EBB 210 – Evidence on Warm Compresses and Hands-on vs. Hands-off for Protecting the Perineum

Listen to EBB 206 here.

Magoga et al. (2019). Warm perineal compresses during the second stage of labor for reducing perineal trauma: A meta-analysis. Eur J Obstet Gynecol Reprod Biol. 240: 93-98.

Aasheim et al. (2017). Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database of Sys Rev Issue 12. Art. No.: CD006672.

Dahlen, et al. (2007). Perineal outcomes and maternal comfort related to the application of perineal warm packs in the second stage of labor: A randomized controlled trial. Birth, 34(4), 282–290.

Huang et al. (2020). The effects of hands on and hands off/poised techniques on maternal outcomes: A systematic review and meta-analysis. Midwifery 87:102712

Pierce-Williams et al. (2019): Hands-on versus hands-off techniques for the prevention of perineal trauma during vaginal delivery: A systematic review and meta-analysis of randomized controlled trials. J Matern-Fetal Neonatal Med.

Mizrachiet al. (2017). Does midwife experience affect the rate of severe perineal tears? Birth, 44(2), 161–166.

Naidu et al. (2017). Reducing obstetric anal sphincter injuries using perineal support: our preliminary experience. Int Urogynecol J 28(3):381-389.

Rebecca Dekker:

Hi, everyone. On today’s Evidence Based Birth® Podcast, we’re going to talk about the evidence on warm compresses, the hands-on technique, and the hands-off technique for preventing perineal tears during childbirth.

Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Dekker, and I’m a nurse with my PhD and 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 perineal tears and some new research on three different methods that are sometimes used to prevent perineal tears. We’re going to talk about warm compresses, provider hands-on and provider hands-off, and whether the evidence shows they’re effective or not for preventing tears. Before we get started, I wanted to let you know that we will be talking about some topics, including tears, severe tears from the vagina to the rectum, and episiotomies.

So today’s episode is the second in a series we’re doing this year called protecting the perineum. In the first episode, which was episode 206, I talked with you about what are perineal tears? How often do they happen? What are the health consequences of tearing during childbirth? And why it’s so important to avoid an episiotomy? If you haven’t listened to that episode already, I’d encourage you to go back and listen to that first before moving forward, because each episode is going to build on the next. In this episode and in future episodes we’ll cover the evidence on ways to prevent perineal tears in birth.

You might be listening to this episode on our podcast, but I also wanted to let you know that there is a video of this episode on our YouTube channel, so if you’re more of a visual learner, I encourage you to visit and subscribe and watch our podcast on our YouTube channel instead. And with that, let’s get started. So first off, what is the perineum? Well, I’ve got a model pelvis here with a model perineum and the perineum is a diamond-shaped area that’s between the thighs and in birthing people it’s going to be the area that is between the symphysis pubis in the front and the rectum in the back.

So when we’re talking about protecting the perineum, we’re talking about protecting the tissue in that diamond-shaped area, and in particular protecting the tissue that is the space between the vagina and the rectum. As I already mentioned in episode 206, perineal tears or tears 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 and a fourth-degree would be the most severe. Most important thing for birthing people and providers to do is to lower the risk of severe tears, which are third or fourth-degree tears. They’re sometimes called OASI tears because those can have severe health consequences. In episode 206, I talked about the different factors that can decrease or increase your risk of having a third or fourth-degree tear, and why it’s so important to avoid an episiotomy.

Now, in this episode, we’re going to talk about three methods that are somewhat popular and used with the intent of decreasing perineal tears. We’re going to talk about whether or not they’re effective and that is warm compresses, hands-on with the provider, or the provider keeping their hands off. So let’s talk about warm compresses first. A warm compress is simply a wet, warm washcloth. And when people in research studies are assigned to warm compresses during childbirth, usually they immerse the compress in warm tap water, and then it’s held against the perineum during and in between pushes in the second stage of labor. Warm compresses are usually started when the baby’s head begins to descend or swell the perineum, or when there’s active fetal descent during the second stage of labor.

In 2019, a research team led by Magoga et al, published a meta-analysis about warm compresses. A meta-analysis is when they take multiple randomized control trials and combine them into one analysis. So in this particular meta-analysis, there were more than 2,100 participants from a total of seven randomized control trials, where they were comparing warm compresses to no warm compresses during birth. And people in the intervention group were assigned to warm compresses, just like I described before, where it was held against the perineum while the baby’s head was descending the perineum. And the researchers found that with the warm compresses, there was an increased rate of intact perineum.

When I say intact perineum, usually what researchers mean by that is that you were able to walk away from the birth with no stitches. So the rate of intact perineum was 22.4% with warm compresses and 15.4% in those without warm compresses. The most important findings though had to do with the severe tears and the risk of episiotomy. The researchers found that when all of these studies were combined, there was a significantly decreased risk of third and fourth-degree tears, so the warm compress group had a severe tear rate of 1.9%, and the group that did not have warm compresses had a severe tear rate of 5.8%. So it’s a pretty significant decline.

If you go back and listen to episode 206, we talk about the risk of severe tearing, and just to give you some context, in some of the worst rates would be closer to 7% and some of the best studies have found rates of less than 1% of a severe tear. So by getting it down to 1.9%, that’s pretty good. And then the risk of episiotomy, which is an incision using scissors of the perineum, that also went down from 17.1% in the no compress group to 10.4% in the group that had the warm compress. There was another meta-analysis published as a Cochrane review by Asheim et al. This one was slightly smaller, only had about 1,800 participants from four randomized control trials, and they also looked at warm compresses and they compared it to either hands-off where the provider is not touching you at all, or no use of warm compress.

And they found that warm compresses held against the perineum during the second stage reduced the rate of severe tears by half, and it did not influence the use of episiotomy or the rate of intact perineum. But again, this was a smaller one, so I would say the Magoga one that I mentioned earlier had a larger sample size. Other researchers who published info before Asheim and before Magoga have noted that warm compresses in the second stage not only reduce severe tears, but can also have other benefits. So one study that was published by Dolan et al in 2007 was looking at maternal comfort related to using warm, wet washcloths in the second stage of labor.

This was a randomized control trial where people who were giving birth in Australia, so they were giving birth for the first time, they hadn’t had babies before, they were randomly assigned to either having a warm compress in the second stage or what they called “standard care.” Standard care was anything that did not include warm compresses. Their protocol was to fill a sterile metal jug with boiled tap water that ranged between 45 and 59 degrees Celsius, and they used that to soak a sterile perineal pad which they then rang out of water before placing it gently on the perineum during contractions. The temperature range of the perineal pad over about a 15 minute period ranged from 38 to 44 degrees Celsius, which is about 100.4 degrees Fahrenheit to about 111 degrees Fahrenheit.

The healthcare workers would re-soak the pad as needed to maintain warmth in between contractions, and they would replace the water in the jug every 15 minutes, so they were paying really close attention to the temperature of the water that was used in the warm compress. This study had about 360 people in the warm compress group and 357 people in the standard care group. When the researchers looked at the data, they found that warm compresses lowered the risk of third and fourth-degree tear from 8.7% in the standard care group, which is pretty high and not very good, to 4.2% in the warm compress group. But they also found some interesting findings related to comfort of the birthing person.

They found that people who had warm compresses used during labor were less likely to have urinary incontinence after the birth, 9.7% in the warm compress group versus 22.4% in the group that did not have warm compresses. And the warm compress group had less pain during birth and postpartum. So they found that it helped decrease pain during the birth, decrease pain postpartum, and helped prevent some urinary incontinence. Episiotomy rates were about 11% in both groups and did not differ between the groups. So what does this evidence mean for birth workers, healthcare workers, and birthing people? Well, the research we have on warm compresses seems to be encouraging. It does seem to significantly reduce the risk of severe tears.

There’s some mixed evidence on whether or not they prevent episiotomy and increase intact perineum, but one study found a much lower risk of urinary incontinence and lower pain during birth and postpartum. Therefore, because of these findings, the use of warm compresses should be routinely offered to birthing people for their comfort since there is no risk and only the potential for benefit for lowering severe tears. One study by Healy et al said that there is, “high-quality evidence suggests that compresses immersed in warm tap water increase the incidence of intact perineum. This low-cost, highly effective intervention could easily be implemented in all birth settings.”

In the United States, ACOG, the American Congress of Obstetricians and Gynecologists recommends, “Because application of warm perineal compresses during pushing reduces the incidence of third and fourth-degree lacerations, OB-GYNs and other obstetric care providers can apply warm compresses to the perineum during pushing to reduce the risk of perineal trauma.” And they state that the evidence for warm compresses during birth is level A evidence based on good and consistent scientific evidence. Warm compresses are also recommended by many other international obstetric guidelines where they cite a high quality of evidence including in England, Austria, Spain, Australia, Canada, Denmark, and Saudi Arabia.

So warm compresses seem to be beneficial, although if you stay tuned, we will talk in a few months about time-tested midwifery practices with preventing severe tears and you’ll find that there are some providers who don’t need warm compresses in order to have great outcomes with their clients. But you’ll have to wait a couple of months till we get to talking about midwifery practices for you to learn more about that. Okay. So the evidence on warm compresses seems pretty clear. Now we’re going to move to something that’s a little bit more confusing and the evidence is a little more mixed, and that’s the evidence on hands-on versus hands-off. So the traditional obstetric management of the perineum during the second stage of labor by OB-GYNs includes something that’s called a hands-on technique.

Hands-on technique is also sometimes referred to as guarding, where the provider uses their hands to support the perineum and/or the fetal head while you’re pushing your baby out. However, there has been some research published. We’ll talk about the effectiveness of hands-off care. Hands-off care is also called hands poised where the hands are close by, but not being physically touching unless there’s a necessary reason for it. So hands-off is when the attendant is not touching the fetal head or the perineum at all, or they only apply very slight pressure on the fetal head to avoid a super rapid birth of the baby’s head. So you don’t want to have a rapid expulsion of the baby’s head because that can also increase the risk of severe tears.

So the first randomized study looking at the effective hands-on versus hands-off was published in 1998 and they compared hands-on versus hands-off, found no difference between the two technique, and ever since then there’s been a trend among midwives to use hands-off or hands poised rather than hands-on and guarding. And you’ll see that the midwives can use different methods depending on how they’re trained. But in general, OB-GYNs tend to have hands-on during the birth. Midwives tend to have hands-off, although that’s not a strict rule and in general that’s what you see in practice. So now we have a lot of research on this and the research is a little confusing so bear with me as I dig down into the details.

The first study I want to talk with you about is a meta-analysis that was published by Huang et al in 2020. In this study, they combined nine randomized control trials with more than 7,000 participants and eight non-randomized control trials with nearly 38,000 participants. These studies came from all over the world, but mostly in China. So 12 of them came from China, one in the United Kingdom, two from Iran, one in Australia, and one in Norway. Most of the studies were published in the 20teens, between 2013 and 2018, and these authors were able to include studies that were published both in English and in Chinese. When they combined all the results from the randomized trials, they found that there was no difference in the rate of second, third, or fourth-degree tears between hands-on and hands-off. They also found no difference in the length of the pushing phase, how long it took you to push your baby out.

They did find though some benefits related to hands-off. They found that hands-off care was linked to fewer episiotomies, which we mentioned last time we talked about this. Avoiding episiotomies is very important. Hands-off was also linked with a higher rate of intact perineum and less pain in the perineum, but there was a trade-off. There were some more first-degree or the least severe kind of tears in the hands-off group. The results from this meta-analysis agreed with earlier meta-analyses and studies that have also found that hands-off, hands poised, lowers the risk of having an episiotomy and does not increase the risk of severe tears. When they looked only at the non-randomized control trials, the results were similar except that they also found an additional benefit to hands-off, and that was fewer second-degree tears. There are a couple of quotes I want to share with you from this study.

One of the quotes was, “Hands-off poised technique requires the midwife’s close attention to watch the perineum. This means midwives should recognize the signs of rapid expulsion and take measures to slow down the expulsion in time. For the less experienced midwife, hands-off poised technique can be a hard task, therefore more training programs and theoretical education is needed to qualify practicing midwives.” They also mentioned that because the studies had very different methods they suggest that further evidence is needed to confirm these findings. They also have a suggestion as to why hands-off was beneficial. So they said, “Why is it that our hands-off technique seemed to be protective against perineal trauma?”

They said, “Several explanations for this finding are possible. Firstly, hands-off poised technique allows the gradual extension of the perineum by not exerting manual pressure on it, which may help to distribute the perineal tension over a larger area, thereby preparing the perineal tissue to accommodate the fetus at crowning. Secondly, the absence of additional pressure on the perineum could prevent perineal ischemia. Side note, ischemia means low oxygen. It has been reported that perineal ischemia may make the perineum more vulnerable to severe perineal tears.” So they basically concluded that hands-off is more protective and is safe to use. Another meta-analysis was published the year before by Pierce-Williams in 2019.

They had a smaller meta-analysis with five randomized control trials and they found no difference between hands-on or hands-off in the rate of severe perineal tears, intact perineum, first, second or fourth-degree tears. But they did find that hands-on was linked to more third-degree tears, 2.6% versus 0.7%. And hands-on was linked with more episiotomies. 13.6% versus 9.8% than hands-off. They said in their study, “Given no benefit and potential harm associated with the hands-on technique, we suggest caution in its use.” I wanted to share a couple of observational studies with you about the effects of training providers on perineal support techniques. There was one study looking back in time in the United Kingdom at a hospital and its labor and delivery staff. This study was published by Naidu et al in 2017.

And in this study, they trained all of their labor and delivery staff in the hands-on technique to support the perineum and they looked at the results before and after the training of the providers. The training consisted of theoretical lectures on the diagnosis of severe tears, the technique of perineal support, the appropriate technique to perform an episiotomy when it’s necessary, and practical hands-on training in perineal support on a model. After that, they supervised hands-on training on people who are giving birth and were in the second stage of labor. The technique that they train their providers on consisted of placing the provider’s non-dominant hand on the advancing head to slow down the delivery of the head during the last part of the second stage at crowning.

At the same time, the dominant hand was used to support the perineum using the thumb and index finger to squeeze lateral parts of the perineum towards the midline and the folded middle finger was used to press against the perineal body to reduce pressure on it. This support was continued during the birth of the head and the shoulders. During the delivery of the head, they train the providers to instruct the birthing person to stop pushing and allow the delivery to progress by uterine contractions with a view of achieving a slow, controlled delivery of the head. And then the perineal support was maintained during the delivery of the shoulders. Over a three-and-a-half-year time span at this hospital in the United Kingdom, more than 11,000 people gave birth, and before they did the training, the rate of third and fourth-degree tears was 0.9%. After the training, it went down to 0.3%.

So, overall this hospital was having very good outcomes, even though they were using the hands-on training that other researchers have found not to be helpful. And this just goes to show you that it’s always important to look at what were the rates of perineal tears. And there are some providers who are very, very skilled in lowering the risk of severe tears. We’re going to talk more about that in a couple of episodes when we get to time-tested midwifery techniques. There was another interesting study published in 2017 by Mizrachi et al. They were looking at more than 15,000 births attended by midwives, and all the midwives in the study used a hands-on technique. They found that the more experienced the midwife was, the lower the rate of severe perineal tears, and each additional year of experience was associated with a corresponding decrease in the risk of their clients having severe perineal tears.

This is consistent with the other study I just talked about showing that experience in hands-on care can improve outcomes. So what does this all mean? It’s a little confusing, because I just told you earlier that hands-off seemed to be better, but these two observational studies found pretty good outcomes with hands-on. So I think that this practice is still controversial and whether or not we should use hands-on or hands-off is still being debated. It’s true that randomized control trials have found that hands-off can lead to lower episiotomy rates and may also lead to higher rates of intact perineum and less pain in the perineum during birth and postpartum. Hands-on has been associated with higher rates of episiotomy and higher rates of severe tears. Overall, hands-on versus hands-off is still being debated, but I think the evidence is leaning more towards hands-off being more protected.

And it seems like hands-on should only be used by experienced providers in a low episiotomy setting where they are also getting other training in how to lower the risk of severe tears. As a side note, we talk about this in our signature article on water birth, but the hands-off delivery method is frequently recommended in clinical practice guidelines for water birth. So if you’re going to plan on having a water birth, you’re most likely going to have the hands-off kind of care. So in this episode, I summarize the research evidence on warm compresses and the debate over hands-on versus hands-off. Next time we come back to this topic in March when we continue this series, we’ll cover the research on perineal massage, which is not just the provider holding their hands-on the perineum, but the provider also doing a massage during the birth of the baby.

Also there is massage during the prenatal period, and we’re going to find out whether that’s effective or not in March. After that in April, we’ll move on to those time-tested methods from midwives who’ve been passing down their ways of preventing tears for countless generations. I hope you found today’s information helpful. I know that the concept or the thought of tearing during childbirth can be really scary for birthing and pregnant families, but I think it’s important to educate ourselves about this topic. Instead of closing your eyes and just not thinking about it, knowing that there are ways to lower the risk of severe tears can be very empowering for both families and healthcare workers and birth workers.

If you really want to dig into this topic right away and you don’t want to wait, you are welcome to check out our Evidence Based Birth® Professional Membership, where we have an in-depth class about this topic, and we also cover protecting the perineum in the Evidence Based Birth® Childbirth Class, so you can find a class near you by going to evidencebasedbirth.com/childbirthclass. I’d love to hear your thoughts and comments. If you follow us on Instagram, make sure you go to our post about the research on this topic from today’s episode and join the conversation about what are healthcare workers using in clinical practice near you, hands-on versus hands-off. I’m really curious what you see used more often, and if you see good outcomes with either method.

All right, everyone, thanks again and I’ll see you next week. Bye.

This podcast episode was brought to you by the book, Babies Are Not Pizzas: They’re Born, Not Delivered. Babies Are Not Pizzas is a memoir that tells the story of how I navigated a broken healthcare system and uncovered how I could still receive evidence based care. In this book, you’ll learn about the history of childbirth and midwifery, the evidence on a variety of birth topics, and how we can prevent preventable trauma in childbirth. Babies Are Not Pizzas is available on Amazon as a Kindle, paperback, hardcover, and Audible book. Get your copy today and make sure to email me after you read it to let me know your thoughts.