Protecting the perineum at birth: an ethnographic study (version 1)
Research type
Research Study
Full title
The culture and context of perineal protection during physiological birth: an ethnographic study
IRAS ID
103293
Contact name
Lindsay Jane Gillman
Contact email
Sponsor organisation
Faculty of Health Social Care and Education
Duration of Study in the UK
1 years, 1 months, 1 days
Research summary
Research Summary:
Why is the study necessary? There is no consensus on the best way to prevent damage to the birth canal during childbirth, and the latest NICE guidelines (2014) state that either the ‘hands on’ (supporting the perineum and flexing the head of the baby during birth) or ‘hands poised’ (facilitating a slow and controlled birth without touching) method may be used. However it is not known which factors influence midwives clinical decision-making in deciding which approach to use. Experiential or tacit knowledge, that informs a midwife's practice is not easily articulated or shared. By exploring this aspect, best practice may be identified leading to improved outcomes for women.What is being studied? The context, culture and knowledge that affects midwives decisions to use the ‘hands on’ or ‘hands poised’ technique. This will be through non-clinical and clinical observation of care provision during labour and birth, and interviews with midwives who have participated in the woman's birth.
Who is eligible? All midwives working within the maternity service at the study site would be eligible to take part. Women who have reached full term (37 to 40 weeks of pregnancy), are over 18, able to give valid informed consent and are expected to have a physiological birth would be invited to participate.
Where? The ethnographic study will take place in the maternity service of a large NHS hospital over 12 months. Participant-observation will take place in the birthing areas, with the researcher observing clinical and non-clinical activity.
How? Non-clinical activity will be observed for a month prior to approaching midwives and women to consent to the observation of clinical activities. Field notes and an observation schedule will be used to record observations. Following observation of a clinical episode of care, the midwife will be invited to participate in an interview.
Summary of Results:
Injury to the muscles and tissues of the birth canal (perineum) during childbirth is a frequent occurrence with most women likely to experience some degree of injury when giving birth for the first time. There is no international agreement on how, or whether, midwives should use their hands to facilitate a birth to reduce damage to the birth canal. English national clinical guidelines suggest using one of two techniques: 'hands on' i.e. guarding the perineum and flexing the baby's head, or 'hands poised' i.e. with hands off the perineum and baby's head but in readiness.This ethnographic study addressed the research question: which strategies do midwives use to reduce perineal injury during physiological birth and what factors affect their decision making?
Data was collected through participant-observation, ethnographic and semi-structured interviews. Three main themes that influence midwives' decision-making were identified: Troublesome language, Troublesome knowledge, and Troublesome environments. The findings from the study contribute to the current body of knowledge by providing further evidence to the ongoing ‘hands on/hands off/hands poised’ debate.
A new model was subsequently developed that shows how the elements of evidence-based clinical decision making and the types of troublesomeness make decision-making a complicated process for midwives.
A unique and detailed inventory of the practices used by midwives to minimise perineal injury was also developed, showing how ‘hands on’ techniques are more complex than the current definition suggests.Recommendations include the adoption of a set of standardised definitions for the terms ‘hands on’, ‘hands off’ and ‘hands poised’, a structured reporting system when a ‘hands on’ technique has been used and an educational approach informing midwifery curriculum design that recognises minimising perineal injury during birth as a midwifery threshold concept.
REC name
Wales REC 4
REC reference
15/WA/0275
Date of REC Opinion
25 Nov 2015
REC opinion
Further Information Favourable Opinion