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Hands on or hands off the perineum: a survey of care of the perineum in labour (HOOPS)

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Abstract

Introduction and hypothesis

There seems to be a temporal association between increasing use of “hands off” the perineum in labour and reduced use of episiotomy with an increasing rate of anal sphincter injuries. We aimed to determine how common the practice of “hands off” the perineum is.

Methods

An observational postal questionnaire study of 1,000 midwives in England in which the main objective was to obtain an estimate of the number of midwives practising either “hands on” or “hands off” was conducted.

Results

Six hundred and seven questionnaires were returned; 299 (49.3%, 95% CI 45.2–53.3%) midwives prefer the “hands-off” method. Less-experienced midwives were more likely to prefer the “hands off” (72% vs. 41.4%, p < 0.001). A higher proportion of midwives in the “hands-off” group would never do an episiotomy (37.1% vs. 24.4%, p = 0.001) for indications other than fetal distress.

Conclusions

The “hands off” the perineum technique is prevalent in the management of labour. We hypothesise that a possible consequence might be an increased incidence of obstetric anal sphincter injury.

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References

  1. Laine K, Pirhonen T, Rolland R, Pirhonen J (2008) Decreasing the incidence of anal sphincter tears during delivery. Obstet Gynecol 111:1053–1057

    Article  PubMed  Google Scholar 

  2. Revicky V, Nirmal D, Mukhopadhyay S, Morris E, Nieto J (2010) Could a mediolateral episiotomy prevent obstetric anal sphincter injury? Eur J Obstet Gynecol Reprod Biol 150:142–146

    Article  PubMed  Google Scholar 

  3. Raisanen S, Vehvilainen-Julkunen K, Gissler M, Heinonen S (2009) The increased incidence of obstetric anal sphincter rupture – an emerging trend in Finland. Prev Med 49:535–540

    Article  PubMed  Google Scholar 

  4. Laine K, Gissler M, Pirhonen J (2009) Changing incidence of anal sphincter tears in four Nordic countries through the last decades. Eur J Obstet Gynecol Reprod Biol 146:71–75

    Article  PubMed  Google Scholar 

  5. Van Dillen J, Spaans M, van Keijsteren W et al (2010) A prospective multicenter audit of labour-room episiotomy and anal sphincter injury assessment in the Netherlands. Int J Gynaecol Obstet 108:97–100

    Article  PubMed  Google Scholar 

  6. Mous M, Muller SA, de Leeuw JW (2008) Long term effects of anal sphincter rupture during vaginal delivery: faecal incontinence and sexual complaints. BJOG 115:234–238

    PubMed  CAS  Google Scholar 

  7. Nordenstam J, Mellgren A, Altman D et al (2008) Immediate or delayed repair of obstetric anal sphincter tears – a randomised controlled trial. BJOG 115:857–865

    Article  PubMed  CAS  Google Scholar 

  8. Fernando RJ, Sultan AH, Kettle C, Radley S, Jones P, O’Brien PM (2006) Repair techniques for obstetric anal sphincter injuries: a randomised controlled trial. Obstet Gynecol 107:1261–1268

    Article  PubMed  Google Scholar 

  9. Richter HE, Fielding JR, Bradley CS et al (2006) Endoanal ultrasound findings and fecal incontinence symptoms in women with and without recognised anal sphincter tears. Obstet Gynecol 108:1394–1401

    Article  PubMed  Google Scholar 

  10. Aukee P, Sundstrom H, Kairaluoma M (2006) The role of mediolateral episiotomy during labour: analysis of risk factors for obstetric anal sphincter tears. Acta Obstet Gynecol Scand 85:856–860

    Article  PubMed  Google Scholar 

  11. Jander C, Lyrenas S (2001) Third and fourth degree perineal tears – predictor factors in a referral hospital. Acta Obstet Gynecol Scand 80:229–234

    PubMed  CAS  Google Scholar 

  12. Dahl C, Kjolhede P (2006) Obstetric anal sphincter rupture in older primiparous women: a case-control study. Acta Obstet Gynecol Scand 85:1252–1258

    Article  PubMed  Google Scholar 

  13. Sheiner E, Levy A, Walfisch A, Hallak M, Mazor M (2005) Third degree perineal tears in a university medical centre where midline episiotomies are not performed. Arch Gynecol Obstet 271:307–310

    Article  PubMed  Google Scholar 

  14. Spydslaug A, Trogstad L, Skrondal A, Eskild A (2005) Recurrent risk of anal sphincter laceration among women with vaginal deliveries. Obstet Gynecol 105:307–313

    Article  PubMed  Google Scholar 

  15. Samarasekera D, Bekhit M, Preston J, Speakman C (2009) Risk factors for anal sphincter disruption during childbirth. Langenbecks Arch Surg 394:535–538

    Article  PubMed  CAS  Google Scholar 

  16. De Leeuw J, Struijk P, Vierhout M, Wallenburg H (2001) Risk factors for third degree perineal ruptures during delivery. BJOG 108:383–387

    Article  PubMed  Google Scholar 

  17. Williams A (2003) Third degree perineal tears: risk factors and outcome after primary repair. J Obstet Gynaecol 23:611–614

    Article  PubMed  CAS  Google Scholar 

  18. Andrews V, Sultan A, Thakar R, Jones P (2006) Risk factors for obstetric anal sphincter injury: a prospective study. Birth 33:117–122

    Article  PubMed  Google Scholar 

  19. Pirhonen J, Grenman S, Haadem K et al (1998) Frequency of anal sphincter rupture at delivery in Sweden and Finland – result of difference in manual help to the baby’s head. Acta Obstet Gynecol Scand 77:974–977

    Article  PubMed  CAS  Google Scholar 

  20. Parnell C, Langhoff-Roos J, Moller H (2001) Conduct of labour and rupture of the sphincter ani. Acta Obstet Gynecol Scand 80:256–261

    Article  PubMed  CAS  Google Scholar 

  21. Samuelsson E, Ladfors L, Wennerholm U, Gareberg B, Nyberg K, Hagberg H (2000) Anal sphincter tears: prospective study of obstetric risk factors. Br J Obstet Gynaecol 107:926–931

    Article  CAS  Google Scholar 

  22. National Institute for Health and Clinical Excellence (2007) CG55 Intrapartum care: care of healthy women and their babies during childbirth. RCOG, London

    Google Scholar 

  23. Munro J, Jokinen M (2008) Midwifery practice guideline: care of the perineum. RCM evidence based guidelines for midwifery-led care in labour, 4th edn. Royal College of Midwives, London

    Google Scholar 

  24. McCandlish R, Bowler U, van Asten H et al (1998) A randomised controlled trial of care of the perineum during second stage of normal labour. Br J Obstet Gynaecol 105:1262–1272

    Article  PubMed  CAS  Google Scholar 

  25. Mayerhofer K, Bodner-Adler B, Bodner K et al (2002) Traditional care of the perineum during birth: a prospective, randomised, multicenter study of 1076 women. J Reprod Med 47:477–482

    PubMed  Google Scholar 

  26. Hals E, Oian P, Pirhonen T et al (2010) A multicenter interventional programme to reduce the incidence of anal sphincter tears. Obstet Gynecol 116:901–908

    Article  PubMed  Google Scholar 

  27. Carroli G, Mignini L (2009) Episiotomy for vaginal birth. Cochrane Database of Systematic Reviews, issue 1. Art. no.:CD000081. doi:10.1002/14651858.CD000081.pub2

  28. Andrews V, Thakar R, Sultan AH, Jones PW (2005) Are mediolateral episiotomies actually mediolateral? BJOG 112:1156–1158

    Article  PubMed  Google Scholar 

  29. Eogan M, Daly L, O’Connell PR, O’Herlihy C (2006) Does the angle of episiotomy affect the incidence of anal sphincter injury? BJOG 113:190–194

    Article  PubMed  CAS  Google Scholar 

  30. Kalis V, Karbanova J, Horak M, Lobovsky L, Kralickova M, Rokyta Z (2008) The incision angle of mediolateral episiotomy before delivery and after repair. Int J Gynecol Obstet 103:5–8

    Article  Google Scholar 

  31. Nakash RA, Hutton JL, Jorstad-Stein EC, Gates S, Lamb SE (2006) Maximising response to postal questionnaires – a systematic review of randomised trials in health research. BMC Med Res Methodol 6:5. doi:10.1186/1471-2288-6-5

    Article  PubMed  Google Scholar 

  32. Edwards PJ, Roberts I, Clarke MJ, et al (2009) Methods to increase response to postal and electronic questionnaires. Cochrane Database of Systematic Reviews, issue 3. Art. no.: MR000008. doi:10.1002/14651858.MR000008.pub4

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Acknowledgements

We thank all the midwives who participated in the survey and Paula Brockman and Angela King for their help with data input.

Details of ethics approval

Approval for the study was sought and obtained from the Plymouth Hospitals NHS Trust R&D Department, who deemed it exempt from Ethics Committee approval.

Funding

The study was funded by the Plymouth Urogynaecology Research Fund.

Conflict of interest

RM Freeman is editor of the International Urogynecology Journal and Lead for the Peninsula Collaboration for Leadership in Applied Health Research and Care (PenCLAHRC). M Waterfield and R Trochez have no conflict of interest to declare.

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Correspondence to Ruben Trochez.

Appendix 1

Appendix 1

Survey of the management of the perineum during vaginal delivery

figure a

Questionnaire

figure b

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Trochez, R., Waterfield, M. & Freeman, R.M. Hands on or hands off the perineum: a survey of care of the perineum in labour (HOOPS). Int Urogynecol J 22, 1279–1285 (2011). https://doi.org/10.1007/s00192-011-1454-8

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  • DOI: https://doi.org/10.1007/s00192-011-1454-8

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