Midwifery Perineal Protection
PERINEAL PROTECTION 10
Humanshavea gestational periodof about40 weeks,anditis thegreatestdesireof bothof themidwivesandthemotherthat babycomeout to theworldsafelywith as littletraumataas possible(Pairman, 2010).Thisworkseeksto inspecthowmidwivescan promotea normalchildbirth.Wealsolookat midwifepracticethat can protecttheperineum during delivery.Based on researchmostof theriskfactorsforperineal tearingare normallyout of controlof themidwife,andto a greatextent,eventhemother.Thesefactorsinclude,
Firstvaginal birthAbigbabyEthnicity(Asian andCaucasian)YoungerandoldermaternalageandHighweightgainduring pregnancySocioeconomicstatus(Albers, 2013).
Perinealmassage fortheperiodof thebirthof theheadhas beenidentifiedas a factorthat can considerably diminishthechancesofperineal tearing.Thispracticehas beenknownto be veryinvasive,anditis onlyeffectivein thirdandfourth degreetearing(Gabriel, 2011). Itis of greatsignificancethatthemidwifefindstimeto discusswith thewomanbefore commencing.Awomanshould not suddenlyfindthefingersof themidwivesin her perineum during deliverywithout priorconsent.Perineal managementin thelatephaseofsecondlabor,beforetheexpulsionof thebabyis necessary in order to easethinningandstretchingof theperineum(Spiby & Munro, 2010). Thisprocesssubstantiallyminimizesthechancesof spontaneoustearof theperineum.
Theclinical measuresbelowandinterventionare essentialin theprocessof protectingperineum andreduceperineal injury.Midwivescan adoptthefollowingintrapartum clinical measuresto protecttheperineum:
Amidwifeshould conducta systematicreviewof researchonvariablequality,comparingpositionsin thesecondstageof laborin referencetoperinealmorbidity. Themidwifeshould weighwhethertheuprightpositionorthesupine positionis theaptestto protecttheperineum. Thispositionhas noknowneffecton therateof thirdandfourth-degreetears(Queensland Maternity andNeonatal Clinical Guidelines Program, 2012). Nevertheless,ithas beenfoundto reduceseverepainduring delivery.
Increase the rate of second-degree tear and
Lowers the rate of episiotomies and assisted vaginal deliveries
Use of birth chairs and stools against supine positions this has been found to reduce the rate of episiotomies but increases the rate of second-degree tear
More recent study show that the need for perineal suturing is linked to semi-recumbent positions and less in the left lateral hand hand-knees positions (Greve, 2009).
Ithas beenshownthata longerperiodof pushing is relatedto increasedperineal pain.In thisregard,midwivesare encouragedto askdeliveringmothersto startactivepushing in reactionto their ownurges, whenfetal andmaternalwell-beingis evident.On theotherhandslowingthebirthof thefetal headat thetimeof crowning has theeffectof reducingperineal tear.Thiscan be achievedby usingmaternaleffortbetween contractionsandwhenattemptingfetal headdeliveryanddiscouragingactivepushing during thistime(Queensland Maternity andNeonatal Clinical Guidelines Program, 2012).
Bothtechniquesincorporatetheuseof counterpressure to thefetal headto preventrapidheadexpulsion.Ithas beenfoundthathands-on andhands-poisedwith ordevoidof modificationreducetheoverall riskof perineal tearandtrauma.Hands-on techniquehas beenund to reducebenignperinealpain,tendaysafter birththoughnosignificanteffecthas beenfoundformoderateandseverepainlevels (MidwifeThinking,2010).Hands-poised techniquesresultto fewerepisiotomies. Whendonein waterbirthitsignificantly minimizestactilestimulation time(Queensland Maternity andNeonatal Clinical Guidelines Program, 2012).Itis ofthe essenceto notethatthere is noevidencethat supportsthefactthatspecificpushingtechniqueorpositionshavetheeffectof protectingperineum during activepushing. Assuchwomenshould adoptcomfortablepositionsandshould be guidedto by their ownurge andnot whatthemidwifethinksis appropriate(Albers, 2013).
High-levelevidenceaccountshowsnosubstantialvariationbetween thehands-onandhandspoisedtechniquein loweringthechancesof perineal tear.Finallyto preventrapidheadexpulsionat thetimeof crowningmidwivesshould advicedeliveringmothersto minimizeactivepushing andusecounterpressureto thefetal head.
Wheresurgicalincisionof theperineum is necessary,itshould be conductedwithcareto enlargethevaginalopeningfordelivery(Queensland Maternity andNeonatal Clinical Guidelines Program, 2012). Itis importantto conductepisiotomy becausetheoverall tearwould be reducedby substitutionof a controlledincisionfora jaggedtearin theperineum. In thisway,episiotomyservesto protectthemuscleof thepelvic floor.Nonetheless,whileepisiotomy has beenfoundtoshorten the second phase of labors significantlyforreasonsof fetal andmaternaldistress,there is noavailabledata to supportanyshort-termorlong-term healthbefit conferredby routineepisiotomy. Itis importantthata midwifeprovidesbothintrapartum andantenatal counseling to women,particularlythoseat riskof perineal tear.Whereepisiotomy is necessary,themidwifeshould providereassurance, emotionalsupport,andadequateinformationbefore conductingrepairprocedures(Albers, 2013).
Thisis thefrequentlyusedtechniqueto repaira tornperineum. Butof mostimportanceis thefactthata midwifeshould geta woman’sconsentbefore proceedingwith therepair.Studieshaveshownthatin seconddegreetear,suturing has not beenfoundto be superiorto othermethods,in relationto healing andrecovery,In thisrespectanduntil there is furtherevidenceof superiorresults,clinicians decisionto sutureshould bebasedon woman’spreferenceandtheir clinical judgment(Albers, 2013).Awomanshould beinformedof theabsenceof long-term resultsandpossiblechanceof slowerhealing process,butprobablybettergeneralfeelingof wellbeing ifleftunsutured.
PolicyRecommendation to Guidefor Midwifery Practice Decisions
1.Theprimary motivation for any decision regarding the care activityshould be geared towards meeting woman’ s and babies health needand to enhance health results (Pairman,2010).Decision about activities should be made in a careful and plannedmanner and:
By a midwife, based on an exhaustive evaluation of the woman and newborn needs.
In partnership with the delivering woman and in collaboration with other members of the multidisciplinary health care team.
After establishing the likely hazards and risks related to the care activity, and strategies to avoid them
Only in situations when it is justifiable, evidence-based reason to execute the activity (Spiby & Munro, 2010).
2.Midwives should be accountable for making professional pronouncementabout when an activity is past their own capability and capacity, orbeyond the scope of their practice and for commencing consultationwith or referral to, other professionals in the healthcare team(Pairman,2010).In this regard judgment should be made in a collaborative manner,through negotiation and consultation with the delivering woman andother staff in the health care team. The pronouncement should be madein consideration of:
Which discipline should offer competence and education evaluation for the activity.
The context of practice and service employer and provider protocols and policies.
Compliance with professional, guidelines, standards and policies.
Whether there is organization support encompassing appropriate skill mix and staffing levels for the practice (Spiby & Munro, 2010).
Midwiveswho wish to integrate activities that are not currently part of theaccepted contemporary scope of midwifery practices into theirpractice should ensure that:
They possess all necessary authorizations, organizational support and certification.
Possess requisite education preparation and experience to achieve such a feat.
Are confident of their capability to carry out the activity safely.
Their competence has been evaluated by a qualified and competent healthcare professional (in this case a more experienced midwife) (Spiby & Munro, 2010).
3.Midwives should be accountable for making decisions relating to whois the apt person to carry out a given activity that is in themidwifery plan of care. Judgment about midwifery practice should bemade by the midwives in collaboration with the delivering woman tomake sure that the appropriate person (midwife) is in the aptposition to offer the appropriate service for the woman and theinfant at the right time (Pairman,2010).Such pronouncements should be made on, supported and justified by,consideration of if:
There is organization need for certification and authority to carry out the activity.
There is professional or legislative prerequisite for the activity to be conducted by a particular health care worker or category of healthcare professionals.
The degree of knowledge, skills, education and assessed competence of the healthcare professional who shall carry out the activity that has been delegated by midwife in accordance with midwifery care plan, has been ascertained by a midwife to see to it that the activity shall be conducted safely (Pairman, 2010).
The midwife is confident and competent of their capability to carry out the activity safely or is prepared to accept delegation, and totally understands that echelon of accountability in performing the activity.
The apt level of clinically- centered supervision can be offered by a midwife for a person performing an activity that has been delegated to them by the midwife.
The midwife has evaluated the delivering woman’s and infant’s needs and established by a fastidious category of health care workers (Spiby & Munro, 2010).
4. Midwifery practice decisions are best made in a collaborativecontext of risk management, planning, and evaluation (Pairman,2010).All healthcare professional including midwives should share a jointresponsibility to build and sustain:
Infrastructure that ropes and encourages autonomous and co-dependent practice, accountability and continuous assessment of results of care and practice decisions.
Environment that supports evidence based practice, safe decisions to the full realm of midwifery practice.
Processes for offering continuous skill development, education and apt clinically centered supervision (Spiby & Munro, 2010).
Inreality there is very little that can be done by a mid wife toprotect the perineums of women during birth. Even so, midwives canuse different techniques to prevent perineal tearing. Maternalposition, pushing techniques and Hands-on andhandspoised techniquesare just but a few way through which midwives can help women givingbirth avoid perineal injury. At the end of the day women in thedelivery room should be informed that perineal tearing is a normalpart of the birth process and that when it occurs the body can healitself.
Albers,L. (2013). Reducing Genital Tract Trauma at Birth: Launching aClinical Trial in Midwifery. Journalof Midwifery & Women`s Health.200348(2) Retrieved from:http://www.medscape.com/viewarticle/452758_5
Gabriel,C. (2011). Naturalhospital birth: The best of both worlds.Boston, Mass: Harvard Common Press.
Greve,T.(2009). Disturbing“New” Trends in Tear Prevention Threaten Midwives’ Autonomy.MidwiferyToday( 92),Winter 2009/2010.Retrieved from:http://www.midwiferytoday.com/articles/tear_prevention.aspMidwifeThinking(2010). PerinealProtectors?Retrieved from:http://midwifethinking.com/2010/08/07/perineal-protectors/
Pairman,S. (2010). Midwifery:Preparation for practice.Chatswood, N.S.W: Elsevier Australia.
Spiby,H.and Munro, J. (2010). EvidenceBased Midwifery.Wiley-Blackwell Pub. Oxford: United Kingdom.
QueenslandMaternity and Neonatal Clinical GuidelinesProgram . (2012). PerinealCare. Queensland Government.Retrieved from: www.health.qld.gov.au/qcg