Hands-off midwifery and the art of balance

Hands-off midwifery and the art of balance is an article that was published in 2009 (Wickham 2009). Now more than a decade on, we have reposted it here. Please be aware that new evidence is emerging all the time and some of what is in here may have been superseded by the time you read it.

A real challenge

Nita has been a community-based midwife for over twenty years, and has more recently moved into independent practice. She is well-versed in what has become known as ‘hands-off’ practice, is expert at knowing how women are progressing in labour by watching, listening and feeling their baby abdominally and only occasionally suggests vaginal examination [VE]. She always seems to know instinctively when a baby needs a little help to be born, yet feels no need to keep her hands on the baby or perineum at all times. Her outcomes are excellent, and women and student midwives love her.

Kiera is one of those students. She described her placement with Nita as “welcome relief” from some of her experiences in more medicalised areas of practice. Yet while Kiera’s heart is with the kind of approach she sees Nita use, the practical reality of how she can reach that place herself is a different matter:

“You work with some midwives who do everything, they do VEs every four hours and have their hands doing all these things when the baby comes, and then you go out with the ones like Nita who are different … and they hardly ever do those things, and you think, well that’s great, and that’s what I want to do … but how do I learn when to do it and not? … and how do I get the practice when I don’t want to subject women to more VEs than necessary? … I’m really conscious of that…”

Introduction

A wide variety of philosophical positions and practical trends have characterised approaches to health and birth throughout history. Early European medicine, for example, was characterised by the theory of ‘humors’, which healers attempted to rebalance with the use of cathartics, purgatives and bleeding. Later, Western medicine was revolutionised by the work of people like Semmelweis and Lister, whose work on germ theory and antisepsis helped prevent the transmission of disease and, from this point, the principles of Western medicine both expanded and gained a firm footing as the dominant approach to healing in the industrialised world through the development of bacteriology, vaccination, pharmacology and surgical techniques. Although a large number of other approaches to conceptualising, diagnosing and treating health and disease still exist, the principles behind Western medicine have continued to gain momentum and, as midwives know only too well, have more recently been applied to the care of women in childbirth as well as in the care of sick people.

The application of the principles of Western medicine during pregnancy and childbirth has not, of course, been universally popular. Nor has this been universally successful. The past few decades have been characterised both by increased medicalisation of pregnancy and birth and by the various responses to this from those who do not consider it appropriate, including the natural birth and midwifery movements. Perhaps inevitably, the exact nature and form of these movements varies geographically. New Zealand has a unique story of midwifery autonomy, while slightly differing political and practice stories have played out in Australia, the US, Canada, the UK and other countries. The trend towards the kind of hands-off approach practised by midwives like Nita, however, can now be found in midwifery practice in all of these countries – and others – and it is this trend and some of the questions it raises for us as midwives that I would like to explore in this article.

What is Hands-Off Practice?

There does not seem to be a clear theoretical definition of what ‘hands-off’ practice means, although it is a term whose meaning is 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 a genuine need to do so, and a genuine desire from the woman that this happens, following honest discussion of the situation and options. This contrasts with the approach taken where systems of care and individual practitioners adopt the use of routine practices or interventions which are then applied to all women on a population basis, rather than according to individual need.

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 (e.g. Cronk 2005), rather than the medical approach of “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 (2005) research, which recognises that vaginal examinations can be both traumatic and problematic for women (e.g. Stewart 2005) 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 McCandlish et al 1998) 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 (Fletcher and Harris 2000), 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.

Each of these examples – and, indeed, the notion of being hands-off in general – illustrates a philosophy which I would suggest has arisen partly in opposition to the medicalised, intervention-heavy approach that has come under criticism from so many sources. I have heard a number of people speaking about how the roots of this approach also lie in related, woman-centred trends such as the use of water for labour and birth, which render the midwife less able to carry out hand manoeuvres and thus place her in a position where she is able to extend her own comfort zones around the need to be hands-on. These notions are supported by a body of research evidence, and by documents such as the WHO Principles of Perinatal Care, which states that, “…care should be based on the use of appropriate technology … reducing the overuse of technology or the application of sophisticated or complex technology where simpler procedures may suffice or indeed be simpler.” (Chalmers et al 2001: 203)

Hands-Off ~ A Personal Perspective

I should probably declare a vested interest in this topic sooner rather than later. I would consider myself a hands-off midwife. Although, like many of my colleagues who espouse this philosophy, I don’t hesitate to ask for permission to use my hands or other tools when I feel the situation genuinely calls for it. For example, I attend breech births with the “hands off the breech” mantra uppermost in my mind, yet at some point I have, with permission, used almost every one of the manual manoeuvres known to midwife-kind when I have felt they were truly warranted. As Ina May Gaskin often mentions (personal correspondence 2003), there is a danger that mantras such as ‘hands off the breech’, if used on their own, can mean that we risk taking the hands-off approach too far and end up with sub-optimal outcomes.

Equally, if I am in a situation where performing a vaginal examination could give myself and the woman important information which we will be truly useful and which we cannot get any other way, I will discuss this option with the woman rather than ploughing on (but with my hands still off) in a situation where I have a concern that I cannot otherwise resolve. Very few women decline intervention when they are in circumstances which truly warrant this and, like so many of my colleagues who take a hands-off approach, my philosophy embraces the (admittedly paradoxical) notions that one should “never say always” and “never say never”.

Instead of being an absolute rule, then, the hands-off approach for the midwives who practice this way seems to be the starting point from which the woman and midwife might decide to add in certain hands-on practices as and when they are deemed appropriate. This contrasts fairly starkly with the medicalised approach where the starting point involves regular manual, technological and pharmaceutical interventions which are only omitted if the woman particularly requests not to have them. The cornerstone of the practice of hands-off midwives doesn’t seem to be about never using manual intervention, but about striving to achieve the art of balance. Like many hands-off midwives, I am by no means under the illusion that I have perfected this art! As I am sure is the case for most of the midwives who are reading this, I still spend hours talking with colleagues about whether I should have waited longer before I intervened in a particular situation, or whether, if I had done something earlier, the eventual outcome might have been different…

Exploring the Challenges…

I have wondered whether the misunderstanding that may arise where we use terms like “hands-off” when we actually mean “hands-off unless there is a real need to put hands on” means that we should re-think the terminology we are using to refer to this approach. However, it seems quite clear to me that, whatever we call it, this approach is what some women want, and that it will continue to be a feature of the increasing autonomy of women and midwives. Indeed, in areas where this kind of care is not an option, more and more women are voting with their feet for a totally hands-off approach by choosing unassisted birth.

However, if we believe that the hands-off practice movement is an important part of the development of twenty-first century midwifery practice, there are a number of questions that need consideration. Among them are the vital matters of how we learn, teach and expand our understanding of hands-off practice, in order that this approach remains central to the needs of women and babies and – given that we live in the modern world – that we can demonstrate that each of the decisions we make with women is clearly thought through within the context of the woman’s needs and the wider picture.

The story at the beginning of this article illustrates the situation which has arisen where a good number of the midwives who have been at the forefront of developing the hands-off approach were already experienced in a more hands-on approach first. Nita’s approach to practice seems to be rooted in a deep kind of experiential knowledge that Kiera and many of her colleagues are now struggling to gain. As a nurse who later became a midwife within the medical model and then gradually moved towards a hands-off approach, Nita has a great deal of practice experience upon which to draw. Not only in the assessment of when intervention is truly warranted, but in having used these interventions enough in the past to perform them when they are needed with skill and dexterity.

Midwives like Nita initially learned to perform intervention on a more regular basis. Perhaps they then gradually expanded their trust of birth and their own comfort zones to a point where they felt able to do less and less and ‘downsize’ from a more medical approach as their experience and knowledge grew. For me, this juxtaposition of the experienced midwife who has grown into the hands-off approach over time with the new midwife who so desperately wants to learn to work this way from the outset but who does not yet, in her own words, have the confidence to wholly do this, illustrates one of the very real challenges which has arisen as a result of the increased autonomy that women and midwives have gained.

Other challenges raised by this movement include the questions of how we develop individual and collective knowledge around this kind of practice, based as it is on a midwifery model rather than a medical model approach. (I am currently engaged in research which looks at these questions, not least because I feel there is such a great need to explore the principles by which experienced, trusting midwives make decisions). Perhaps even more important is the question of how we find safe ways in which we can openly discuss these issues – and review our practice – without falling prey to unwarranted criticism from outside, particularly from those groups who do not feel able to take an open and honest approach to the evaluation of their own practice.

Finding Answers…

How we continue to explore, expand, learn and teach the art of a balanced, hands-off approach are, I feel, among the biggest questions which face midwifery today. How do we ensure that student midwives have gained enough experience of vaginal examination to ensure that they really feel confident about what they are feeling when they do need to perform this, when we, their mentors, are also trying hard not to subject women to more vaginal examinations than are truly necessary? How do we enable students and newly-qualified midwives to feel confident with the manual manoeuvres which are rarely used in hands-off practice, yet which might one day be the very thing they need in a particular situation? Rather than removing the concept of labour assessment from our practice completely when we want to embrace hands-off practice and do less vaginal examinations, how can we continue to develop and share less invasive forms of evaluation such as auditory and visual observation using physiological signs like the purple line?

Perhaps most importantly of all, how can we explore and encapsulate the cognitive tools and criteria which experienced midwives are using to decide when an intervention is essential and life-saving, and when it is unnecessary interference, such that we can further our knowledge and share this with those who follow us? One possible starting point for this last question might be the conclusions that were reached by some of the midwives who joined me in a recent workshop exploring these issues. They decided that, as a rough guide, an intervention should be contemplated when the midwife and woman both agree that it is really necessary, because either:

There is a real concern that there may be a problem, and the intervention (which includes screening tests like vaginal examination) could give further information about whether this problem exists or not, or
The woman and her midwife are in a situation where the outcome of a test (like vaginal examination) or manoeuvre might impact upon an important decision (such as the decision to transfer from home to hospital in labour), or
The outcome of an action (like helping a breech baby to birth) is more likely to change the outcome of the situation for the better than it is to cause problems, risks or an unacceptable degree of discomfort for the woman and / or baby.

Ultimately, I feel that all of these questions are rather interesting ones, and a part of me is excited that we have reached a point where we need to explore them, because the fact that we need to ask them is indicative of the increasing autonomy experienced by women and midwives. Rather than seeking to balance the humors, as our ancient colleagues did, the challenge for modern midwives is not only to perfect the art of balance in our own practice, but also to find ways of expanding and sharing this art with those who follow.

References

Chalmers B, Mangiaterra V and Porter R (2001) WHO Principles of Perinatal Care: The essential antenatal, perinatal and postpartum care course. Birth 28(3): 202-7.

Cronk M (2005) Hands off that breech! AIMS Journal 17(1):3-4

Dixon, L (2005) Building a picture of labour: how midwives use vaginal examination during labour. New Zealand College of Midwives Journal 33: 24-28)

Fletcher D, Harris H. (2000) The implementation of the HOT program at the Royal Women’s Hospital. Breastfeeding Review. 8(1):19–23.

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

Stewart M (2005) ‘I’m just going to wash you down’: sanitizing the vaginal examination Journal of Advanced Nursing 51(6): 587-94

Wickham S (2009) Hands-off and the art of balance. Birthspirit Midwifery Journal 1: 22-24