“Hands on” or “ Hands off “ Blog for Twitter Chat  @WeMidwives June 22nd 2014 8pm

June 2, 2014

Whether midwives have their “hands on” at the point of birth or “hands off” is a very emotive topic in maternity care. Thus it’s choice as a topic for a Tweet chat June 2014. @WeMidwives


What “hands on” actually means is a very debatable point, but having been a midwife for over 28 years I would like to pose the following to promote discussion.

Full “hands on” I believe means:- one hand pressing gently on the baby’s head as it is being born, slowing its progress, whilst at the same time protecting the perineum with another.  You can feel the progress of the baby this way. You can feel and work with the woman at this important point of birth to ensure a controlled delivery.

There are variations, which include; trying to flex the head down towards the anus to ensure the smallest part of the head exits the vagina first. There is also pursing (squeezing together) of the perineum upwards to somehow prevent the perineum from stretching too far and result in a tear. These practises appear to have died out over the years, but were very much in practise in the late 80’s.

“Hands off” appears more simple to describe, in that there are no hands nearby and the baby is allowed to deliver itself with the force of his/her mother’s efforts. This is clearly most evident at a water birth.  But this “hands off” approach is used in all settings and I imagine must be used when there is no birth attendant. The lack of any birth attendant is a cause of maternity and neonatal mortality in the developing world.  If hands are there, they do support the baby as it is delivered, but do not restrict in any way his/her progress into the world. There is strong evidence that “hands off” does reduce the risk of an episiotomy. (Cochrane Collaboration 2011)


So are we concerned?  Does it matter how a baby is delivered. There was a suspicion that the “hands off” approach might lead to women suffering more third and fourth degree tears however this is not supported by current evidence NICE (2007)

A small proportion of women who suffer a third or fourth degree tears, go on to develop severe long term debilitating problems with their bowel and bladder function. This can be extraordinarily disabling, especially with a newborn baby to care for.   

So surely it is an area of care we need to consider and debate, to see if what we do at the delivery can be adapted to prevent trauma occurring. A recent study found that the median national OASIS (Obstetric Anal Sphincter Injuries) rate was 2.85 % (Range 0-8 %) (Thiagamoorthy  Incidence 2014)  In a unit where 3000 women deliver annually this would mean 85 women would suffer this damage to their perineum with implications for her future life and future deliveries.


The study that midwives like to quote when looking for evidence to support “hands off” care is the Hands on or Poised (HOOP) Trial. Hands on or poised (McCandllish R et al 1998) This trial concluded there was evidence of a difference in postnatal pain, however did not look at comparing the incidence of perineal trauma..

The best review of the topic I believe is contained in the Cochrane Collaboration 2011 Perineal techniques during the second stage of labour for Reducing Perineal Trauma. Cochrane Collaboration 2011 They conclude after reviewing all the studies there is only area of intervention with clear evidence, that a warm compress applied during the 2nd stage of labour does reduce the likelihood of a severe perineal tear.


I am an old midwife (funny never thought I would be) qualified 1986 and in my training and in the textbooks we used way back then, the way you delivered was “hands on”. This technique seemingly was the one that had been used for years. This fact was there in the “Call the midwife” BBC series based on Jennifer Worth’s book. They did research to ensure that what was done on screen was what was done actually in the 1950’s.

My midwifery mentor explained that the reason why we did this was to slow down the birth, to give the perineum a chance to stretch to avoid severe tears.

It felt obvious and made common sense to me. I know I have found it very useful when women have found birth difficult and become very uncomfortable and uncontrolled with their pushing. Feeling the birth as it happened has helped me as a midwife over the years to slow some births down and prevent severe trauma.

I also believe that you need to take real care with the baby’s shoulders and once the first has appeared you gently flex the baby the other way to deliver the second. I have been witness to many a perineum being torn by a shoulder being brought through, by a quick uncontrolled anxiety driven delivery.  Waiting for restitution and the next contraction are important aspects of the technique.

I may be wrong but I don’t believe there has been a clear randomised study of “hands on” versus “hands off”. The study would be very difficult to perform as you would have to really stipulate what kind of “hands on” or “hands off” you were prescribing and have women happy to be randomised to one or the other.

The RCM 2012 state in their Care of the Perineum Evidenced Based care document

Studies are inconclusive on using guidance or flexion of the presenting part with the aim of reducing perineal trauma (Aasheim et al. 2011; Pirhonen et al 1998; Myrfield 1997). NICE (2007) recommend that either the ‘hands on’ or the ‘hands poised’ technique can be used to facilitate spontaneous birth.


There has more recently however, been a study in the Netherlands which has made me think more deeply about the topic.  A massive study population (31709 women) by Katariina Laine et al (2012. bmjopen)  Which showed a 50% decrease in the incidence of 3rd/4th deg tears, by the application of a more hands on approach.

I was lucky enough to see the presentation of this study at an (OASIS) Obstetric Anal Sphincter Injury) Study day in Plymouth 2013. I also spoke to Ms Laine and witnessed her real hands on head, supporting perineum technique.  Her technique for supporting the baby’s head and the perineum was a bit extreme in my personal opinion. She applied a lot of pressure to the head and the perineum. Her study was also not randomised, so its findings are challengeable. However the effect on reducing the incidence of third and fourth degree tears was so impressive, there may be something important to learn from this study.


Since the Netherlands study and my visit to the Plymouth OASIS study day I shared some of the knowledge and evidence for “hands on” with my colleagues. Our third/fourth degree tear rate seemed high, sometimes ten or eleven women a month.  This was too many. 

An Obstetric Colleague (Dr Jonathon Frost) devised on online training about the topic and how to detect a third/fourth deg tears. We also did some awareness raising workshops about the topic for 6 months in the maternity unit. This was real collaborative work.

It is unclear whether any of this activity was the direct reason for the effect, but in the past year our 3rd and 4th degree tear rate has dropped by 30%. This data is soon to be published in the medical and midwifery press in 2014.


I personally am not advocating that all midwives suddenly put their hands on at all deliveries.  I am just suggesting that a “hands on” approach might be necessary in some cases.

It would assist the debate and the data gathering, if all birth centre, home and hospital birth settings collected data on this. However many current hospital IT systems, do not record whether “hands on” or “hands off” was utilised at the delivery. Often this is not recorded in long hand in the notes either. (I am an Audit Midwife I see a lot of notes). I think we should record what we did to support the birth, to inform best practice.

There are other sides of this topic however, one is of course verbal support and encouragement. There is extensive evidence that we should stop asking women “to take a deep breath and push”. (RCM 2005) This evidence has been around for years but this approach is still used when midwives are running out of ideas as to how to get the baby delivered in difficult frightening circumstances, often as a last resort.  Another topic for another Tweet chat maybe.

The position of birth is also of interest in this area of care. When women adopt positions of their choice it is often difficult to apply a “hands on” technique.  But birthing stool and squatting deliveries are also suspected as having higher 3rd or 4th degree tear rates.


Looking forward to the Tweetchat.





Aasheim Vet all2011 Cochrane CollaborationPerineal techniques during the second stage of labour for reducing perineal trauma (Review)


Garcia Jo 1999 BMJ Hands on or poised  Pub med

Laine  Katriina BMJOpen 2012;2: Incidence of obstetric anal sphincter injuries after training to protect the perineum: cohort study  Downloaded April 15 2013

NICE 2007 Clinical Guidance 55 Intrapartum Care p30

RCOG 2007 Green top Guideline 29 Management of Third and Fourth degree tears

RCM 2012 Evidenced Based Guidelines for midwifery care in labour. Care of the Perineum

RCM 2005 Campaign for normal births http://www.rcmnormalbirth.org.uk/stories/if-at-first/second-stage-pushing   

Thiagamoorthy G et al 2014National survey of perineal trauma and its subsequent management in the United Kingdom  http://www.ncbi.nlm.nih.gov/pubmed/24832856#


2 Responses to ““Hands on” or “ Hands off “ Blog for Twitter Chat  @WeMidwives June 22nd 2014 8pm”

  1. macaroonlady Says:

    Goodness. The Netherlands study is quite compelling. Thanks for sharing for those of us that don’t have access to journals.

    With regards to verbal encouragement to push….could you clarify? do you mean us labouring mothers-to-be shouldn’t be consciously pushing? I read somewhere about letting your body do the work but is this actually practised anywhere? The media has convinced us Mums that we have to push with all our might and I fear that most midwives want this too.

    • There is good research by Midwife Ann Thomson. Mothers should be encouraged to do what their body is telling them to do. The old “take a deep breath and push” should be saved as a last resort when all else has been tried. Work with your body it knows what to do

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