1. Peggy Seehafer, midwife & anthropologist M.A.
Results With the change from the 19th to the 20th century the stages of labour were downscaled from five to three accompanied by a loss of explanation of women’s needs and behavior while giving birth. Earlier times textbooks from the beginning of the 19th century untill 1900 describe five stages of labour and make a split both in the first and second stage of labour compared with three times system afterwards. Each stage is characterized by different but specific body positions. The women’s knowledge is based on ethnic-culturalbackground and social status and oral lore much more by familiy members than by professionals (6). The split-up in the second stage of labour allows a nuanced reflection and new interpretations of recommendations of different obstetric instructions or interventions. The arguments for the upright positions are, there is less risk of compressing the mother’s aorta and thus a better oxygen supply to the baby. Upright positioning also helps the uterus contract more strongly and efficiently and helps the baby get in a better position to pass through the pelvis. Finally, the actual dimensions of the pelvic outlet become wider in the squatting and kneeling/hands-knees positions (5). Researchers hypothesize that pushing in an upright position, gravity can assist in bringing the baby down but out (?). A wider pelvic outlet in the squatting and kneeling/hands-knees positions seems perfect for the heads transition, but not for passing the gate. Pushing against previously tightly stretched and ischaemic pelvic floor muscles leads to bigger perineal injuries, evidenced by the higher rate in sphincter injuries whilst squatting. New observational studies from Denmark and Norway show better results in perineal outcome while practising active perineal care (3). Different positions chosen by the woman which allows a good practice of perineal protection are: sideways positions, all-fours position, leaning back at a birth seat,kneeling, sitting on a birth bed etc-
As long as we describe the second stage of labour as only one phase, we will produce misunderstandings. Using the older classification of the stages of labour does not result in the current mismatch between the upright body position and the active perineal protection. This leads to a range of opportunities in women's care and a more precise scientific discussion about the correlation between perineal techniques and birth positions.
MISSING LINK: Perineal techniques and the upright position in the second stage of labour
Peggy Seehafer, midwife & anthropologist M.A.
In 1824 the head is crowning while the biggest diameter of the head is standing in the cervix. Now in the US references does it mean the occiput is rolling over the perineum.
”Perineal protection is a combination of palpation
findings and visual assessment” (Schultze, 1900)
If the head really would be crowning at this time, there is a risk for prolongation of the last stage of active labour and the head cames out with bigger diameter and higher risk for perineal injuries. In references the ’crowning head’ is described as the right time for pushing – the duration of pushing & the fetal and maternal outcome depend on the meaning of crowning.
”Perineal protection under skirts
and blankets is futile” (Schultze, 1900)
Introduction:
Lots of vaginal births are associated with some form of trauma to the genital tract. To avoid perineal injuries by different birth positions and perineal techniques is an everlasting discussion. Upright position in the second stage of labour seems to be a handicap for perineal protection. There is no evidence about correlation between hands on or hands off and perineal injuries. But some new Scandinavian studies show better perineal outcomes with active perineal protection, which makes it necessary having a view about the perineum. A new review from 2015 comparing spontaneuos pushing versus Valsalva found no differences in perineal outcomes, but maternal satisfaction. Today a lot of different processes are pooled in the second stage of labour, the (long) period from the superior cephalic position until the head is rolling over the perineum. The absent of smaller differentiation does not allow a structured discussion and description about the differences in women’s needs and midwifery interventions.
Materials/Methods:
Research in historical documents and midwifery/obstetric textbooks from the last 200 years till actual studies about perineal care. Comparing and discussing identical and different recommendations of perineal care with due regard to birth positions. Mostly German obstetric text books from 1800 till 2014 with explicit descriptions for perineal protection are used.
Results:
With the change from the 19th to the 20th century the stages of labour were downscaled from five to three accompanied by a loss of explanation of women’s needs and behavior while giving birth. Earlier times textbooks from the beginning of the 19th century untill 1900 describe five stages of labour and make a split both in the first and second stage of labour compared with three times system afterwards. Each stage is characterized by different but specific body positions. The women’s knowledge is based on ethnic-cultural background and social status and oral lore much more by familiy members than by professionals.
Second stage
Transition – 3rd time
The split-up in the second stage of labour allows a nuanced reflection and new interpretations of recommendations of different obstetric instructions or interventions.
The arguments for the upright positions are, there is less risk of compressing the mother’s aorta and thus a better oxygen supply to the baby. Upright positioning also helps the uterus contract more strongly and efficiently and helps the baby get in a better position to pass through the pelvis. Finally, the actual dimensions of the pelvic outlet become wider in the squatting and kneeling/hands-knees positions. Researchers hypothesize that pushing in an upright position, gravity can assist in bringing the baby down. But out?
A wider pelvic outlet in the squatting and kneeling/hands-knees positions seems perfect for the heads transition, but not for passing the gate. Pushing against previously tightly stretched and ischaemic pelvic floor muscles leads to bigger perineal injuries, evidenced by the higher rate in sphincter injuries whilst squatting. New observational studies from Denmark and Norway show better results in perineal outcome while practising active perineal care. Different positions chosen by the woman which allows a good practice of perineal protection are: sideways positions, all-fours position, leaning back at a birth seat, kneeling, sitting on a birth bed etc.
As long as we describe the second stage of labour as only one phase, we will produce misunderstandings. Using the older classification of the stages of labour does not result in the current mismatch between the upright body position and the active perineal protection. This leads to a range of opportunities in women's care and a more precise scientific discussion about the correlation between perineal techniques and birth positions.
Second stage
Perineal Protection - 4th time
Conclusion
A come back to a more detailed classification will allow a better understanding and more precise discussions about body positions and forms of perineal care. Women can move in upright position till the head become visible in the vulva. When the head starts rolling over the perineum every woman will find a comfortable position for herself, which allow the midwife the perineal protection with an overview over the perineum. Which kind of pelvic protection will be the best in the end, will be part of future research. Finally perineal protection is an intervention, which needs woman‘s informed consent. The one and only goal ist : Primum Non Nocere - most of all do not harm References at the author