Perineum tears are a common injury during childbirth, though many are minor. The head of the baby puts a huge amount of strain on the area between the vulva and anus. Severe tears can have long-term consequences, making it more difficult to use the restroom or have sex.
Many practitioners are trained to use a hands-on technique to protect the perineum during labor and reduce injury, but lately, a new hands-off or hands-poised technique has been suggested instead. There's fierce debate over which practice is best.
A hands-on technique is, simply put, when the midwife or doctor puts gentle pressure on the perineum with one hand while using the other to press the babies' head into a downward position.
This approach employs a variety of techniques, some of which are more effective than others. Some midwives argue that hands-on approaches are unnecessarily invasive. They argue that a hands-off or hands-poised technique, where midwives' hands hover above the perineum and only apply pressure if needed, is better.
Hands-off techniques are part of a growing movement to reduce medical intervention during labor. Many champions of the hands-off approach aren't against helping with delivery when necessary but believe that the person giving birth should have more say over how and when they are touched. Hands-on approaches are only applied as needed with consent.
Hands-off approaches result in fewer episiotomies. This is a significant benefit. Episiotomy is a procedure where doctors or midwives cut the perineum with surgical scissors.
The ACOG and the WHO both recommend that doctors limit episiotomies only to emergencies, but many doctors and midwives still perform them unnecessarily and without consent to speed up delivery, causing physical and emotional trauma. Hands-off also gives the parent more privacy and freedom of movement and may reduce tearing overall.
The research around the hands-poised approach leading to fewer tears in the perineum is mixed. Some studies show a reduction in the amount of pain and tearing with a hands-off approach, while others indicate the opposite.
More research is needed to determine how effective these approaches are. Some techniques for relieving pain during labor do require a hands-on approach.
Hands-on approaches have been used for thousands of years to reduce pain and aid delivery. Some hands-on techniques, like massaging oil into or pressing warm compresses again the perineum, can help the area become more flexible before delivery.
During birth, a midwife using a hands-on technique is already situated to adjust the position of the baby's head and gently ease the baby out.
Not all hands-on techniques have the same outcome. Differences can be minor, and the placement or position of the fingers has been shown to increase pressure on the perineum by up to 104% rather than reducing it.
While some studies do indicate a reduction in postpartum pain and tearing overall from hands-on approaches, the advantage is often minor.
Giving birth on all fours rather than lying back may help reduce pressure on the perineum and give more space for the baby to be born. Birthing pools could also help.
During delivery, slow, controlled pushes can give muscles more time to stretch. Doing kegel exercises in the months before birth, may help strengthen the perineum and reduce tearing.
Hands-off is a bit of a misnomer, as various hands-on techniques can be employed during a hands-off birth. When practitioners use these techniques depends on how labor is progressing.
A midwife who notices that the baby is putting extra pressure on the vulva during a hands-off birth may ask the parent for permission to reposition the baby. In an emergency, such as the baby becoming stuck or distressed, doctors may need to use hands-on techniques to safely deliver.
Parents can combine hands-off and hands-on techniques in a variety of ways. Keeping the perineum warm helps to reduce tearing, so a parent may request a warm cloth but ask their midwife not to press or massage their perineum.
Parents might ask their doctor to keep hands-off until the moment of birth to allow greater comfort or freedom of movement, but then support them when the baby's head crowns.
Parents may have to shop around to find a provider who is comfortable using a hands-off approach. Doctors tend to prefer using a hands-on technique, while newly-trained midwives are the most likely to favor a hands-poised approach. High-risk pregnancies may merit more intervention.
The ideal birth approach depends on many factors, including the health of parent and baby, resources in the area, and personal preference. People have a right to decide how they give birth, and parents can always discuss options and preferences with their healthcare provider.
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