Skip to main content

Advertisement

SpringerLink
Log in

The role of thumb and index finger placement in manual perineal protection

  • Original Article
  • Published:
International Urogynecology Journal Aims and scope Submit manuscript

Abstract

Introduction and hypothesis

Comparison of the modifications of the Viennese method of manual perineal protection (VMPP) and hands-off delivery techniques by applying basic principles of mechanics with assessments of tensions within perineal structures using a novel biomechanical model of the perineum. Evaluation of the role of the precise placements of the accoucheur’s posterior (dominant) thumb and index finger in perineal tissue tension when performing a modified Viennese method of MPP.

Methods

We carried out an experimental study on a biomechanical model of the perineum at NTIS (New Technologies for Information Society, Pilsen, Czech Republic). Hands-off and 38 variations of VMPP were simulated during vaginal delivery with the finite element model imitating a clinical lithotomy position.

Results

The main outcome measures were quantity and extent of strain/tension throughout the perineal body during vaginal delivery. Stress distribution between modifications of VMPP showed a wide variation in peak perineal tension from 72 to 102 % compared with 100 % for the “hands-off” technique. Extent of reduction depended on the extent of finger movement across a horizontal, transverse x-axis, and on final finger position on a vertical, antero-posterior y-axis. The most effective modification of VMPP was initial position of fingers 12 cm apart (x = ±6) on the x-axis, 2 cm anteriorly from the posterior fourchette (y = +2) on the y-axis with 1cm movement of both finger and thumb toward the midline on the x-axis (Δx = 1) with no movement on the y-axis (Δy = 0).

Conclusions

In a biomechanical assessment with simulation of vaginal delivery, exact placement of fingertips on the perineal skin, together with their co-ordinated movement, plays an important role in the extent of reduction of perineal tension.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Baghestan E, Irgens LM, Børdahl PE, Rasmussen S (2010) Trends in risk factors for obstetric anal sphincter injuries in Norway. Obstet Gynecol 116:25–34

    Article  PubMed  Google Scholar 

  2. Jansova M, Kalis V, Rusavy Z, Zemcik R, Lobovsky L, Laine K (2014) Modeling manual perineal protection during vaginal delivery. Int Urogynecol J 25:65–71

    Article  PubMed  Google Scholar 

  3. DeWees WB (1889) Relaxation and management of the perineum during parturition. JAMA 24:841–848

    Article  Google Scholar 

  4. Zemčík R, Karbanova J, Kalis V, Lobovsky L, Jansova J, Rusavy Z (2012) Stereophotogrammetry of the perineum during vaginal delivery. Int J Gynaecol Obstet 109:136–139

    Google Scholar 

  5. Ritgen G (1855) Ueber sein Dammschutzverfahren. Monatschr Geburtsk Frauenkrankh 6:321–347

    Google Scholar 

  6. McCandlish R, Bowler U, van Asten H, Berridge G, Winter C, Sames L 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 

  7. Mayerhofer K, Bodner-Adler B, Bodner K, Rabl M, Kaider A, Wagenbichler P et al (2002) Traditional care of the perineum during birth. A prospective, randomized, multicenter study of 1,076 women. J Reprod Med 47:477–482

    PubMed  Google Scholar 

  8. Berghella V, Baxter JK, Chauhan SP (2008) Evidence-based labor and delivery management. Am J Obstet Gynecol 199:445–454

    Article  PubMed  Google Scholar 

  9. National Institute for Health and Clinical Excellence (2007) Intrapartum care: care of healthy women and their babies during childbirth. RCOG 2007; CG55 London. www.nice.org.uk/CG55

  10. 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. www.rcm.org.uk

  11. Aasheim V, Nilsen AB, Lukasse M, Reinar LM (2011) Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev. doi:10.1002/14651858.CD006672.pub2, CD006672

    PubMed  Google Scholar 

  12. Pirhonen JP, Grenman SE, Haadem K, Gudmundsson S, Lindqvist P, Siihola S 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 

  13. 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 

  14. Laine K, Skjeldestad FE, Sandvik L, Staff AC (2012) Incidence of obstetric anal sphincter injuries after training to protect the perineum: cohort study. BMJ Open. doi:10.1136/bmjopen-2012-001649

    PubMed  PubMed Central  Google Scholar 

  15. Laine K, Rotvold W, Staff AC (2013) Are obstetric anal sphincter ruptures preventable? Large and consistent rupture rate variations between the Nordic countries and between delivery units in Norway. Acta Obstet Gynecol Scand 92:94–100

    Article  PubMed  Google Scholar 

  16. Hals E, Øian P, Pirhonen T, Gissler M, Hjelle S, Nilsen EB et al (2010) A multicenter interventional program to reduce the incidence of anal sphincter tears. Obstet Gynecol 116:901–908

    Article  PubMed  Google Scholar 

  17. Stedenfeldt M, Øian P, Gissler M, Blix E, Pirhonen J (2012) Risk factors for obstetric anal sphincter injury after a successful multicenter intervention programme. BJOG 119:724–730

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  18. Kalis V, Karbanova J, Bukacova Z, Bednarova B, Rokyta Z, Kralickova M (2010) Anal dilation during labor. Int J Gynaecol Obstet 109:136–139

    Article  PubMed  Google Scholar 

  19. Reginelli A, Mandato Y, Cavaliere C, Pizza NL, Russo A, Cappabianca S et al (2012) Three-dimensional anal endosonography in depicting anal-canal anatomy. Radiol Med 117:759–771

    Article  PubMed  CAS  Google Scholar 

  20. Knowles AM, Knowles CH, Scott SM, Lunniss PJ (2008) Effects of age and gender on three-dimensional endoanal ultrasonography measurements: development of normal ranges. Tech Coloproctol 12:323–329

    Article  PubMed  CAS  Google Scholar 

  21. Handa VL, Lockhart ME, Fielding JR, Bradley CS, Brubaker L, Cundiff GW et al (2008) Racial differences in pelvic anatomy by magnetic resonance imaging. Obstet Gynecol 111:914–920

    Article  PubMed  PubMed Central  Google Scholar 

  22. Berger MB, Doumouchtsis SK, Delancey JO (2013) Bony pelvis dimensions in women with and without stress urinary incontinence. Neurourol Urodyn 32:37–42

    Article  PubMed  PubMed Central  Google Scholar 

  23. Dietz HP, Shek C, Clarke B (2005) Biometry of the pubovisceral muscle and levator hiatus by three-dimensional pelvic floor ultrasound. Ultrasound Obstet Gynecol 25:580–585

    Article  PubMed  CAS  Google Scholar 

  24. Gregory WT, Nardos R, Worstell T, Thurmond A (2011) Measuring the levator hiatus with axial MRI sequences: adjusting the angle of acquisition. Neurourol Urodyn 30:113–116

    Article  PubMed  Google Scholar 

  25. Svabik K, Shek KL, Dietz HP (2009) How much does the levator hiatus have to stretch during childbirth? BJOG 116:1657–1662

    Article  PubMed  CAS  Google Scholar 

  26. Schimpf MO, Harvie HS, Omotosho TB, Epstein LB, Jean-Michel M, Olivera CK et al (2010) Does vaginal size impact sexual activity and function? Int Urogynecol J 21:447–452

    Article  PubMed  PubMed Central  Google Scholar 

  27. Ashton-Miller JA, Delancey JO (2009) On the biomechanics of vaginal birth and common sequelae. Annu Rev Biomed Eng 11:163–176

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  28. Fung YC (1993) Biomechanics—mechanical properties of living tissues, 2nd edn. Springer, New York

    Google Scholar 

  29. Lee SL, Darzi A, Yang GZ (2005) Subject specific finite element modelling of the levator ani. Med Image Comput Comput Assist Interv 8:360–367

    PubMed  Google Scholar 

  30. Chen L, Ashton-Miller JA, DeLancey JO (2009) A 3D finite element model of anterior vaginal wall support to evaluate mechanisms underlying cystocele formation. J Biomech 42:1371–1377

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

This study was supported by the internal grant project SGS-2013-026 of the University of West Bohemia, by the European Regional Development Fund (ERDF), project “NTIS—New Technologies for the Information Society,” European Centre of Excellence, CZ.1.05/1.1.00/02.0090, and by the Charles University Research Fund (project number P36).

Conflict of interest

All authors declare no conflicts of interest and no instances of plagiarism.

Author information

Authors and Affiliations

  1. New Technologies—Research Centre, University of West Bohemia, Pilsen, Czech Republic

    Magdalena Jansova & Ludek Hyncik

  2. Department of Obstetrics and Gynecology, University Hospital, Faculty of Medicine, Charles University, Alej Svobody 80, 304 60, Pilsen, Czech Republic

    Vladimir Kalis, Jaroslava Karbanova & Zdenek Rusavy

  3. NTIS—New Technologies for Information Society, Faculty of Applied Sciences, University of West Bohemia, Pilsen, Czech Republic

    Libor Lobovsky

Authors
  1. Magdalena Jansova
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Vladimir Kalis
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Libor Lobovsky
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ludek Hyncik
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jaroslava Karbanova
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Zdenek Rusavy
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Vladimir Kalis.

Additional information

Magdalena Jansova and Vladimir Kalis are joint first authors

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Jansova, M., Kalis, V., Lobovsky, L. et al. The role of thumb and index finger placement in manual perineal protection. Int Urogynecol J 25, 1533–1540 (2014). https://doi.org/10.1007/s00192-014-2425-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00192-014-2425-7

Keywords

Search

Navigation