Perineal injury associated with hands on/hands poised and directed/undirected pushing: A retrospective cross-sectional study of non-operative vaginal births, 2011-2016

Int J Nurs Stud. 2018 Jul;83:11-17. doi: 10.1016/j.ijnurstu.2018.04.002. Epub 2018 Apr 5.


Background: Clinicians hand position and advised pushing techniques may impact on rates of perineal injury.

Objective: To assess the association of four techniques used in management of second stage with risk of moderate and severe perineal injury.

Design: Retrospective cross-sectional study.

Setting: A metropolitan maternity hospital and a private maternity hospital in Brisbane, Australia.

Participants: Term women with singleton, cephalic presentation experiencing a non-operative vaginal birth from January 2011 to December 2016.

Methods: The research sites perinatal database recorded data on clinicians approach to instructing women during second stage and hand position at birth. Women were identified from matching the inclusion criteria (n = 26,393) then grouped based on combinations of hands-on, hand- poised, directed and undirected pushing. The associations with perineal injury were estimated using odds ratios obtained by multivariate analysis. Primary outcomes were the risk of moderate and severe perineal injury. The significance was set at 0.001.

Results: In Nulliparous women there was no difference in the risk of moderate or severe perineal injury between the different techniques. In multiparous women the use of a hands-on/directed approach was associated with a significant increase in the risk of moderate (AOR 1.18, 95% CI 1.10-1.27, p < 0.001) and severe perineal injury (AOR 1.50, 95% CI 1.20-1.88, p < 0.001) compared to hands-poised/undirected.

Conclusions: A hands poised/undirected approach could be utilised in strategies for the prevention of moderate and severe perineal injury.

Keywords: Hands off; Hands-on; Hands-poised; Obstetric anal sphincter injury; Perineal injury; Perineal support; Vaginal birth.

MeSH terms

  • Adult
  • Cross-Sectional Studies
  • Delivery, Obstetric / methods*
  • Female
  • Humans
  • Obstetric Labor Complications*
  • Outcome Assessment, Health Care
  • Perineum / injuries*
  • Pregnancy
  • Queensland
  • Retrospective Studies
  • Vagina*
  • Valsalva Maneuver