{"id":7866,"date":"2018-03-16T14:46:54","date_gmt":"2018-03-16T13:46:54","guid":{"rendered":"https:\/\/mojababica.si\/midwifery-interventions-during-the-second-stage-of-labor-in-relation-to-second-degree-perineal-injuries\/"},"modified":"2018-03-16T14:46:54","modified_gmt":"2018-03-16T13:46:54","slug":"midwifery-interventions-during-the-second-stage-of-labor-in-relation-to-second-degree-perineal-injuries","status":"publish","type":"post","link":"https:\/\/mojababica.si\/en\/midwifery-interventions-during-the-second-stage-of-labor-in-relation-to-second-degree-perineal-injuries\/","title":{"rendered":"Midwifery Interventions During the Second Stage of Labor in Relation to Second-Degree Perineal Injuries"},"content":{"rendered":"

Many first-time mothers experience some form of perineal trauma. Second-degree tears can have long-term consequences for women and are a risk factor for occult perineal injuries. <\/p>\n

Practice and several studies show that multi-step midwifery intervention is effective in reducing second-degree tears in first-time mothers. Here are some examples during the second stage of labor. <\/p>\n

MIMA Model<\/strong><\/p>\n

The MIMA model of multilayered midwifery intervention during the second stage of labor is based on the theoretical framework of woman-centered midwifery care and consists of three components (Edqvist et al., 2016):<\/p>\n

    \n
  1. Spontaneous pushing:<\/strong><\/em> the woman feels a strong urge to push and follows this urge, but does not exert excessive abdominal pressure. The midwife helps the woman as needed to achieve a controlled and slow birth by encouraging appropriate breathing, making it easier for the mother to resist the urge to push excessively during the final contractions. <\/li>\n
  2. Flexible pelvic ring positions:<\/strong><\/em> birth positions with flexibility in the pelvic joints, which widen the pelvic outlet (kneeling, standing, on all fours, lateral position, and birth on a birth stool\/birthing chair).<\/li>\n
  3. Use of the two-step principle of head-to-body birthing technique (two-step principle of head-to-body birthing technique)<\/em>, when possible. With this technique, the head is born at the end of a contraction or between contractions, and the shoulders are born with the next contractions. <\/li>\n<\/ol>\n

    The MIMA multilayered midwifery intervention helps reduce the rate of second-degree tears in first-time mothers without increasing the incidence of episiotomy. The intervention can also be implemented in larger healthcare facilities and centers where midwives provide care to women with low- and high-risk pregnancies (Edqvist et al., 2016). <\/p>\n

    Finnish Intervention<\/strong><\/p>\n

    The MIMA care model and the Finnish intervention are multilayered interventions based on the same premise: slow expulsion of the baby’s head will protect the mother from tearing. However, the Finnish intervention differs from the MIMA model in that it focuses on the use of specific hands-on perineal support and recommends episiotomy when indicated. One concern regarding the Finnish intervention is the increased number of episiotomies in maternity units where this intervention has been implemented (Edqvist et al., 2016). <\/p>\n

    The procedure called the “Finnish intervention” is a care bundle introduced in Norway. It consists of four elements (Poulsen, Madsen, Skriver-M\u00f8ller, Overgaard, 2015): <\/p>\n

      \n
    1. Good communication between the midwife\/doctor and the mother<\/li>\n
    2. “Finnish maneuver”: the speed of crowning is controlled by applying pressure to the occiput with one hand. At the same time, the thumb and index finger of the other hand are used to support the perineum, while the bent middle finger provides a grip on the baby’s chin. Once a good grip is achieved, the mother is asked to stop pushing and to breathe rapidly, while the midwife slowly helps the baby’s head through the vaginal introitus. When most of the head is out, the perineum is pushed under the baby’s chin. <\/li>\n
    3. Use of a birth position that allows visual inspection of the perineum in the final minutes of birth.<\/li>\n
    4. Mediolateral episiotomy when indicated.<\/li>\n<\/ol>\n

      In Norway, 48% of maternity units use the Finnish intervention. However, this intervention remains controversial and its use is heavily debated. Proponents of hands-on perineal support techniques generally claim that pressure on the perineum protects delicate tissue, and that pressure on the baby’s head before crowning ensures the smallest diameter, thereby reducing the risk of tears (Poulsen, Madsen, Skriver-M\u00f8ller, Overgaard, 2015). <\/p>\n

      Critics of this intervention argue that the fetal head naturally travels through the birth canal in a way that ensures the smallest diameter at crowning. According to critics, pressure against the fetal head could disrupt the natural orientation and direct the head toward the delicate perineum, thereby increasing the risk of tears. Other criticisms of the Finnish intervention are directed at the use of episiotomy for indications such as a “rigid perineum” and imminent perineal tearing, and they also see the limitation of birth positions to only those that allow visual inspection of the perineum as problematic (e.g., lateral position, read RV4 here<\/a><\/strong>). <\/p>\n

      A series of seven observational studies from Nordic countries found a reduced incidence of perineal injuries after the introduction of the Finnish intervention for all vaginal births compared to periods when the Finnish intervention was not routinely used. However, the level of evidence from these studies is low, and the physiological mechanisms underlying the Finnish intervention are not well documented. Implementation of the Finnish intervention in clinical settings cannot be recommended until a broader range of maternal and perinatal effects is further evaluated in randomized controlled trials (Poulsen, Madsen, Skriver-M\u00f8ller, Overgaard, 2015). <\/p>\n

      Other Hands-On Perineal Support Techniques<\/strong><\/p>\n

      In Norway, more than 90% of maternity units recommend the use of hands-on support techniques (Poulsen, Madsen, Skriver-M\u00f8ller, Overgaard, 2015):<\/p>\n

        \n
      1. Head flexion technique:<\/strong><\/em> DeWees described the technique in 1889. In head flexion, the midwife\/doctor presses with the hand on the occiput of the fetal head in the direction toward the perineum <\/li>\n
      2. Ritgen’s maneuver<\/strong><\/em>: Described by Ritgen in “Williams Obstetrics,” 1st edition, 1903. The birth attendant applies upward pressure on the perineum with one hand while extending the head upward with the other hand. Both techniques, although completely opposite, are used with the aim of reducing the diameter of the emerging head and preventing birth injuries to the mother. Although the techniques have been used for more than a century, the question remains whether they actually help preserve the perineum, as there is very little research on this topic. After studying the normal birth mechanism, it becomes clear that the fetus automatically positions itself in the most suitable position to pass through the birth canal. As the head passes through the birth canal, it is gentle extension that allows the head to be born with the smallest diameter. The head flexion technique thus does not reduce the diameter of the emerging head and may create additional pressure on the perineum. The force with which the birth attendant acts on the head probably only slows the birth of the head, which affects the slow stretching of the perineum and consequently fewer injuries. This explains why this technique has so many advocates among midwives. Extending the fetal head using Ritgen’s maneuver causes the head to be born with a larger circumference. Both techniques can thus increase the likelihood of birth injuries. <\/li>\n
      3. Modified Ritgen’s maneuver:<\/strong><\/em> described in “Williams Obstetrics” 15th edition, from 1976, is identical to Ritgen’s maneuver, except that it is performed during a contraction. <\/li>\n<\/ol>\n

        Studies show that multilayered midwifery intervention helps reduce the rate of second-degree tears, but we must not overlook the experience and knowledge of the midwife or doctor performing the intervention, as well as the concerns about using some of the techniques I mentioned above. The midwife and obstetrician must adapt to the woman and decide for each woman individually whether it would be better to use a hands-off technique or to support the perineum with one of the techniques mentioned above. <\/p>\n

        SOURCES:<\/p>\n

        Source1<\/a>, Source2<\/a><\/p>\n

        Photo<\/a><\/p>\n

        READ ALSO:<\/p>\n

        Tehnike in postopki, ki pripomorejo k ohranitvi presredka<\/a><\/p><\/blockquote>\n