Hands-poised technique: The future technique for perineal management of second stage of labour? A modified systematic literature review

Midwifery. 2015 Feb;31(2):274-9. doi: 10.1016/j.midw.2014.10.004. Epub 2014 Nov 5.


Background: vaginal birth is often accompanied with perineal trauma that affects postpartum morbidity. There are many techniques for protecting the perineum from injury during childbirth. The Hands-On or Hands Poised (HOOP) study (McCandlish et al., 1998) was the first trial that compared different techniques of perineal protection during the second stage of labour with very little research subsequently being undertaken.

Objectives: to systematically review all available literature that compares the hands-on and hands-poised techniques of perineal management during the second stage of labour.

Methods: using the principles of a modified systematic literature review, quantitative, comparative and primary research studies were selected. These were assessed for quality using the Critical Appraisal Skills Programme (CASP) framework including a data extraction form. The results were reported narratively.

Main results: five studies were included and outlined the importance of both techniques. The hands-poised technique appeared to cause less perineal trauma and reduced rates of episiotomy. The hands-on technique resulted in increased perineal pain after birth and higher rates of postpartum haemorrhage.

Conclusion: as the five studies selected for this review have widely differing variables, comparisons that have been drawn must be viewed with caution. Evidence would suggest that the hands-poised technique is a safe and recommended technique for perineal management and discussions of such a technique should be included in all midwifery education and training programmes. The challenge for midwives is how to support women in making informed choices about perineal management during childbirth. Until there is conclusive evidence, the choice of the hands-on or hands-poised technique will ultimately be determined by the clinical judgment of the individual midwife at the time of birth. Further research is recommended. Thorough conclusions could significantly impact on reducing postpartum morbidity and improving women's sexual health and well-being in the long term, throughout the world.

Keywords: Birth; Hands-on; Hands-poised; Midwife; Second stage of labour.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Delivery, Obstetric / methods*
  • Episiotomy / adverse effects*
  • Female
  • Humans
  • Midwifery / methods*
  • Obstetric Labor Complications / prevention & control*
  • Parturition
  • Perineum / injuries*
  • Perineum / surgery
  • Pregnancy