sara wickham
A version of this article originally appeared
in MIDIRS Midwifery Digest.
The topic of perineal care is enormous, and has been a
source of heated debate for centuries. This paper highlights
some of the issues and questions for debate in this area,
although it serves as an overview of 'hot topics' rather
than an in-depth analysis of all of the issues.
The history of perineal care offers an important insight
into current practices and perceptions, and even a brief
exploration of the research in this area highlights how little
we know about the physiology of birth and the quantity
and scale of the questions which need to be answered
before we make any generalisations about
appropriate midwifery practice in this area.
If babies needed hands to guide them out,
wouldn't women be born with an extra pair
attached to their inner thighs?
The evening before the study day at which this paper was
presented, Jane Evans and I discussed the above statement,
and the issue of whether women really needed their midwives
to perform routine manual perineal manoeuvres and Jane
suggested that the labia acted as a 'guiding' mechanism for
the baby. How confined are we by the ideas that we have
been taught, and by the concepts of 'care' and 'practice'
- which both seem to imply action on the part of the midwife?
The term 'perineal care' itself implies action and one may be
more immediately drawn to thoughts of manual or other
interventions rather than issues of maternal positioning,
rapport or enabling relaxation through verbal or non-verbal
means. Should we be trying to 'sit back and watch' more of
the time, or do we somehow feel obliged to manually
participate in the birth of the baby - and for what reasons?
Historical Issues
A quick reading of almost any midwifery or obstetric textbook
will reveal the current trends in perineal care and -
throughout history - an almost limitless supply of ways
to manually handle the perineum, anus, vulva and presenting part.
Thankfully, we have moved away from Playfair's (1884, p 341)
reporting of the suggestion that we should assist the woman
to relax by inserting, “one or two fingers of the left hand …
into the rectum” and using them to 'hook up' and pull the perineum
forward over the baby's head. (I have yet to meet a woman
who would find this relaxing, especially during the second stage
of labour.) Yet myriad other practices remain, and, as
Renfrew (1998, p 143) notes, the area of perineal care is
characterised by, “strong opinions and sparse data.”
Floud (1994) presents a comprehensive overview of the history
of perineal care and found that, in the past, manual interference
in normal labour was 'deplored' by professional birth attendants,
who considered their role to be one of patiently watching and waiting.
As many midwives know, the perineum only became visible after
Louis XIV persuaded his partner onto her back so that he could
watch the birth of their baby and Floud shows that many of the
manoeuvres which have been described over the last few decades
are simply not possible if women adopt upright positions during
the second stage. These findings make the question of what we
do with our hands at the point of birth secondary to the fact that,
if more women were enabled to adopt the upright positions which
are known to facilitate physiological birth, we would more often
than not find ourselves unable to do anything with our hands
other than hold them ready to 'catch'.
During Birth: Research and Other Evidence
Despite this, the HOOP trial (McCandlish et al 1998) was still
carried out in order to evaluate the practices of midwives having
their 'hands on' or 'hands poised'. While the results showed that
three per cent more women experienced 'some pain in the previous
24 hours' in the 'hands poised' than the 'hands on' group, there
were no differences in the 'mild', 'moderate' or 'severe' pain ratings,
perhaps reflecting the difficulties that emerge when trying to
quantify something as individual and intangible as pain.
The women in the 'hands poised' group were also slightly more likely
to have their placenta manually removed although, as this outcome
is the result of a clinical decision - which may differ according to
practitioner - it is not as effective an outcome measure as something
which is not generally open to individual interpretation
(such as the gender of a baby).
It should be acknowledged that it is far easier to find sources of
potential bias in a research trial than it is to set up a trial which is
beyond criticism, and the HOOP trial has been a valuable addition to
the knowledge base in this area in a number of ways, not least of which
is the discussion and debate it has generated. Discussion with some of
the midwives who participated in this trial revealed that they had
reflected on their experiences and were generating more knowledge
through their experiences; it is my hope that some of them will publish
their thoughts in order to continue and expand this debate.
Research is only one of the forms of evidence available to women and
midwives. Indeed, other forms of evidence may better serve to
answer questions which are outside the boundaries of research.
Hartley (1999) explored the knowledge held in this area by
experienced midwives; most of the midwives she talked to stressed
the fact that there are no 'absolute rules' to be followed in this
area of practice. They stressed that the needs and desires of the woman
and the positions she chose for the second stage were a priority,
and the rapport between women and midwife was considered of
paramount importance. One midwife discussed the concept of
'masterly inactivity', although a number of 'tricks of the trade'
were discussed as options for times when the midwife felt that
some kind of 'activity' was warranted. One of the major implications
of this paper concerns the usefulness of reflection on practice in
developing our knowledge base and learning from our own experience
and that of others.
One of the key issues in current research in this area is
consideration of the cultural norms and context in which midwifery
practice and maternity care is based. A systematic review of the
practice of 'non-suturing' is being carried out, on the basis that
the authors suggest that:
“some midwives have begun to restrict their
use of suturing … despite the fact that there is
no reliable evidence about risks and benefits of
non-suturing compared to suturing ... The change
in practice may affect the health of large numbers
of women.” (McCandlish et al 2000)
Only in a culture where technology and intervention are seen as the
norm is there a need to prove that it is safe (or not a potential cause
of relative ill health) to omit the intervention which has become the norm.
This is true even (and this is commonly the case) when the intervention
was originally brought into practice with no real evidence of its value.
In a culture that is reliant on technology and intervention, the
burden of proof remains on those who still believe that women's
bodies are capable of developing, nurturing, birthing and healing
without routine assistance. We need to recognise that research studies
are based in the cultural norms of our society and that the philosophical
focus of these can tell us a lot about the 'way women birth' and what
is valued in that society.
Perineal Care Before Birth
I learned early on in my experience as a midwife in the USA
that there were some fundamental differences between midwifery
there and midwifery in the UK. One of the most apparent of
these concerned the issue of perineal massage during pregnancy.
In the UK, I had never met a midwife who did any more than offer
women a 'handout' on this, sometimes apologetically, perhaps explaining
that it may or may not work, but it was the women's 'informed choice'
to consider as an option. In the US (at least in the states where I
worked), I rarely met a midwife who did not spend at least
twenty minutes discussing this during an antenatal visit,
sometimes adding detailed diagrams or an actual demonstration.
Clearly, a significant difference in approach.
Subsequent discussions with the midwives who were recommending
this revealed that, while some were aware that the evidence on
whether this practice made a difference to the state of the
perineum at and following the birth was mixed (Labreque 1999, 2000),
they had other reasons for suggesting it as an addition to 'pregnancy
lifestyle'. Some felt that it helped women 'get in touch' with
their bodies, and learn about the sensations they might feel
during the birth. Others feel that it causes women, many of
who work into late pregnancy, to slow down and 'connect'
with their baby. While it is absolutely important to make sure
this is an informed choice, and may be truly beneficial for a
particular woman, perhaps we should take care not to assume
that there has to be a 'physical' justification for a particular
practice, or that this takes precedence over other needs.
There seems to be more of a move towards evaluating the practice
of antenatal perineal massage over the last few years, despite
the inherent difficulties of carrying out such research.
There are three main issues with such studies:
1. Is the research studying physiological birth or
birth which is being 'managed'? While it is acknowledged
that the majority of women may not experience physiological
birth in this country, this does not change the fact that
carrying out research in a context of 'management'
renders the research less than useful on a more general
basis. So many variables may enter the equation that
the findings can ultimately be meaningless.
2. With a technique such as perineal massage, the
immediate question concerns how we quantify that
technique, in order to ensure that everybody is doing
the same thing and that variation between women is not
affecting the research. Yet how can everybody 'do the
same thing' when no two women's hands, fingers, perinea
or external genitalia are the same shape and size?
It would seem to me that the amount of individual
variation would be enough to introduce the possibility
of bias into such a study and render it less than
helpful from the outset.
3. Even if the above issues could be dealt with,
I would be surprised if the best-designed study came
up with an absolute 'answer' that highlighted something
(eg perineal massage) as being good for all women 'on a
routine basis'. Research and inquiry carried out in the
last ten years has increasingly shown that no intervention
is beneficial on a routine basis; all have their uses, but
application to the population of childbearing women as
a whole is ultimately more detrimental than beneficial.
For this reason, among many others, it is imperative that
we begin to move away from a system (of either thought
or care) which looks for absolute or 'umbrella' answers.
We might instead look toward capturing and reflecting
upon women's knowledge and midwives' experience as
relatively untapped sources of information.
Postnatal Perineal Care
A quick 'straw poll' amongst midwives, student midwives and midwife
teachers revealed the following list of practices which they had
- either now or in the past - suggested to women as ways of
relieving pain and promoting postnatal perineal healing:
these are shown in the table below.
Lavender / camomile baths
Arnica tablets or oils
Ice packs / sanitary towels (sometimes suggested with oils or herbs added)
Exposing to the air / air drying / drying the perineum with a hairdryer
Salt baths
Massaging the perineum with oil
Herbal baths
Comfrey or calendula (herbal) salve
Rubber rings
Vulval toilet
A brief analysis of this list shows that the suggestions fall into
five main categories; adding heat, adding cold, keeping the
perineum wet, keeping the perineum dry, and adding substances.
I can't think of a lot else that one could do with the perineum,
so the list probably reflects all of the potential options,
regardless of efficacy! Some of the suggestions (e.g. drying
with a hairdryer, sitting on a rubber ring) are known -
particularly by those who suggested them as historical additions
to the list - as being potentially more harmful than beneficial.
Others have yet to be evaluated on a large scale, although,
as before, I have little doubt that midwives possess the knowledge
and experience needed to do this; it is simply a case of bringing
this evidence together in appropriate and meaningful ways.
Lewis (1995) conducted a study whose implications may be useful
for all midwives to consider in relation to their own practice.
She helped midwives to audit their 'perineal management' using
diaries kept by women. Not only did the episiotomy rate fall
from 17.5% to 11% and the rate of not-suturing rise from 20%
to 80%, but midwives were able to reflect upon their practice
in relation to the woman's experience, something which midwives
working in systems without continuity of partnership are not often
given the opportunity to do. (Over the past few years I have
heard several cases of units which audited and 'displayed' the
episiotomy rates of individual midwives, often with great success
in reducing these rates.) One of the major findings of Lewis'
research were that women wanted to be more realistically informed
about postnatal perineal healing; some had little idea of what to expect.
The women in this study stated that they liked keeping the diaries
which they were asked to write in for the research - perhaps this
was being used as a form of journalling, or postnatal debriefing?
We all know that women love - and need - to talk through their
birth experiences, and Lewis has found an effective way of
auditing practice in a way which may also be helpful to women
in relation to their mothering journey. One women emphasised
the importance of the perineum by saying:
“I appreciate the attention you are giving the
subject. Typically, those areas which are exclusively
female are not attended by 'the system'. I am aware
that the perineum and surrounding area is crucially
important to most women's sense of well-being and
sense of self. I had no idea before this experience
(of birth) how every movement - sitting up, getting
into bed etc. is felt in this central point.”
(Lewis 1995, p5)
Perineal 'Pampering'?
Finally, in the same way that others have challenged the terminology
we use as midwives, I would like to return to the question of how
we are using the term 'perineal care', and whether this implies
midwifery 'management' of the perineum as opposed to the woman
being empowered to decide for herself how she wishes to care for
her perineum, perhaps in the same way that she chooses how to care
for her hair, or skin. We all have different preferences as to the
type of soap, shampoo and creams we like to use, and which best
suit our skin type - why should the perineum be any different?!
With this in mind, we need to beware of implying that we need to
'care for', 'guard' or 'protect' this part of the body (which is then
presumably not capable of 'caring for' or 'protecting' itself).
Used improperly, the term may imply both a need for action
rather than passivity and that this action should be taken by
the midwife, rather than the birthing woman.
This is in contrast to experiential suggestions by midwives that
the 'ring of fire' felt by the woman as the baby crowns is a
physiological mechanism which instinctively causes the woman to
ease the baby out, thereby reducing the possibility of perineal
damage and enabling her to feel in control of her baby's birth.
Although some midwives have suggested to me that the sensation of
burning causes some women to want to push harder, I wonder if the
environment of birth, the attitude of the midwife or the hormones
which are in play at the time (i.e. whether adrenaline is dominant
rather than endorphins) can mitigate this? If we adopt a philosophy
of 'watching and waiting' which enables the woman to follow her
instincts, would the term 'attending the perineum' be more appropriate?
This terminology would not rule out the occasional need to use
midwifery skills for the woman who, for whatever reason, appears
more likely to sustain a tear without assistance.
Perhaps the concept of 'perineal pampering' is not so far removed
from the emphasis we need to place upon the woman having access
to the range of possibilities which exist in this area before, during
and after birth, and deciding which might be the most appropriate for her.
As midwives, we may need to spend more time reflecting upon our
own practice and discussing with colleagues the real experiences
of the women we are with, in order not just to expand our knowledge
base in this area but to focus on what works for different women
at this time. Certainly as far as the postnatal period is concerned,
in the same way that we do all like different things in our bath, we
might find that there are lots of 'answers' which apply to different
kinds of women, in relation to their own needs, their bodies and
the kind of birth they experience.
Without doubt, this debate will continue, and midwives will find
answers which suit their own practice and the women they are with.
While the body of literature on the subject is vast, and offers many
perspectives, the time may have come to explore more of the
experiential knowledge on this topic as well as utilising evidence
from quantitative research. While we have spent years debating
the relative merits of different substances, options and practices,
we may have reached a stage where we no longer seek an 'absolute'
answer which will fit every woman, but begin to explore how we can
help women, as individuals, to find answers and options which work for them.
Acknowledgements
Thanks to Jane Evans for her wisdom in reflecting on
practice issues, to Lorna Davies for being eternally willing
to debate the language of birth and midwifery,
to Helen Eatherton and Sharon McDonald for commenting
on earlier drafts of this article, to my colleagues who gave
their time to share their practice and recall perinal care
in their early days as midwives and to those midwives
attending the MIDIRS study day who offered their
own reflection and experience on this topic.
References
Floud, E (1994)
Protecting the perineum in childbirth 1: A retrospective view.
British Journal of Midwifery, vol 2, No 6, pp 258-63.
Hartley J (1999)
Save the Perineum!
The Practising Midwife, January 1999, Vol 2, No 1, pp 14-15.
Labreque M, Eason E and Marcoux S (1999)
Randomized controlled trial of prevention of perineal
trauma by perineal massage during pregnancy.
American Journal of Obstetrics and Gynecology,
March 1999, part 1, Volume 18o, No 3, pp593-600.
Labreque M, Eason E and Marcoux S (2000)
Randomized trial of perineal massage during pregnancy;
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American Journal of Obstetrics and Gynecology,
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Lewis L (1995)
“Are you sitting comfortably?”
Midwifery Matters, Autumn 1995, Issue 66, pp 3-5.
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