“There does not seem to be a clear theoretical definition of what ‘hands-off’ practice means, although it is a term whose meaning might seem fairly obvious to most people. In relation to midwifery, it appears to be used in at least two ways. Firstly, it describes a general attitude; a low-tech and individualised approach where the practitioner does not manually intervene unless there is both a genuine need to do so and genuine consent has been obtained from the woman. This contrasts with the approach taken where systems of care and individual practitioners adopt routine practices or interventions which are then applied to all women on a population basis, rather than according to individual need or choice.
Secondly, the term ‘hands-off’ is used specifically in relation to a number of different aspects of midwifery practice, including;
- An approach to facilitating breech birth which involves careful watching, waiting and manual intervention only as appropriate[i], rather than the medical approach to “delivering” the breech baby through a series of relatively standardised manual interventions while the woman lies in a lithotomy or semi-recumbent position.
- An approach to attending women in labour such as that described in Lesley Dixon’s research[ii], which recognises that vaginal examinations can be both traumatic and problematic for women[iii] and involves undertaking these only when truly indicated, rather than at regular and / or pre-defined, intervals.
- An approach to attending the birth of a baby where the midwife will not automatically place her hands in a particular series of positions on the baby’s head (and possibly the woman’s perineum) and attempt to assist flexion and guide the birth in a relatively standardised way, but instead may either hold her hands ‘poised’ (as described by Rona McCandlish and colleagues[iv]) and use them only if she perceives a particular need to do so, or will adapt her practice depending on the situation.
- An approach where the midwife helps the mother to learn to breastfeed her baby without using her own hands to position and latch the baby on his mother’s breast[v], thus enhancing the woman’s self-confidence in her ability to do this when the midwife is not able to be physically there to help her.” (Wickham 2009: 22)
But when is appropriate? How do we know when to put our hands on or keep them off? How do we learn and teach skills such as vaginal examination or supporting physiological breech birth where we are either trying to minimise these or when we see the relevant situation only occasionally? And what about adapting our practice to the needs of individual women?
The article I’ve uploaded today, Hands off midwifery and the art of balance, is a 2009 article published in the very first issue of Maggie Banks’ Birthspirit Midwifery Journal. It offers some ideas about these issues, but by no means would I say that it includes the answers. This debate is going to run and run and, as ever, I welcome your thoughts…
[i] Cronk M (2005) Hands off that breech! AIMS Journal 17(1):3-4
[ii] Dixon, L (2005) Building a picture of labour: how midwives use vaginal examination during labour. New Zealand College of Midwives Journal 33: 24-28)
[iii] Stewart M (2005) ‘I’m just going to wash you down’: sanitizing the vaginal examination Journal of Advanced Nursing 51(6): 587-94.
[iv] McCandlish R, Bowler U, van Asten H et al (1998). A randomised controlled trial of care of the perineum during the second stage of normal labour. British Journal of Obstetrics and Gynaecology 105: 1262-1272
[v] Fletcher D, Harris H. (2000) The implementation of the HOT program at the Royal Women’s Hospital. Breastfeeding Review. 8(1):19–23.
Wickham S (2009) Hands-off and the art of balance. Birthspirit Midwifery Journal 1: 22-24