The culture and context of minimising perineal injury during physiological birth: an ethnographic study

Injury to the tissues of the perineum during childbirth is a frequent occurrence with most women likely to experience a degree of perineal injury when giving birth for the first time, with this leading to significant consequences in some cases. There is no international agreement on how, or whether, midwives should use their hands to facilitate a physiological birth to reduce perineal injury. 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. The technique used by midwives is a contentious issue with speculation that adoption of the 'hands poised' approach has led to an increase in severe perineal injury. The use of the terms 'hands on' and 'hands poised' (often used interchangeably with the term 'hands off') to label midwifery techniques is problematic. The terms are not used consistently in the literature and are frequently undefined. This thesis addressed the research question: which strategies do midwives use to reduce perineal injury during physiological birth and what factors affect their decision making? An ethnographic study was undertaken in a large maternity unit in the southeast of England with data collected through participant-observation in the obstetric-led delivery suite and co-located midwifery-led birth centre. During the study it became apparent that the concept of minimising perineal injury during birth was troublesome for midwives for several reasons. The data was subsequently considered within the context of threshold concept theory. Three main themes were identified from the data: 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 'hands on/hands off/hands poised' debate. A novel model is presented that illustrates the intersection between the elements of evidence-based clinical decision making and the types of troublesomeness that make this a complicated process for midwives to successfully navigate. A unique and detailed inventory of the practices used by midwives to minimise perineal injury has been developed, which demonstrates how 'hands on' techniques are more complex than the current definition implies. 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 that recognises minimising perineal injury during birth as a midwifery threshold concept.