EBB 221 – Evidence on Birthing Positions and Tried-and-True Midwifery Practices for Protecting the Perineum

• Support the work of Mercy In Action in the Philippines (and check out their U.S.-based midwifery college) here https://www.mercyinaction.com/.
• Check out Episode 206 of the EBB Podcast to learn about perineal tears and avoiding an episiotomy, Episode 210 to learn about warm compresses and hands-on vs. hands-off techniques, Episode 216 to learn about perineal massage during pregnancy, and Episode 218 to learn about perineal massage during labor.
• Go to our YouTube channel to see video versions of all our podcasts! (including PowerPoint presentations when used).
• Visit https://evidencebasedbirth.com/childbirth-class/  to learn more about the Evidence Based Birth® Childbirth Class.
• Take a continuing education class on this topic (and earn a contact hour) by joining the EBB Professional Membership  here: https://evidencebasedbirth.com/become-pro-member/

• Albers, L. L., Sedler, K. D., Bedrick, E. J., et al. (2005). “Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: A randomized trial.” J Midwifery Women’s Health 50(5): 365-72. https://www.ncbi.nlm.nih.gov/pubmed/?term=PMC1350988
• Edqvist, M., Blix, E., Hegaard, H. K., et al. (2016). “Perineal injuries and birth positions among 2992 women with a low-risk pregnancy who opted for a homebirth.” BMC Pregnancy Childbirth 16(1): 196. https://pubmed.ncbi.nlm.nih.gov/27473380/
• Declercq, E. R., Sakala, C., Corry M. P., et al. (2014). “Major Survey Findings of Listening to Mothers(SM) III: Pregnancy and Birth: Report of the Third National U.S. Survey of Women’s Childbearing Experiences.” J Perinat Educ 23(1): 9-16. https://pubmed.ncbi.nlm.nih.gov/24453463/
• Zang Y, Lu H, Zhang H, Huang J, et al. (2020). “Effects of upright positions during the second stage of labour for women without epidural analgesia: A meta-analysis.” J Adv Nurs 76(12):3293-3306. https://pubmed.ncbi.nlm.nih.gov/33009847/
• Crowley, Elbourne, Ashurst, et al. (1991). “Delivery in an obstetric birth chair: A randomized controlled trial.” Br J Obstet Gyn 104(5): 567-571. https://pubmed.ncbi.nlm.nih.gov/1883790/
• de Jong, Johanson, Baxen, et al. (1997). “Randomised trial comparing the upright and supine positions for the second stage of labour.” British J Obstet Gyn 104(5): 567-571. https://pubmed.ncbi.nlm.nih.gov/9166199/
• Zhang, Huang, Guo et al. (2017). “A randomized controlled trial in comparing maternal and neonatal outcomes between hands-and-knees delivery and supine position in China.” Midwifery 50: 117-124. https://pubmed.ncbi.nlm.nih.gov/28414983/
• Lin, Gau, Kao et al. (2018). “Efficacy of an ergonomic ankle support aid for squatting position in improving pushing skills and birth outcomes during the second stage of labor: A randomized, controlled trial. J Nurs Res 26(6):376-384. https://pubmed.ncbi.nlm.nih.gov/29553965/
• The Epidural and Position Trial Collaborative Group (2017). “Upright versus lying down position in second stage of labour in nulliparous women with low dose epidural: BUMPES randomised controlled trial.” BMJ 359: j4471. https://www.bmj.com/content/359/bmj.j4471
• Elvander, C., Ahlberg, M., Thies-Lagergren, L., et al. (2015). “Birth position and obstetric anal sphincter injury: a population-based study of 113 000 spontaneous births.” BMC Pregnancy Childbirth 15: 252. https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-015-0689-7
• Begley, C., Guilliland, K., Dixon, L., et al. (2019). “A qualitative exploration of techniques used by expert midwives to preserve the perineum intact.” Women and Birth 32(1):87-97. https://pubmed.ncbi.nlm.nih.gov/29730096/
• Gurol-Urganci, I., Bidwell, P., Sevdalis, N., et al. (2021). “Impact of a quality improvement project to reduce the rate of obstetric sphincter injury: a multicentre study with a stepped-wedge design.” BJOG 128(3): 584-592. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7818460/
• Laine, K., Pirhonen, T., Rolland, R., et al. (2008). “Decreasing the incidence of anal sphincter tears during delivery.” Obstet Gynecol 111:1053-7. https://pubmed.ncbi.nlm.nih.gov/18448735/

Hi everyone. On today’s podcast, we’re going to talk about the evidence on birthing positions and time-tested midwifery practices for preventing tears in childbirth. Welcome to the Evidence Based Birth Podcast. My name is Rebecca Dekker and I’m a nurse with my Ph.D. I’m the founder of Evidence Based Birth. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details.

Hi everyone. And welcome to today’s episode of the Evidence Based Birth Podcast. My name is Dr. Rebecca Dekker, pronouns she, her, and I will be your teacher for today’s episode. Today I’m so excited to bring some evidence based information to you about perineum tears and research on preventing tears with birthing positions and time-tested midwifery practices. Before we get started, I want to let you know that we will mention topics including tears of the vagina, severe tears from the vagina to the rectum, and obstetric violence related to episiotomies and being forced to give on your back.

Also, I have another important announcement for you. This episode is coming out on April 20, 2022. And starting tonight at 8:00 PM Eastern, we have a free public webinar all about failure to progress or failure to wait where we’re going to debunk myths about labor progress and talk about factors that lead to longer or shorter labors. We’re going to have two identical showings of the webinar. The first is tonight and the second is Sunday, April 24th. If you cannot attend live, go ahead and sign up to attend anyways because we’ll send you the link to the replay afterwards. We only have these free public webinars twice a year. So don’t miss your chance to engage with me, the research team at EBB, and the rest of our community.

During this time, we’re also celebrating the fact that the Evidence Based Birth pro membership is on sale at 20% off the regular monthly or annual price. So if you’ve been wanting to try out our continuing education membership, that the proceeds go to support all the work we do at EBB, you can check out the discounted rate by just going to evidencebasedbirth.com/membership and that will be available through Tuesday, April 26. You can also go to evidencebasedbirth.com/webinar to sign up for the free public webinar.

So today’s episode is the fifth in a series we’re doing this year called, Protecting the Perineum. In the first episode, number 206, I talked with you about perineal tears, what are the factors that increase the risk, the health consequences of tears, and why it’s so important to avoid in the episiotomy. In the second episode, 210, I talked about warm compresses and compared the hands-on versus hands-off technique. In the third episode which was episode 216, I talked about the practice of perineal massage during pregnancy. And I revealed how some of the research on that topic is highly flawed and perhaps even fraudulent. That was an interesting episode. In 218, I talked about perineal massage during labor and why it’s not necessary for preventing tears even though it’s used at most hospital births and it’s sometimes done without informed consent.

So today we’re going to wrap up the series by talking about the evidence on birthing positions and other time-tested midwifery practices that have been passed down through the generations. Many midwives see themselves as the guardians and protectors of normal birth. And one of their priorities as caregivers is to help as many clients as possible leave birth with an intact perineum meaning you don’t need stitches, you don’t have any tears. Since this is such a strong aspect to midwifery practice, that’s why I’m going to focus on research from expert midwives. If you haven’t listened to the episodes earlier that I mentioned, I would encourage you to go back and listen, especially to episode 206 because all of these episodes are building on one another. Also, just in case you’re listening to this on a podcast app, I want to let you know there is a video of this episode on our YouTube channel. So if you’re more of a visual learner or you want to see our PowerPoint slides with all the research, I encourage you to visit and subscribe to the EBB YouTube channel.

Also, as I have at the start of each of these episodes, I want to quickly define the perineum for those who did not get a chance to listen to episode 206 and they’re just finding EBB for the first time. The perineum is a diamond-shaped area that’s between your thighs and in birthing people’s area that’s between the symphysis pubis or the front of the pelvis and the rectum at the back. And so when we’re talking about protect the perineum, we’re talking about protecting that tissue and in particular, protecting the tissue that’s the space between the vagina and the rectum.

A perineal tear or a tear of the perineum that can happen during childbirth can be rated as first, second, third or fourth degree. A first degree is the least severe, third and fourth degrees are the most severe. And the most important thing we can do is to prevent or lower the risk of severe tears, the third or fourth-degree tears, sometimes called OASI tears, O-A-S-I, because they can have severe health consequences. So a lot of the time when we’re looking at the research on these practices, we’re looking to see if they’re effective for helping you avoid a severe tear, sometimes called an OASI tear or severe perineal trauma. And for methods that help you avoid in episiotomy. And then we’re also interested in the effectiveness of interventions for helping you have an intact perineum, which means you leave the birth without needing any stitches.

So let’s dive into the evidence on birthing positions. As you’re listening to this, think about what position you would like to be in if you were giving birth to a baby sometime soon. Most movies and television series depict people as giving birth lying on their back or semi-sitting in bed. But many people have given the choice instinctively choose a more upright position for birthing their babies, such as kneeling, squatting, or hands and knees. So upright birthing positions include standing or squatting, often you’re being supported by a partner or a prop, kneeling, using hands and knees. And sometimes people don’t like to refer to that as an upright position, but in most of the research it’s considered upright and using a birth seat such as a birthing stool.

Researchers believe that giving birth in an upright position is beneficial for several reasons. In an upright position, gravity can help bring the baby down and out. Also, if you’re giving birth in an upright position, there’s less risk of compressing your aorta, the large blood vessel that carries oxygenated blood from your heart to the rest of your body which means that when you’re upright, there’s a better oxygen supply to the baby. Upright positioning also helps the uterus contract more strongly and efficiently and helps the baby get in a better position to pass through the pelvis. MRI studies have shown that compared to the back lying position, the measurements of the pelvic outlet become wider in the squatting, kneeling, and hands and knees positions.

Finally, there is a lot of research showing that upright birthing positions increase satisfaction, decreased pain, and lead to more positive birth experiences. When we go to the non-upright positions, general terms that refer to lying on your back or side are called recumbent and semi-recumbent. So lying on your back with your pretty much flat on your back is called supine. If your feet are being held up in the air or are being held by stirrups, then that’s called the lithotomy position. If you are laying on your back, but they’ve raised the head of the bed so that you’re semi-sitting up in bed, that is still not considered an upright position in the research, that’s referred to as semi-recumbent so you’re laying back and you’re sitting up. And then there’s the lateral position which means side-lying.

 Another way to classify birthing positions is whether or not your body weight is on or off the sacrum or the large tailbone at the base of your spine. When a position takes the weight off the sacrum and allows that sacrum to move, the pelvis can expand more easily for spontaneous birth. So I put a star next to the ones that are sacrum flexible. So the standing, squatting, kneeling, hands and knees, using a birth seat, and the lateral or side-lying position are all sacrum flexible. Even though the upright birthing positions and the sacrum flexible positions have been clearly documented as being more beneficial, most people giving birth in the US hospitals are still giving birth lying on their backs or in a semi-sitting lying possession with the head of the bed raised up.

Only a small portion of people in US hospitals give birth in other positions such as side-lying, squatting or sitting or hands and knees. In contrast, my own homebirth midwife told me that most of her clients spontaneously choose the hands and knees position. Other research from home birth settings confirms that when birthing people are free to choose the position of their choice, they do not usually choose to lay on their backs or semi-sitting in bed. In Europe, a study nearly 3,000 people who had planned home births found that the majority, 65% gave birth in either upright or side-lying positions. So if upright positions are so beneficial and the non-upright ones are the opposite, they’re harmful. Why are non-upright positions so common? Well, the truth is around the world, many caregivers, especially obstetricians prefer it when people are lying back or in the lithotomy position or semi-sitting when they’re giving birthing. It’s thought that most people are encouraged to push on their back because it’s more convenient for the care provider and it gives them a better view of what’s going on.

It’s also easier for them to access your abdomen for the electronic fetal monitoring and for other devices and interventions. Also, this is how most care providers around the world specifically obstetricians are trained. While lying in your back is not beneficial for normal vaginal birth, it is the most common way to position Noelle. Noelle is the birthing mannequin that most nursing and medical schools use to simulate birth for medical nursing and sometimes even midwifery students. In fact, if you want Noelle to get into an upright position, sometimes you have to jerry-rig a different way of making the mannequin work in that position.

Also, many people in the US have epidurals for birth which contributes to the higher use of back lying positions. Obstetricians and nurses may believe that upright positions are not possible with an epidural. And if you have a heavy epidural meaning there’s a high dose of medication in it, it can be impossible or very difficult to get yourself into an upright position without trained help. Finally, there are systems pressures and hospitals that limit nurses from truly supporting birthing people. Too few nurses, too much charting duties really limits their ability to provide hands-on support for different birthing positions.

So I want to dive a little bit more into the evidence on birthing positions just to really drive home that point that it’s important that birthing positions, that this be a choice. In 2020, a group of researchers led by Zhang combined 12 randomized control trials with more than 4,300 participants. They excluded any studies where people had epidurals. So this is specifically looking at people who are having unmedicated birth. And the researchers combined the data from all the studies where they were looking at people who were upright during the pushing phase versus recumbent which could include lying back.

This study is interesting because they specifically excluded any researchers that used the lithotomy position which is the stirrups position. And they wrote that lithotomy position has known strong negative effects on birth outcomes including an increased risk of forceps and vacuum, severe perineal trauma, and episiotomy. So they said, in fact, lithotomy is so harmful, we’re not even going to include it in this study. So they were comparing the upright positions, the walking, standing, leaning, birth chairs, semi-sitting, squatting, and kneeling to the recumbent positions which were side-lying, supine laying on your back, and semi-recumbent which is semi-sitting. The studies took place in the United Kingdom, Finland, Brazil, China, Ireland, Turkey, and South Africa. And the publication dates range from 1983 to 2017.

Unfortunately, the risk of bias was unclear in eight studies and high in four studies. So these were not the highest quality randomized control trials. Most of them had problems when they were randomly assigning people. Many of them did not blind to the researchers. So everybody knew who was in which group and a few studies had problems with people dropping out of the study. So we really needed to take all these findings with a grain of salt. When they combined the data, they found the upright positions led to a lower rate of needing forceps or vacuum to get the baby out, no difference in the length of the second stage, a shorter length of the active pushing phase by about eight minutes on average, and a substantial decrease in the risk of severe perineal trauma. There were only two studies that reported the data on severe perineal trauma.

They found that higher risk of second-degree tears was squatting and sitting and they think that was a trade-off because fewer episiotomies were cut in those people so they were more likely to have a natural tear. And they found no difference in blood loss between groups which is a difference from older meta-analysis who did find higher blood loss with upright positions. But we think that those studies might have been really flawed because they were just like visually measuring the blood loss instead of actually measuring it. So in this study they found no difference in blood loss.

As usual, when I look at a meta-analysis, I like to pull out the most important studies from that meta-analysis and just look and see, where is this data coming from? Is it really applicable to today’s environment? And as you see in this table I’m showing on YouTube, both of the studies, all of the studies, actually, that I’m looking at took place in high episiotomy settings which means these data might not translate to low episiotomy settings. In Ireland, they were looking at about 1200 people who gave birth in a birthing chair versus the semi-recumbent or left side-lying position. They found that the chair group had a lower episiotomy rate. However, that was offset by a higher rate of spontaneous tears. So they lowered the episiotomy rate, but it was replaced with a higher rate of spontaneous tears.

In South Africa, de Jong et al. looked at about 500 people and randomly assigned them to squatting versus lying on their back. And they found that those who squatted had a lower episiotomy rate and significantly less pain. And they found that most people who were assigned to squatting were able to birth in that position. 97% were able to squat when they were assigned to squatting and 89% actually gave birth in the squatting position. Those who had to give birth in bed in that study had significantly higher rates of abnormal fetal heart rate tones. And the bed group was also much more likely to rate their birthing pain as severe and extreme. A study by Zhang et al. looked at 11 hospitals in China with nearly 900 participants and they were comparing hands and knees versus lying on your back. The researchers found a significantly lower rate of episiotomy in the hands and knees group. As 1.8% versus 37.7% in the bed group.

There were zero cases of shoulder dystocia where there’s difficulty with the birth of the shoulder and the hands and knees group while there were four cases in the experimental group of lying on your back. There are also zero emergency cesareans in the hands and knees group indicating that the babies probably had pretty good blood flow in that position, whereas there were six emergency cesareans in the lying in the bed group. And finally, a study by Lin et al. in Taiwan, looked at about 168 participants and they were comparing squatting with the device that helps support your ankles versus squatting without that support device versus semi-recumbent laying back in bed. They found that the squatting groups had significantly lower pain scores in both of the squatting groups. So pain was much higher-lying on your back in bed.

Unfortunately in this study, they made everyone lie on backs for the actual delivery. So you were allowed to squat while you were pushing, but then you were forced to line your back for the delivery. And they cut episiotomies on almost everybody in the study and they had extremely high rates of third and fourth-degree tears. Basically, a 100% of people in the study had an episiotomy so they had a severe tear rate of about 19% which is just horribly high. Now, if we’re looking for research evidence on birthing positions with epidurals, is it protective to have a different birthing position other than lying on your back if you have an epidural? Well, there’s several meta-analysis on this topic about epidurals and birthing positions, but most of the data comes from a single randomized control trial on birthing positions conducted by a group in the United Kingdom.

This is the largest study that’s ever been done on this topic by far. And they compared upright versus side-lying positions in more than 3,200 participants who were giving birth for the first time with a low dose epidural. So it’s easier for them to move around than someone with an epidural that has high doses. About 40% of people in this study were being induced. So these were high intervention births with epidurals induction and they had extremely high rates of instrumental delivery. The rate of vacuum and forceps birth was about 51% to 55%, which is just horribly high. I’ve never really heard of rates that high since the 1960s. Their rates of the episiotomy were 55% to 59%. And they had, again, a horribly high rate of severe tears of 10.4% to 13.8%. These numbers are just strangely high and concerning. In the US for example, the overall rate of vacuum and forceps births is only around 3%. And in this study it was like more than half the participants.

Now it’s interesting though because in this study, everybody had a sacrum flexible position. You were either upright or you were lying on your side. So they found that people who were side-lying with an epidural had slightly better spontaneous vaginal birth rates 41%, versus 35% in the upright group. The researchers really didn’t find any differences in any other health outcomes, but we can’t really apply many of these study results to places where we’re not using episiotomies, forceps, and vacuums so frequently. I did want to point out one observational study, because these randomized trials are taking place in settings where there’s just extremely high rates of interventions, sometimes it’s helpful to look at what’s going on in other places. And there is a study by Elvander et al. where they looked at more than a 100,000 birth records in Sweden.

The database includes midwives records of which position the birthing person used during the actual birth. The majority of people in this study were using epidurals and everyone gave birth vaginally to a single baby without an episiotomy. So episiotomies were not being used here. They found that the lowest rates of severe perineal tears occurred among those who gave birth in a standing position and the highest rate of severe tears occurred among those who delivered in the lithotomy position. So unfortunately the research we have on birthing positions has a lot of limitations. Most of the research from the randomized trials comes from high episiotomy settings where you could have episiotomy rates as high as 50% to 100%. Also, participants in these studies, aren’t allowed to choose which upright position they want to use. They’re told you must squat or you must get into hands and knees or you must sit on this birth seat.

And a lot of the benefit from upright birthing positions comes from getting into the position that feels good to you. And I think that’s a key part of most midwives’ model of practice. And unfortunately, even in these research studies, sometimes the participants are made to lie back for the delivery which lessens any benefits and introduces harm by making it extremely likely that you’ll have an episiotomy cut or perhaps even forceps or vacuum. Unfortunately, this is not low limited just to research. Over the past 10 years, as I’ve been researching and writing at Evidence Based Birth, I’ve had the opportunity to travel around North America, speaking and giving presentations at various regional and local events. And as I talk with people in the room, I have heard over and over that many providers in Canada and the US may be willing to support you pushing in an upright position, but when it comes to the actual delivery or birth, they insist that you get on your back either in a semi-sitting position or the lithotomy position or even worse, just lying flat on your back.

The desire for some healthcare workers to have the delivery happen in a controlled manner, being in a non-upright position is so strong that many people have shared with me stories of either being coerced or forcibly placed into non-upright positions during childbirth. And we’re going to be talking with Mandy Ivy soon about this topic and about the lithotomy position and how that is technically a restraint. And especially if it’s being done against your will.

The use of forcing people into the caregivers preferred position has been described as a form of obstetric violence. In a paper published in the Journal of Perinatal & Neonatal Nursing by Pascucci and Adams, they state that, “Obstetric violence is in its simplest form, a form of violence against women that occurs in the childbirth setting. It is an attempt to control someone’s body and decisions and may involve coercion, bullying, threats, and withdrawal of support as well as other violations of informed consent and physical force. Obstetric violence might manifest as forcing someone’s supine because that is the doctor’s preferred position for the birth. Forcing someone into a particular delivery position could be viewed by the courts as negligence or battery”.

So in summary, when we’re talking about birthing positions number one, the lithotomy position, lying on your back or sitting back with your feet in stirrups is considered harmful and unethical so much so that it’s not even being included in research studies anymore. However, there are quite a few randomized control trials that have found benefits to upright positions. And several studies have found a significant can decrease in severe perineal tears with upright positions. Upright positions and sacrum flexible positions have multiple benefits, but I believe they also work by preventing interference because if you’re squatting or if you’re in a birthing stool or you’re around hands and knees, it’s a little bit more difficult for the healthcare worker to mess with you while you’re giving birth. It also makes it more difficult to cut in episiotomy.

However, multiple studies have also found that being upright is less painful and it’s pretty consistent in the research that it’s safer for the baby. You have fewer problems with fetal heart rate issues and fewer cases of cesareans for failure to progress. Okay. So now that we’ve talked about birthing positions which are a cornerstone of most midwives practice styles. I wanted to now move on to other time-tested midwifery practices. And if you think about it, midwives have been attending births for countless generations and they’ve been passing on their wisdom because many midwives share with their clients, the goal of having as many people have intact perineums after the birth as possible. So I’m going to talk about a study that we mentioned in the podcast episodes 210 and 218. And that is a study by Albers et al. published in 2005 where they did a randomized trial at the University of New Mexico.

In this study, they had 12 experienced nurse-midwives whose general episiotomy rate was less than 1%. At this time it was 0.8%. So much lower than what we’re seeing in some hospitals and other parts of the world. They randomly signed about 1200 participants to either have a warm compress on their vagina, massage with lubricant, that’s perineal massage or hands-off care. The researchers found that none of the interventions had superior outcomes to the others. In other words, using a warm compress, using perineal massage, did just as well as keeping your hands off and doing nothing. And 73% of the sample had no need for stitches. That’s an incredibly high intact perineum rate. The severe tear rate was 0.7% to 1.5%. Only 10 episiotomies were cut in the entire study and none of them extended to third or fourth-degree tears. 80% of the participants were sitting upright when they were giving birth, 23% had zero tissue damage at all and if you include some minor unstitched perineal tears, the total was 73%.

 The author suggested that their midwifery culture of favoring a slow, calm, controlled delivery of the head and slow expulsion to the infant, non-Valsalva pushing which means you’re not holding your breath while you push as well as giving birth upright and delivering the baby’s head in between contractions may have helped. They stated, “Delivery of the head between contractions requires communication, synchrony, and shared responsibility for a slow and gentle expulsion of the infant.” The researchers conclude that it’s possible that these three techniques may have benefits that could be seen in other settings, but in setting where clinicians already had such excellent outcomes, it probably is not necessary to do perineal massage.

Another study published by Begley et al. in 2019 was an interview with 21 expert midwives from New Zealand and Ireland. In order to be included as an expert midwife and to be interviewed for this study, you had to have an episiotomy rate of less than 12%, a no suture rate of 40% or greater and a severe perineum tear rate of less than 3.2%. Out of the 21 expert midwives, the average length of time working as a registered midwife was about 17 years with a range from 5 to 36 years. One strategy that they talked about in the interviews was having a calm, controlled birth. This meant that most of the time they sat on their hands, they were observing not doing anything. They also talked about the importance of not having time limits and to encourage their clients to take it nice and slow. And they weren’t trying to rush the process. They also talked about keeping the room calm, using quiet voices, making sure the room is warm enough, having minimal staff in the room, keeping it dark and private. And that this was really important.

They also emphasized the importance of helping their clients feel empowered and reassured. They talked about all of the affirmations they used when the client was birthing. The expert midwives also said birthing position is important that they encouraged their clients often used hands and knees, squatting, moving around, sometimes wiggling their pelvis, dancing, and using a birthing stool or birthing seat. If pain control was needed, they used warm hot compresses for comfort. And these expert midwives were split about 50/50 in terms of whether they use their hands-off or hands-on practice.

One of the things they had in common was the importance of believing in patience. One of them said, “Let her do it at her own pace.” The midwives talked about how the baby’s head might remain on the perineum for four to five contractions. And some midwives might even see that it took up to 10 contractions. They said this gives time for the perineum to stretch. So they kept reinforcing patients, patients patience. Also, the midwives talked about being gentle with the birth of the shoulders, waiting for internal rotation of the shoulders to occur first and not rushing it.

This study was limited by the fact that it’s a small study that took place in two countries. And you could argue that we could look at data from midwives who have even higher intact perineum rates and even lower episiotomy rates. And so that brings me to some data that were sent to me by Mercy In Action which is a midwifery school, our own Chante Perryman program team manager is a midwifery student there. And they also run midwife-led freestanding birth centers in the Philippines. I was fortunate to be emailed by Vicki Penwell, a licensed midwife and certified professional midwife who’s the Founder and Executive Director of Mercy In Action, Vineyard Inc. And they are responsible for more in 16,000 safe births in the Philippines since the 1990s at no cost to the parents with outcomes four times better than the country’s national average.

Vicki Penwell actually was a guest on the EBB podcast. If you want to look for her episode, it’s 122 where we talked about home birth during the pandemic. Vicki has more than 40 years experience accepting clients in labor who are seeking care at the very end of pregnancy. And she’s got more than 29 years experience serving as a disaster based midwife, responding to national disasters. Vicki said to me, hey, Rebecca, she didn’t say that exactly, but she said, “You said you were going to research next on the importance of breathing the baby out and encouraging a slow delivery of the baby’s head.” Vicki goes on to say, “I want to point out, based on our research in our midwife-led birth centers in the Philippines with thousands of cases to look at, that women do not tear more when they give birth spontaneously under their own steam with no verbal instructions or caregiver directed pushing and no caregiver hands on their genitalia at all.”

In these cases, babies can often come out fast and rarely pause at crowning. Our tear rate is low overall and even lower at the point we stopped trying to prevent tears in the classic midwife behaviors, just perineal massage or stretching perineal guarding and verbal directions to slow down and breathe the head out. Vicki says, “I believe it is a totally unnatural way to give birth to have an outside voice telling you when to push or when not to push. Caregiver-directed pushing is actually on the list of harmful practices in the international childbirth initiative approved by ICM and Vygo.” So Vicki connected me with their researcher, a student midwife with her PhD and a research background and that’s Nicole Werner. Nicole’s been working on a data set for Mercy In Action, and they were kind enough to send me some of their results. So they have a database of more than 6,000 births from people who identify as women where caregivers do not verbally or manually try to slow down the birth.

And it’s in a population that’s not necessarily well nourished. A lot of people say, well, the best thing you can do to prevent tears is to eat well. Well, eating well is important, but this goes to show you that these techniques can work even if you haven’t had good nutrition. Their population is a mix of people who are high risk and low risk and that’s why their statistics are so important. They also looked at shoulder dystocia which is really interesting. So they’re measuring the intact perineum and intact in their data set means the perineum is intact and there’s no other need for sutures. They also measure the different type of tears, including severe tears, third or fourth-degree tears and the incidents of shoulder dystocia.

The statistics are broken down in the three types of births that can happen an interventive birth or intervention birth. Their definition of that is any aspect of trying to control the birth such as caregiver directed pushing or hand on the genitalia, holding or guarding, massaging the perineum, pushing down on the pelvic floor or spreading the tissue. Then they also classify some births as having some support, meaning the provider’s hands are guarding, but they’re not moving or entering the vagina or doing any massage or stretching of the tissue. And then most of their data is from the hands-off or undisturbed birth. The clients in their clinics are allowed the position of their choice, although they do discourage flat on the back for reasons of safety for the baby. Most of those giving birth in their birth centers lie on their side or are upright on the birthing stool. All of the births in their birth centers are natural unmedicated births with care led by midwives.

Nutrition is discussed and prenatal vitamins are given if the patient comes in for prenatal care, but a significant portion of their client’s start care or late in pregnancy or arrive in labor having had no prenatal care. Importantly, their definition of a hands-off for undisturbed birth means that there’s no verbal coaching to push or stop pushing unless there’s a complication such as fetal distress. They believe if they’re starting to tell someone to push and they put their gloved hands in the vagina, that means something is wrong and they feel there’s a need to intervene to get the baby out quickly for survival reasons.

I’m going to read Vicki’s own words what she says she sees in these hands-off undisturbed births. Vicki says, “In my experience of watching normal birth carefully without disturbing it in any way, we take vital signs discreetly, otherwise leave them alone to deliver. I observe that babies are all often born quickly once the head is visible. It is normal if undisturbed for the head to deliver at the peak of the contraction and then the rest of the contraction turns the shoulders. Not all babies pause at the head. Many are born all the way with the second part of a pushing contraction. And when the baby does pause, the top shoulder’s often visible. In this way, we rarely see a shoulder dystocia. This is what I have personally witnessed in at least 1,000 births. I also see the head-turning and adjusting as it crowns, which I never saw before when I had my hands on to guard the perineum which means my hands were preventing those small movements of the baby.

As someone who delivered babies the standard way, trying to prevent tears by slowing down the birth of the head for the first half of my career, then switching to allow them to be undisturbed at the moment of birth, this is a revolution to me. I now believe it is a dangerous intervention in normal birth to ask a woman to stop pushing or blow when she gets to crowning or to guard the perineum thereby effectively holding back the baby from emerging too fast. Most dangerous of all maybe to try to deliver the baby’s head between contractions as then the shoulders are not able to do the internal rotation in the same contraction that delivers the head. By choosing to allow a physiological delivery of the head. We have seen that we can significantly reduce shoulder dystocia and reduce tears.” So let’s take a look at the data that Nicole Warner sent us from Mercy In Action. So let’s look at some tables and figures that Nicole sent us with data for more than 6,000 births at their midwifery birth centers.

You can see that 69% had intact perineums. As Vicki said earlier, this means no tearing and no stitches. That’s an incredibly high rate of intact perineum. 29% had first or second-degree tears and 2% had third or fourth-degree tears. When they break it down and look at tear rates by delivery style, you can see that 75% of those who had hands-off care left the delivery intact while 25% had a first or second-degree tear. And there were zero third or fourth-degree tears. Of those who had some support, remember that some guarding of the perineum, the intact rate was 68%. The first and second-degree tear rate was 30%. And the third and fourth-degree tear rate looks like it 4% or lower. And those who had an interventive cell birth, 47% left the birth with an intact perineum, 47% had a first or second-degree tear, and 6% had a third or fourth-degree tear.

Now we know that those giving birth for the first time have a higher risk of sphere tears. They also broke it down by parody. And at overall at all of the births at their birth centers, those giving birth for the first time had a 53% intact rate. 43% had a first or second-degree tear and only 4% had a severe tear. And those outcomes were even better for those people who had a history of a prior vaginal birth, 74% of them had an intact perineum 25% had a first or second-degree tear. And a very small number looks like less than 2%. Maybe around 1% had a third or fourth-degree tear.

It’s also really interesting to look at shoulder dystocia. We’ve talked about shoulder dystocia on this podcast before and how that can also be affected by how the provider handles the second stage, the pushing phase, and the delivery of the baby. With hands-off care, there were almost no cases of shoulder dystocia, and you can see how the rates of shoulder dystopia go up with some support and get as high as 10% with an interventive birth in sending me other resources.

Vicki also sent me some advice she had recently given to a student. One of her midwifery students had said, “With my preceptors, we unfortunately don’t practice in the hands-off way. We routinely guard, coach them to slow down at crowning, and sometimes manually rotate the baby’s head after delivery.” The student said, “In a significant proportion of first-time births, we end up using directed pushing and have our hands in their vaginas if progress is not being made and transport is imminent. I would love the experience of doing this differently like Mercy In Action advocates for. I hope I will have that opportunity in the future. Incidentally, we have a lot of tears that require suturing.”

Vicki wrote back to the student and said that, I should say this methodology is a full package of undisturbed birth. For this method to work to prevent tears that they’re using at Mercy In Action, all the providers and support people have to be fully conscious of what ‘disturbs’ the birthing person’s brain. The necessary elements are quiet. No one’s encouraging you to push, not even the doula or partner. No one’s interrupting your pushing grunts by asking you questions. It takes training and discipline to get to the point where you cannot ask, “do you feel like pushing” when those sounds are heard. In the environment that allows the birthing person to change positions suddenly or even to cry out something like, “I can’t do this” Or “I’m going to die.” And still everyone stays silent. All these things are signs that have left undisturbed the fetal ejection reflects is about to happen and the baby will be out soon. The birth team should gather at the side not right in the birthing person’s line of sight. And for sure not posed at the crotch.

If the client is side-lying, I get them on the side of their back and if they’re upright, I get to the level of her knee where I can see clearly and know immediately if there is blood or a tight cord or any other problem. And I can take fetal heart tones and pulse often, but where I’m inobtrusive. In this position, you learn so much about what true physiological birth looks like. This is what has convinced me that we are artificially causing a very unnatural birth process to happen in the second stage by being well-meaning and trying to prevent tears. Vicki goes on to say, with primiparous, especially that means first time birthing parents, if they start pushing hard and several contractions go by with no head visible, we will ask to check their cervix, but otherwise we make it a point not to check the cervix when they first feel grunty because many people feel a slight urge to push or make grunting sounds eight to nine centimeters.

And we are starting the second stage artificially early if we’re always checking and pushing back the cervical lip. Most people will not spontaneously start pushing until the fetal head reaches the pelvic floor and then it is close to being born. And if undisturbed up to that point, it’s possible for the baby to be born so quickly that there is no discernible second stage. We attribute this to the undisturbed hormones of birth which lead to the possibility of a true fetal ejection. We can’t make it happen, but we know for sure it won’t happen if we are waking you up out of your hormonal brains that you birth in your neocortex and that’s what’s happening when we actively manage second stage. Vicki says, “Thank you for your interest in this, Rebecca. I realize it is so much easier when midwives have a trick or a technique learning to do less and see a full picture is much harder.”

So thank you, Vicki. And thank you, Nicole, for reaching out and sending us all this information about your outcomes and that you’ve been able to have such good outcomes with this type of hands-off approach that includes physiological birth and not disturbing the process. I want to show, in contrast, what’s happening in other parts of the world. So that’s what’s going on with Mercy In Action in the Philippines. In Europe, they’ve had something that’s a little bit different. They are actively working to lower perineal tear rates by doing more intervention. And I’ve heard a lot of talk on social media from people from European countries about something called the OASI bundle. Remember OASI is talking about Obstetric Anal Sphincter Injuries or third or fourth-degree tears. The OASI bundle was inspired by some good outcomes in Finland, where they have a 0.3% to 0.6% OASI tear rate.

And the OASI bundle was developed in Norway. The bundle includes having the providers hands-on to slow the birth of the head using something called the Finnish Grip and doing a different type of episiotomy called mediolateral episiotomy. It also includes educating women about OASI and what can be done to lower their risk, giving them all a pamphlet at the end of pregnancy and using that hands-on their perineum and genitalia, unless the patient objects or the chosen birth position doesn’t allow it. When indicated they recommend that the episiotomy should be cut at a 60° angle or mediolaterally at crowning. So you’re not cutting straight towards the rectum, but more at an angle diagonally. There are no special steps in this bundle to ask providers to lower the cutting of episiotomies. They don’t discourage the episiotomies. They say that episiotomy can still be used for fetal distress along second stage of labor and whenever they think a severe tear is imminent which is of course very subjective.

They also recommend using it with forceps and for some vacuum-assisted births. I mentioned the finish maneuver earlier. That is definitely a very hands-on interventive, involves keeping a hand on the baby’s head while it’s crowning, instructing them not to push while the head delivers because you’re trying to slow down the process. In addition, the provider grips the baby’s chin with a flex middle finger of the other hand, and they tell their patients to move freely and push in the position that’s most comfortable. But during the last few minutes, you’re asked to get into position where the care provider can do the maneuver and observe the perineum.

Finally, after birth everyone should be examined and have their tears documented. So they did a huge study in the United Kingdom testing the before and after of the rollout of this OASI bundle, they looked at more than 55,000 vaginal births. The authors declared success because their OASI rate declined from 3.3% to 3.0%. However, rates of forceps were high at 13.3%, vacuum delivery rates were high at 7.4%, and episiotomy rates remain high as well at one in four people having an episiotomy cut on them. Also because of the high rate of forceps births, a lot of those people had OASI tears as well.

The risk of having an OASI tear with a forceps birth was 7.6% versus 2.2% in someone who gave a birth without forceps or vacuum. So what’s the problem with this bundle? How is it different than say Vicki’s bundle? Well, obviously in the OASI bundle, they’re looking at high intervention births. Many of these people have epidurals and inductions, they’re not free to move around, but I think what’s missing in this bundle is emphasizing the importance of avoiding an episiotomy. Maybe they only have a 3.3% severe tear rate, but also 25% of the people in this study had an episiotomy. That is completely unacceptable.

So they’re not looking at trying to increase intact perineum. They also don’t acknowledge the importance of birthing positions during the actual moment of delivery. Instead, they’re probably getting people to sit back in a way that’s more convenient for the provider and violates the birthing person’s human rights. They don’t emphasize the concept of patients which is probably why they have such higher rates of forceps in vacuum. And they don’t use other time-tested midwifery practice such as reassurance, quiet voices, having a dark room with minimal people. Now it is unclear to me from reading all of this research what are the best practices to use with an epidural? Because the physiologic birth that Vicki was describing might not be possible in someone who’s epiduralized and numb from the waist down.

However, we do know that if you’re in a high episiotomy setting, you’re going to really benefit from a hands-off approach. Or if you can get the care provider to do some other way to sit on their hands and prevent their hands from cutting an episiotomy, perhaps asking them to use a warm compress instead, so they feel like they’re doing something. If you’re a healthcare worker, a student or obstetrician, physician, or midwife, do you review or observe the practices of colleagues with low tear rates? Who trained you? How many episiotomies did they cut? How many people did they have to stitch up after every birth? What were their rates of severe tears?

If you haven’t shadowed or worked with someone who has excellent outcomes like they have at Vicki’s clinics, look for someone who can help train you in this and give you confidence in using a more hands-off method. Also, I think it’s really important for us to think about the importance of communicating about these issues and educating families and nurses and OBs and midwives about these issues. Also, we believe that childbirth education should emphasize evidence-based practices and talk about the facts about tears so we can take it from being something really scary to something we’re like, okay, I can lower my risk. I can do these things.

Also, birthing positions. This should be chosen by you, the birthing person, not you the caregiver who’s listening to this. The lithotomy position is incredibly harmful and stirrups have no place during normal childbirth. It’s super important for healthcare workers to provide a calm, quiet, private environment during pushing and not to direct people’s pushing by yelling at them or shouting at them to hold their breath and counting to 10. In fact, the best results seem to happen with hands-off in non-interventive care when you let the process of the baby’s head being born and shoulders being born happen on its own, especially if someone’s unmedicated.

My final thoughts after spending several months preparing all these episodes and teaching them on the podcast and YouTube. Number one, if you are a practitioner, are you tracking your stats? Do you know your rate of intact perineum, your rate of severe tears or first or second-degree tears? Are you doing what Vicki’s doing where you’re tracking these things? Number two, if you’re a healthcare provider and you are attending births, get mentorship and training from someone who has excellent outcomes. Three, let’s have compassion for people who have tears and let’s destigmatize talking about it. I’ve read that in some countries it’s normal for you to get examined shortly after the birth, both immediately after and a few days afterwards to check how you’re healing down there and if you need pelvic floor support or therapy. And fourth advocacy, if you see things like aggressive perineal massage, forcing people to lie on their back. In the cutting of episiotomies, speak up, talk about how it’s harmful, say something and interrupt these patterns that are abusive to birthing women and people.

That’s it for this series on Protecting the Perineum. I hope you found it helpful. If you enjoyed this episode, make sure you go back and listen to 206, 210, 216, and 218. You can access them on any podcasting app or on YouTube and let your friends know that this series on Protecting the Perineum is available. Also, if you’ve enjoyed learning from this podcast, please go leave us an honest review on whatever podcast app you use. We’ve had some semi-coordinated attacks on a review page from people who are angry with us for fighting racism which sounds really strange and sad. I guess it shouldn’t be surprising to me, but if you’re interested in helping counteract the racist people who don’t like us talking about racism and how it affects maternal mortality, please leave a review about what you’ve found helpful about the Evidence Based Birth Podcast and tell your friends about our podcast. Word of mouth is one of the top ways that people find out EBB.

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