birth. J Midwifery Womens Health 2006;51(2):106–11. 19. Fahami F, Shokoohi Z, Kianpour M. The effects of perineal management techniques on labor complications. Iran J Nurs Midwifery Res 2012;17(1):52–7. 20. Hals E, Oian P, Pirhonen T, Gissler M, Hjelle S, Nilsen EB, et al. A multicenter interventional program to reduce the incidence of anal sphincter tears. Obstet Gynecol 2010;116(4):901–8. 21. Smith LA, Price N, Simonite V, Burns EE. Incidence of and risk factors for perineal trauma: a prospective observational study. BMC Pregnancy Childbirth 2013;13(March):59. http://dx.doi.org/10.1186/1471-2393-13-59. 22. Trochez R, Waterfield M, Freeman RM. Hands on or hands off the perineum: a survey of care of the perineum in labour (HOOPS). Int Urogynecol J 2011;22(10):1279–85. 23. East CE, Lau R, Biro MA. Midwives’ and doctors’ perceptions of their preparation for and practice in managing the perineum in the second stage of labour: a cross-sectional survey. Midwifery 2015;31(January (1)):122–31. http:// dx.doi.org/10.1016/j.midw.2014.07.002. 24. Zemcˇı´k R, Karbanova J, Kalis V, Lobovsky´ L, Jansova´ M, Rusavy Z. Stereophotogrammetry of the perineum during vaginal delivery. Int J Gynaecol Obstet 2012;119(1):76–80. 25. Jansova M, Kalis V, Lobovsky L, Hyncik L, Karbanova J, Rusavy Z. The role of thumb and index finger placement in manual perineal protection. Int Urogynecol J 2014;25(November (11)):1533–40. http://dx.doi.org/10.1007/s00192014-2425-7. 26. Jansova M, Kalis V, Rusavy Z, Zemcik R, Lobovsky L, Laine K. Modeling manual perineal protection during vaginal delivery. Int Urogynecol J 2014;25(January (1)):65–71. http://dx.doi.org/10.1007/s00192-013-2164-1. 27. Henderson J, Burns EE, Regalia AL, Casarico G, Boulton MG, Smith LA. Labouring women who used a birthing pool in obstetric units in Italy: prospective observational study. BMC Pregnancy Childbirth 2014;14(January):17. http:// dx.doi.org/10.1186/1471-2393-14-17. 28. Kopas ML. A review of evidence-based practices for management of the second stage of labor. J Midwifery Womens Health 2014;59(3):264–76.
Please cite this article in press as: Wang H, et al. The effect of ‘‘hands on’’ techniques on obstetric perineal laceration: A structured review of the literature. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.02.006
WOMBI-410; No. of Pages 5 Women and Birth xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
REVIEW ARTICLE
The effect of ‘‘hands on’’ techniques on obstetric perineal laceration: A structured review of the literature Haiying Wang a, Rasika Jayasekara b, Jane Warland b,* a b
Women’s & Children’s Hospital, South Australia, Australia School of Nursing & Midwifery, University of South Australia, Australia
A R T I C L E I N F O
Article history: Received 5 January 2015 Received in revised form 4 February 2015 Accepted 25 February 2015 Keywords: Hands on Hands off Hands poised Perineal laceration Birth
A B S T R A C T
Objective: The purpose of this structured review was to review current evidence of ‘‘hands on’’ and ‘‘hands off’’ techniques as it relates to rates of perineal laceration in order to provide direction for future research in this important area of midwifery practice. Method: A structured literature search using all identified keywords and index terms was undertaken in MEDLINE, EMBASE Joanna Briggs Institute, CINAHL, TRIP, and OVID nursing database. Findings: A total of 24 papers were identified from the initial searches as potentially relevant to the review questions. Of these a total of nine papers were considered relevant for this review. These nine included one systematic review with meta-analysis, four randomised controlled trials (RCTs), one quasiexperimental study and three cohort studies. Conclusion: ‘‘Hands on’’ techniques have been traditionally used but not been well defined in the literature, therefore it is currently unclear as to whether or not ‘‘hands on’’ technique can reduce perineal laceration. More studies are required to test the effectiveness of a standardised ‘‘hands on’’ technique and also to determine what part other factors such as maternal position, visualisation and use of water might play in perineal laceration rates. ß 2015 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives.
1. Introduction and background Perineal laceration is a common outcome following vaginal birth. Perineal laceration can occur in 50–85% women with an estimated one quarter to one third requiring suture repair.1 It is well established that perineal laceration may affect postpartum recovery and has been found to have short-term or long-term physical and psychological impact on women’s health.2,3 Additionally, a third and fourth degree perineal laceration can cause anal incontinence and sexual dysfunction4 as well as an increased risk of subsequent perineal laceration with the next vaginal birth.4,5 The incidence of third and fourth degree perineal laceration is estimated to be between 0.5% and 7% variously in developed countries.1,2 Risk factors associated with perineal laceration are primiparity, infant weight, instrumental birth6,7 Occipito-Posterior (OP) birth, prolonged second stage, gestational
* Corresponding author at: GPO Box 2471, Adelaide 5001, Australia. Tel.: +61 08 83021161; fax: +61 08 83022168. E-mail address: [email protected] (J. Warland).
diabetes8 and maternal age.2 Many studies focus on preventing perineal laceration, but to date there has been no consistent conclusion regarding which strategies are the best. Traditionally ‘‘hands on’’ or ‘‘guarding’’ the perineum was believed to have reduced the risk of perineal trauma. However, since the publication of the results of the hands on or poised study (HOOPS)9 and in keeping with current midwifery practice of minimising intervention there seems to be a current worldwide trend towards midwives choosing ‘‘hands off’’ or ‘‘poised’’ method rather than ‘‘hands on’’ method. Traditionally ‘‘hands on’’ generally means that during vaginal birth, the accoucher places their hands on the perineum and/or the foetal head as the head is crowning to ‘flex’ the head and support the perineum, this is thought to protect the perineum from laceration. Whereas, ‘‘hands off’’ or ‘‘hands poised’’ means that the accoucher does not routinely place their hands on the foetal head during birth but closely observes the progress of the head and perineum only placing hands on if they deem it necessary.10 ‘‘Hands off’’ or ‘‘hands poised’’ method has been reported as having significantly less risk for episiotomy compared with ‘‘hands on’’ method,9 but with an increased chance of incidence of obstetric anal sphincter injuries (OASIs).11–13
http://dx.doi.org/10.1016/j.wombi.2015.02.006 1871-5192/ß 2015 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives.
Please cite this article in press as: Wang H, et al. The effect of ‘‘hands on’’ techniques on obstetric perineal laceration: A structured review of the literature. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.02.006
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Whether the accoucher uses ‘‘hands on’’ or ‘‘hands off’’ can also depend on an individual health care institutions’ routine procedures, and both ‘‘hands on’’ and ‘‘hands off’’ techniques can be used across the same country, e.g. the United Kingdom (UK).9 It may be interesting to note a reported steady increase in incidence of third and fourth degree perineal laceration in some Nordic countries over the last decades.7 One hypothesis is that this increase may be due to the wide adoption of ‘‘hands off’’ technique during birth by midwives in these countries.7 The purpose of this structured review was to review current evidence of ‘‘hands on’’ and ‘‘hands off’’ techniques as it relates to rates of perineal laceration in order to provide direction for future research in this important area of midwifery practice. 2. Review method The review questions for this review were: Does ‘‘hands on’’ technique make any difference compared to ‘‘hands off’’ technique on perineal outcomes following vaginal birth? Which technique has better perineal outcomes, ‘‘hands on’’ or ‘‘hands off’’? 2.1. Inclusion criteria The review included studies which reported any ‘‘hands on’’ technique (manual protection perineum) or ‘‘hands off/poised’’ used by the attending accoucher during spontaneous vaginal birth. The outcome measures included were: incidence of perineal laceration or any damage to the perineal body during vaginal birth that occurred either spontaneously or intentionally by surgical incision (such as episiotomy). This review also considered all degrees of perineal tearing. All published randomised controlled trials (RCTs), quasi-experimental studies and cohort studies evaluating the effect of ‘‘hands on’’ and/or ‘‘hands off/poised’’ techniques on perineum outcomes after vaginal birth were considered. 2.2. Search method A literature search using all identified keywords and index terms was undertaken in MEDLINE, EMBASE Joanna Briggs Institute, CINAHL, TRIP, and OVID nursing database. The search terms were ‘‘birth’’, ‘‘deliver*’’, AND ‘‘Perine*’’, AND ‘‘hands on’’ hands off’’ ‘‘hands poised.’’ Reference lists of identified papers as well as Google scholar were searched for additional studies. The search was limited to papers published in English between 1st of January 2004 and 31st December 2014. 3. Results A total of 24 papers were identified from the initial searches as potentially relevant to the review questions. Of these a total of nine papers were considered relevant for this review. These nine included one systematic review with meta-analysis,14 four randomised controlled trials (RCTs),15–18 one quasi-experimental study19 and three cohort studies.11,20,21 Papers not included in this review because they did not meet inclusion criteria were: literature reviews, those studies that only evaluated hands on or hands of but made no comparison between perineal outcomes between the two techniques or described animal or experimental model set-up to determine the most effective way to place hands. All included studies are summarised in Table 1. 3.1. RCTs A Cochrane review which conducted a metasynthesis of data from two RCTs14 suggested that the hands-off technique reduces
the use of episiotomy without increasing incidence of third- and fourth-degree tears. However, four other randomised controlled studies comparing hands on and hands off/poised report conflicting results. The most recent of these indicated that third degree trauma and episiotomy was slightly more common in the ‘‘handson’’ group and periurethral tears that ‘‘did not need mending’’ were more common in the ‘‘hands off’’ group.15 Foroughipour and colleagues16 also used a RCT to evaluate the effect of ‘‘hands on’’ versus ‘‘hands poised’’ on perineal trauma and birth outcomes in 100 women having their first baby, deemed at low risk of complications. They also found the ‘‘hands poised’’ method resulted in lower episiotomy rates and perineal trauma as well as less post-partum haemorrhage. Jo¨nsson et al.17 compared use of ‘‘Ritgen’s maneuver’’ (sometimes known as ‘chinning’) versus standard ‘‘hands on’’ care in 1423 women having their first baby and found there was not a statistically significant difference in the rate of third and fourth degree tears between the two groups. Finally, de Souza Caroci da Costa’s group18 enrolled 70 women having their first baby into their RCT and found laceration rates did not differ between the ‘‘hands on’’ and ‘‘hands off’’ cohorts. It is noteworthy that all women in this trial birthed in the left lateral position. None of the other RCTs specifically mentioned the position the women birthed in so there can be no comparisons made regarding whether or not this position provides any additional benefit in reducing perineal laceration. Overall these RCTs show the incidence rate of episiotomy in ‘‘hands on’’ groups is likely higher than ‘‘hands off’’ groups, however the ‘‘hands on’’ technique seems to reduce rate of OASIs. 4. Quasi-experimental study Fahami and others19 compared hands off, hands on and perineal massage using lubricant during birth using a quasi-experimental approach. They recruited 99 women having their first baby using convenience sampling and then randomly assigned them to receive one of three interventions. Their outcomes measures were incidence and degree of perineal trauma and post birth pain assessed at 24 h and 6 weeks post-partum. They found that ‘‘hands-off’’ technique was associated with fewer tears and lower pain scores than the other two interventions. 4.1. Cohort studies Two cohort studies reported that introducing a ‘‘hands on’’ intervention reduced perineal laceration-OASIs (referred to third and fourth degree tear) by 50% compared with that before the intervention program.11,20 The intervention program aimed to reduce the incidence of OASIs, which consisted of four components: (1) good communication; (2) adequate perineal support; (3) visualisation of the perineum and (4) restricting episiotomy. Among these, manual support of the perineum was considered the core element of this intervention. These two studies were conducted in Norway and recruited 71,861 participants in total. In the Hals et al. study,20 the incidence of OASIs decreased from 4–5% to 1–2% in four participating hospitals from 2003 to 2009. They showed there was significant effectiveness in providing perineal support during birth (p < 0.001). In Laine et al.’s study,11 the incidence of third and fourth degree perineal laceration dropped from 4% to 1.9%. Therefore, both studies showed the effectiveness of ‘‘hands on’’ in reducing OASIs but it is also important to note that incidence of episiotomy in both studies increased compared with pre and post the intervention program, from 20.36% to 22.8% in Laine et al.’s study,11 and from 14.67% to 23.76% in Hals et al.’s study.20 The other cohort study21 set out to determine risk factors for perineal trauma. They prospectively recruited 2754 women to
Please cite this article in press as: Wang H, et al. The effect of ‘‘hands on’’ techniques on obstetric perineal laceration: A structured review of the literature. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.02.006
Outcome
Study design
Placement of hands on/off description
Sample/setting
Key findings
Reducing perineal trauma
Meta-analysis of 2 RCTs
N/A
Two studies, 6547 women
de Souza Caroci da Costa and Gonzalez Riesco18 Fahami et al.19
Frequency, degree, and location of perineal lacerations and the neonatal outcomes Incidence and degree of perineal tears. Incidence and severity of perineal pain 24 h and 6 weeks after delivery Perineal trauma, and pain
RCT
At crowning the accoucher places the index, middle, ring, and little fingers of the left hand close together on the foetal occiput, with the palm turned towards the anterior region of the perineum. When foetal head distends vagina, one hand places forward direction pressure onto foetal chin (Adjusted Ritgen maneuver). Hands off: perineum not touched during crowning but ‘‘left hand prevented sudden exit of baby’s head’’.
RCT
Fingers of one hand support foetal occiput and the other hand applies slight pressure on the head to control the delivery of the head during crowning.
70 nulliparas divided equally between the ‘‘hands off’’ and ‘‘hands on’’ groups (n = 35 per group) 99 primiparas Comparison of Ritgen maneuver (hands on), hands-off technique and perineal massage with lubricant 100 low risk primiparas randomly assigned to two hands-on and hand-poised (hands-off) groups
Hals et al.20
Assessment of an education interventional program designed to decrease the frequency of anal sphincter tears
Interventional cohort study
Jo¨nsson et al.17
Rate of 3rd and 4th degree tears
RCT
Laine et al.11
Pre- and posteducation intervention study
Populationbased cohort study
Rezaei et al.15
Reduction in perineal laceration
RCT
Smith et al.21
Incidence of and risk factors for perineal trauma
Observational cohort
The accoucher presses the foetal head with the left hand to control the speed of crowning whilst the right hand supports the perineum and tries to grip the foetal chin. When a good grip has been achieved, the woman is asked to stop pushing and to breathe rapidly until most of the head is out, then the perineal ring is pushed under the neonate’s chin. Ritgen’s maneuver during a uterine contraction using one hand to pull the foetal chin from between the maternal anus and the coccyx, and the other on the foetal occiput to control speed of delivery. Standard care: perineal support with one hand and control of the speed of crowning with the other. During crowning: slowing the delivery of the baby’s head with one hand, supporting perineum with the other hand and squeezing with fingers (first and second) from the perineum lateral parts towards the middle in order to lower the pressure in middle posterior perineum, and asking the delivering woman not to push. Hands-off: midwife. Observes and only places hands on if there is a delay after the delivery of head. Hands-on: during crowning midwife maintains flexion by places the index, ring, and little fingers of her left hand close together on the fetus’s occiput, with the palm turned towards the anterior region of the perineum. Simultaneously, the right hand is flattened, and placed on the posterior perineum, with the index finger, and the thumb forming a ‘‘U’’ shape, exerting pressure. Whether the hands were on or off the perineum and/or baby’s head.
Hands-off technique reduces the use of episiotomy without increasing incidence of third- and fourthdegree tears. Result based on meta-analysis of two studies (Mayerhofer10 and McCandlish9). Perineal laceration occurred in 81.4% of all the women. Laceration rates did not differ between the ‘‘hands off’’ and ‘‘hands on’’ groups (p > 0.05). Neonatal outcomes were similar in both groups. In the Ritgen maneuver group, the frequency of tears, the relative frequency of tear degrees, the severity of perineal pain 24 h after delivery and the frequency of pain and perineal pain severity 6 weeks after delivery were significantly different from the other two methods. The rate of episiotomy was higher in hands-on group (84% vs. 40%, p = 0.001). The rate of postpartum haemorrhage was higher in hands-on group (12% vs. 4%, p = 0.04). The rate of mild and moderate postpartum pain in hands-on group was higher than hands-off group (70% vs. 58% and 29% vs. 10%, p < 0.001) but severe pain was not statistically different in two groups. Anal sphincter tears decreased from 4–5% to 1–2% during the study period in all four hospitals (p < 0.001). The number of episiotomies increased in two hospitals but remained unchanged in the other two. The lowest proportion of tears at the end of the intervention (1.2% and 1.3%, respectively) was found in the two hospitals with an unchanged episiotomy rate. The rate of third- to fourth-degree tears was not statistically significant in those assigned to Ritgen’s maneuver and those assigned to simple perineal support (relative risk 1.24; 95% confidence interval 0.78–1.96).
Foroughipour et al.16
Quasiexperimental
40,152 vaginal deliveries
1423 nulliparous women in term labour, singleton pregnancy, and cephalic presentation
The OASIS incidence was significantly reduced by 50%, from 4% (591/14,787) in the first time period to 1.9% (316/16,922) in the second.
600 nulliparous women (n = 300 per group)
Non-Significant difference in overall perineal trauma between groups (p = 0.74). Third degree trauma slightly more common in ‘‘hands-on’’ group, 8:1 (p = 0.1). Episiotomy was performed more frequently in ‘‘Handson’’ 38:17 women (p = 0.003) groups. Periurethral tears that ‘‘did not need mending’’ were more common in the hands off group 47:28 (p = 0.01).
2754 women with a planned singleton vaginal birth
Using ‘‘hands on’’ as the reference group the ‘‘hands off’’ group were slightly less likely to tear however after adjustment this was not a statistically significant finding AOR 0.77 (0.39, 1.52).
3
907 women identified with obstetric anal sphincter injury
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Source Aasheim et al.14
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Please cite this article in press as: Wang H, et al. The effect of ‘‘hands on’’ techniques on obstetric perineal laceration: A structured review of the literature. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.02.006
Table 1 Summary table of included studies.
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their study. One of their observations was whether or not the accoucher placed their hands on or off the perineum. No details were given about how hands were placed or what the accoucher did with their hands. Whilst they initially found a slight difference between perineal trauma rates in the ‘‘hands off ‘‘group (OR 0.48, 95% CI 0.27, 0.86), this association disappeared following adjustment (AOR 0.77, 95% CI 0.39, 1.52). It should be noted that in all of the studies we reviewed ‘‘hands on’’ and ‘‘hands off’’ are described variously or not at all. Table 1 includes a brief description of the hands on/off technique used to enable comparisons between the studies included in this review.
5. Discussion Traditionally accouchers have used ‘‘hands on’’ technique during vaginal birth.10 The evidence with respect to ‘‘hands on’’ or ‘‘hands off’’ techniques is probably largely based on one randomised controlled trial conducted in the UK, the ‘HOOP’ study.9 The HOOP study initially was designed to evaluate whether ‘‘hands poised’’ method would reduce perineal pain at 10 days after birth compared with the ‘‘hands on’’ method. This study recruited 5471 women in two hospitals of southern England. The authors concluded that pain was less in the ‘‘hands on’’ group compared with the ‘‘hands poised’’ group. The results of this study showed there were no differences in the location, frequency and severity of perineal trauma between two groups. They also found the likelihood of episiotomy in ‘‘hands poised’’ group was lower but the rate of manual removal of placenta was greater compared with ‘‘hands on’’ group. It is noteworthy that there has been no evaluation of the uptake of ‘‘hands off’’ or ‘‘hands poised’’ since the HOOP results were published nor has there been any evaluation of whether there has been a change in prevalence rates of perineal trauma. However, there has been wide uptake of ‘‘hands off’’ for example, a UK survey exploring 1000 midwives preferred perineal management ‘technique’ found the group to be almost evenly split (hands off 49.3%; hands on 50.7%).22 A more recent study, also a survey, indicated that a group of Australian midwives and doctors would use the hands on, hands off or episiotomy depending on the specific clinical situation.23 This suggests that this ongoing debate has resulted in clinicians using a range of techniques in order to try to minimise perineal trauma during birth. It is not yet known what the best technique is to place ‘‘hands on’’ however, some reports have indicated a theory for applying effective manual perineal protection. For example, one study by Zemcˇı´k et al.,24 in Czech Republic used stereophotogrammetry to analyse and quantify perineal deformation and strain at the final stages of birth. This study showed that the highest tissue strain occurred at the posterior fourchette in a transverse direction. To effectively reduce the tension, the authors suggested the approach of placing their right thumb and index finger alongside the forchette pulling towards to each other to reduce the tension in the midline at the time of pushing. Other fingers of the right hand might be placed on the median part of the perineum and provide gentle support as the head crowns. This study was the first to quantify the strain on the perineum that occurs during vaginal birth and thereby providing a scientific explanation for how the accoucher may place and use their hands during birth. Two other reported studies25,26 using biomedical models have also indicated that squeezing the perineum between the thumb and index finger of the accoucher’s dominant-posterior hand during birth significantly reduces tissue tension throughout the entire thickness of the perineum; thus, this kind of ‘‘hands on’’ intervention might help reduce obstetric perineal trauma. Manual perineal protection is therefore probably not as simple as whether the accoucher
places their ‘‘hands on’’ or leaves their ‘‘hands off’’ or ‘‘poised. It is a matter of how and when to put the hands on the perineum. Unfortunately all studies in this review provided different descriptions of the ‘‘hands on’’ technique making comparisons between reported outcomes difficult. Additionally, details are lacking as to exactly where fingers are placed, if both hands are used (one supporting, one squeezing), what time to put ‘‘hands on’’, i.e. between a contraction or during the contraction, during pushing or between pushing. There are also other factors in play as to whether or not hands are placed on or off. For example, clear visualisation of the perineum may be influenced by a number of factors including birth into water27 and woman’s position, especially if she is upright.28 Thus further research that occurs in this area should standardise exactly what is done with the accoucher’s hands but also report if the woman is birthing into water or land, and what position she was in. Much of this information is currently missing from these reports therefore, a conclusion cannot yet be drawn as to whether ‘‘hands on’’ is better than ‘‘hands off’’ or vice versa. 6. Conclusions ‘‘Hands on’’ techniques have been traditionally used but not been well defined in the literature, therefore it is currently unclear as to whether or not ‘‘hands on’’ technique can reduce perineal laceration. However, evidence indicates that ‘‘hands on’’ techniques which support (squeeze) the two sides of the posterior fourchette towards the midline may have a significant effect on reducing perineal laceration especially third and fourth degree tears. The effectiveness of this technique may be associated with other factors such as slowing down ‘‘flexing’’ the foetal head and supporting the perineum as the head ‘crowns’. More studies are required to test the effectiveness of this specific ‘‘hands on’’ technique and also to test if it is also effective in reducing first and second degree obstetric perineal laceration and what part other factors such as maternal position, visualisation and use of water might play. 7. Implications for research and practice The results of this review show there is a need for further investigation of effective ‘‘hands on’’ technique of reducing all degrees of perineal laceration associated with birth. Unified definition and detailed descriptions of an exact ‘‘hands on’’ technique such as where and when to place hands and fingers, and if the accoucher is applying pressure or squeezing, and in which direction, are required. Such details would then allow a standardised use of ‘‘hands on’’ and studies using such a standard to be replicable. More studies are also required to test if ‘‘hands on’’ techniques can decrease the incidence of first and second degree perineal lacerations. References 1. Li Z, Zeki R, Hilder L, Sullivan EA. Australia’s mothers and babies 2011. Perinatal statistics series. Canberra: AIHW National Perinatal Epidemiology and Statistics Unit; 2013. 2. Kettle C, Tohill S. Perineal care. Clin Evid (Online) 2011;2011(April). pii:1401. 3. McCandlish R. Perineal trauma: prevention and treatment. J Midwifery Womens Health 2001;46(6):396–401. 4. Nakai A, Yoshida A, Yamaguchi S, Kawabata I, Hayashi M, Yokota A, et al. Incidence and risk factors for severe perineal laceration after vaginal delivery in Japanese patients. Arch Gynecol Obstet 2006;274(4):222–6. 5. Harkin R, Fitzpatrick M, O’Connell PR, O’Herlihy C. Anal sphincter disruption at vaginal delivery: is recurrence predictable? Eur J Obstet Gynecol Reprod Biol 2003;109(2):149–52. 6. Hirayama F, Koyanagi A, Mori R, Zhang J, Souza JP, Gulmezoglu AM. Prevalence and risk factors for third- and fourth-degree perineal lacerations during vaginal delivery: a multi-country study. BJOG 2012;119(3):340–7.
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WOMBI-410; No. of Pages 5 H. Wang et al. / Women and Birth xxx (2015) xxx–xxx 7. Laine K, Gissler M, Pirhonen J. Changing incidence of anal sphincter tears in four Nordic countries through the last decades. Eur J Obstet Gynecol Reprod Biol 2009;146(1):71–5. 8. Hauck YL, Lewis L, Nathan EA, White C, Doherty DA. Risk factors for severe perineal trauma during vaginal childbirth: a Western Australian retrospective cohort study. Women Birth 2015;28(1):16–20. 9. McCandlish R, Bowler U, van Asten H, Berridge G, Winter C, Sames L, et al. A randomised controlled trial of care of the perineum during second stage of normal labour. BJOG 1998;105(12):1262–72. 10. Mayerhofer K, Bodner-Adler B, Bodner K, Rabl M, Kaider A, Wagenbichler P, et al. Traditional care of the perineum during birth. A prospective, randomized, multicenter study of 1,076 women. J Reprod Med 2002;47(6):477–82. 11. Laine K, Skjeldestad FE, Sandvik L, Staff AC. Incidence of obstetric anal sphincter injuries after training to protect the perineum: cohort study. BMJ Open 2012;2(5). 12. Revicky V, Nirmal D, Mukhopadhyay S, Morris EP, Nieto JJ. Could a mediolateral episiotomy prevent obstetric anal sphincter injury? Eur J Obstet Gynecol Reprod Biol 2010;150(2):142–6. 13. Raisanen S, Vehvilainen-Julkunen K, Gissler M, Heinonen S. The increased incidence of obstetric anal sphincter rupture – an emerging trend in Finland. Prev Med 2009;49(6):535–40. 14. Aasheim V, Nilsen AB, Lukasse M, Reinar LM. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev 2011;(December (12)). http://dx.doi.org/10.1002/14651858.CD006672.pub2. CD006672. 15. Rezaei R, Saatsaz S, Chan YH, Nia HS. A comparison of the ‘‘hands-off’’ and ‘‘hands-on’’ methods to reduce perineal lacerations: a randomised clinical trial. J Obstet Gynaecol India 2014;64(December (6)):425–9. 16. Foroughipour A, Firuzeh F, Ghahiri A, Norbakhsh V, Heidari T. The effect of perineal control with hands-on and hand-poised methods on perineal trauma and delivery outcome. J Res Med Sci 2011;16(August (8)):1040–6. 17. Jo¨nsson ER, Elfaghi I, Rydhstrom H, Herbst A. Modified Ritgen’s maneuver for anal sphincter injury at delivery: a randomized controlled trial. Obstet Gynecol 2008;112(2 Pt 1):212–7.
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18. de Souza Caroci da Costa A, Gonzalez Riesco ML. A comparison of ‘‘hands off’’ versus ‘‘hands on’’ techniques for decreasing perineal lacerations during birth. J Midwifery Womens Health 2006;51(2):106–11. 19. Fahami F, Shokoohi Z, Kianpour M. The effects of perineal management techniques on labor complications. Iran J Nurs Midwifery Res 2012;17(1):52–7. 20. Hals E, Oian P, Pirhonen T, Gissler M, Hjelle S, Nilsen EB, et al. A multicenter interventional program to reduce the incidence of anal sphincter tears. Obstet Gynecol 2010;116(4):901–8. 21. Smith LA, Price N, Simonite V, Burns EE. Incidence of and risk factors for perineal trauma: a prospective observational study. BMC Pregnancy Childbirth 2013;13(March):59. http://dx.doi.org/10.1186/1471-2393-13-59. 22. Trochez R, Waterfield M, Freeman RM. Hands on or hands off the perineum: a survey of care of the perineum in labour (HOOPS). Int Urogynecol J 2011;22(10):1279–85. 23. East CE, Lau R, Biro MA. Midwives’ and doctors’ perceptions of their preparation for and practice in managing the perineum in the second stage of labour: a cross-sectional survey. Midwifery 2015;31(January (1)):122–31. http:// dx.doi.org/10.1016/j.midw.2014.07.002. 24. Zemcˇı´k R, Karbanova J, Kalis V, Lobovsky´ L, Jansova´ M, Rusavy Z. Stereophotogrammetry of the perineum during vaginal delivery. Int J Gynaecol Obstet 2012;119(1):76–80. 25. Jansova M, Kalis V, Lobovsky L, Hyncik L, Karbanova J, Rusavy Z. The role of thumb and index finger placement in manual perineal protection. Int Urogynecol J 2014;25(November (11)):1533–40. http://dx.doi.org/10.1007/s00192014-2425-7. 26. Jansova M, Kalis V, Rusavy Z, Zemcik R, Lobovsky L, Laine K. Modeling manual perineal protection during vaginal delivery. Int Urogynecol J 2014;25(January (1)):65–71. http://dx.doi.org/10.1007/s00192-013-2164-1. 27. Henderson J, Burns EE, Regalia AL, Casarico G, Boulton MG, Smith LA. Labouring women who used a birthing pool in obstetric units in Italy: prospective observational study. BMC Pregnancy Childbirth 2014;14(January):17. http:// dx.doi.org/10.1186/1471-2393-14-17. 28. Kopas ML. A review of evidence-based practices for management of the second stage of labor. J Midwifery Womens Health 2014;59(3):264–76.
Please cite this article in press as: Wang H, et al. The effect of ‘‘hands on’’ techniques on obstetric perineal laceration: A structured review of the literature. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.02.006
