Perineal support during delivery

[sddoc]

I'm an FP intern who is currently on OB service. Some of the attendings that I have worked with are telling me that I need to provide perineal support while delivering the posterior shoulder. Short of growing an extra hand to do this, I simply can't see a good way to do it without risking dropping the kiddo. Does anyone have any good suggestions?

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[pruritis_ani]

Use one hand to deliver, one hand on the perineum. Do this for the posterior shoulder, than move both hands up for the rest of the delivery. After you get the posterior shoulder out, there is still a lot of kid to deliver, thus mom's posterior vaginal wall is still supporting much of the kid, so you should not be at risk to drop the baby.

I actually support until the baby bottom is out too, then let go of perineum and grab legs with the lower hand as they deliver. Just have a good grip with your upper hand, move deliberately, and no problemo.

 

[ohbee gin]

While I support the perineum too, it is odd that there's not much lit supporting hands-on perineal support.

OBJECTIVE: To investigate the influence of the traditional hands-on versus the innovative hands-poised method on the risk of perineal trauma during vaginal delivery and on neonatal outcomes. STUDY DESIGN: In a prospective, randomized, multicenter study, 1,161 of 1,505 women giving birth at the Departments of Obstetrics and Gynecology of the University Hospital of Vienna and Semmelweis Women's Hospital, Vienna, between February and September 1999, were randomized into the trial. In the hands-on method, the left hand of the midwife puts pressure on the infant's head, and the right hand is placed against the perineum. In the hands-poised method, the midwife guides the parturient through the birth without touching the perineum, prepared to apply light pressure on the infant's head. RESULTS: One hundred eighty-seven of 574 women (32.5%) in the hands-on group and 180 of 502 women (35.8%) in the hands-poised group experienced perineal tears (P = .5). Sixteen women (2.7%) treated with the hands-on method developed third-degree perineal tears as compared with five women (0.9%) treated with the hands-poised method (P < .05). In the hands-on group, 103 women (17.9%) underwent episiotomy as compared with 51 cases (10.1%) in the hands-poised group (P < .01). No significant differences in neonatal outcomes were observed between the two groups. CONCLUSION: Our data suggest that a policy of hands-poised care is more suitable for preserving the perineum during birth and is a safe and effective birthing alternative for women.

- Traditional care of the perineum during birth. A prospective, randomized, multicenter study of 1,076 women. Mayerhofer K. Reprod Med. 2002

OBJECTIVE: To compare the effect of two methods of perineal management used during spontaneous vaginal delivery on the prevalence of perineal pain reported at 10 days after birth. DESIGN: Randomised controlled trial. SETTING: Two English maternity care units. SAMPLE: 5471 women who gave birth between December 1994 and December 1996. METHODS: At the end of the second stage of labour women were allocated to either the 'hands on' method, in which the midwife's hands put pressure on the baby's head and support ('guard') the perineum; lateral flexion is then used to facilitate delivery of the shoulders, or the 'hands poised' method, in which the midwife keeps her hands poised, not touching the head or perineum, allowing spontaneous delivery of the shoulders. MAIN OUTCOME MEASURE: Perineal pain in the previous 24 hours reported by women in self-administered questionnaire 10 days after birth. RESULTS: Questionnaires were completed by 97% of women at 10 days after birth. 910 (34.1%) women in the 'hands poised' group reported pain in the previous 24 hours compared with 823 (31.1%) in the 'hands on' group (RR 1.10, 95% CI 1.01 to 1.18: absolute difference 3%, 0.5% to 5%, P = 0.02). The rate of episiotomy was significantly lower in the 'hands poised' group (RR 0.79, 99% CI 0.65 to 0.96, P = 0.008) but the rate of manual removal of placenta was significantly higher (RR 1.69, 99% CI 1.02 to 2.78; P = 0.008). There were no other statistically significant differences detected between the two methods. CONCLUSION: The reduction in pain observed in the 'hands on' group was statistically significant and the difference detected potentially affects a substantial number of women. These results provide evidence to enable individual women and health professionals to decide which perineal management is preferable.

-A randomised controlled trial of care of the perineum during second stage of normal labour. McCandlish R. 1998. BJOG

 

[ohbee gin]

After some thought, I realize I actually don't support the perineum after delivering the anterior shoulder using (gentle) downward traction. With the ant shoulder free, I use both hands to support the fetal head and neck while moving sharply upwards to free the post shoulder without it ever engaging the post-perineum. In my mind, this is the only way to do it. The idea of delivering the post shoulder and buttocks before grabbing the baby by a leg seems awkward, uncoordinated, and more prone to mishap. Anyone else on this?

 

[pruritis_ani]

After some thought, I realize I actually don't support the perineum after delivering the anterior shoulder using (gentle) downward traction. With the ant shoulder free, I use both hands to support the fetal head and neck while moving sharply upwards to free the post shoulder without it ever engaging the post-perineum. In my mind, this is the only way to do it. The idea of delivering the post shoulder and buttocks before grabbing the baby by a leg seems awkward, uncoordinated, and more prone to mishap. Anyone else on this?

Gentle downward traction, deliver anterior shoulder. Suction. Then, one hand on perineum, providing basically a platform for baby to slide over while supporting the perineum, while the other head pulls baby sharply upward. Once all the big parts are out (ie shoulders and hips), the hand that is supporting perineum simply transists from a platform to a hand that grips the legs (not one leg) at about thigh level. Baby is delivered, and I am not just holding baby by the head with two hands (which seems awkward to me, just having a grip on the head with both hands.)...baby is cradled in one arm, dried off, more bulb suction if needed, cord clamped and cut, and baby is off to mom or the warmer.

Perhaps it may seem awkward, but it is actually quite simple. Since this is how I deliver, and how I was trained to deliver at every Ob rotation I have been in, it does not seem awkward or uncoordinated to me. Never seen or heard of a mishap this way.

Given that the evidence shows that either way is effective, it makes sense to perform the delivery in the manner that you are most experienced and comfortable. No matter how you deliver, the first few are certainly awkward. And, once you get comfortable with a method, other methods may seem awkward.

 

[tiredmom]

Pruitis ani -
How is the platform hand facing... palm up or palm down? Are you squeezing with fingers/thumb widely apart? I'm trying to picture it to see about trying it.
What I've found that I do is deliver the head with 1 hand on head, 1 hand supporting perineum. Then I take perineum hand and move to head to deliver shoulders, then I slide the posterior hand along baby's back to grab bottom/legs. That way I've got two hands up to deliver shoulders but don't end up holding the baby by the head.
Are you sitting or standing to deliver?
Thanks!

 

[pruritis_ani]

Pruitis ani -
How is the platform hand facing... palm up or palm down? Are you squeezing with fingers/thumb widely apart? I'm trying to picture it to see about trying it.
What I've found that I do is deliver the head with 1 hand on head, 1 hand supporting perineum. Then I take perineum hand and move to head to deliver shoulders, then I slide the posterior hand along baby's back to grab bottom/legs. That way I've got two hands up to deliver shoulders but don't end up holding the baby by the head.
Are you sitting or standing to deliver?
Thanks!

Platform hand is basically perineal support with index finger and thumb, little finger down. Fingers widely apart. The "platform" is essentially the webbing area between thumb and first finger. As baby slides over, I really just have to move my hand a minimal amount, just a quick turn around and I am in prime leg grabbing position.

Every delivery is a bit different, so there are small variations. Many times I do use both hands to get the shoulders out, and slide down as you do, but I usually do provide some perineal support for the delivery of the baby bottom. If I have a big baby, I tend to try to offer more in the way of support to the perineum. I find by being very deliberate, and controlling the speed of delivery, I can get my hands where I want them to be with a minimum of flailing around. But, I can tell you that my first several deliveries were less than graceful when trying to actually learn how to support the perineum throughout. Given the data that do not really support the need for this, it may be wasted motion.

I am always standing to deliver.

 

[sddoc]

Thanks for all of your help... I really appreciate it.

 

[MadameLULU]

thanks. very helpful.

 

[sddoc]

I just caught something I hadn't seen before. You suction after the anterior shoulder is delivered? All of the attendings that I have worked with have us suction after the head is delivered. Are you delivering through the anterior shoulder to prevent dystocia?