I think it is fair to say that most of us learned early on in our days as student midwives that one of the most effective, useful and comforting things we can do to support a woman in labour is to place a hand on her sacrum and slowly and firmly rub this area, especially during contractions. This is certainly one of the first things I learned as a student; it often became my designated job, especially while I was learning about the different aspects of labour. As there were a few women who didn’t like being touched, I also learned how to establish whether this was OK with the labouring woman, by watching how my mentors used their communication skills to determine whether a particular woman would welcome touch or would prefer to be left “in her own space” at this time.
I learned about other kinds of touch too, and I discovered, again mainly by watching other midwives, the immense value of using our hands to help convey all of the things that midwives want to convey to women during labour: that everything will be OK, that they are doing a great job, that it might not be a good idea to hyperventilate… The whole area of midwives’ touch is one of those which (perhaps thankfully, considering the ethical implications) does not easily lend itself to investigation by RCT, but the value of appropriate touch surely cannot be doubted by anyone who has watched a skilful midwife in action.
And midwives do tend to be incredibly good “sacrum-rubbers”. However hard we try to involve them in the process, it is not uncommon for a woman who has a male partner present during her labour to reject his efforts in favour of the midwife’s back-rubbing skills. Because this skill is so valued by women, I would argue that this is a crucial part of our learning as midwives ~ although I also have a sneaking suspicion that this is an instinctive skill, rather than one that can easily be taught.
This does not mean, of course, that all of the kinds of touch used by midwives are unproblematic. There are huge issues being debated around touch, not least the trauma created by the current trend of frequent vaginal examination ~ which, in some areas, seems to have become a two-hourly procedure. As Ventegodt (2004: 1) points out, “A surprisingly large number of women report that they have felt humiliated and devaluated by the gynaecological procedure or pelvic examination”, and this is clearly something we need to look at further in relation to midwifery practice. But do we need ~ or want ~ to professionalise all forms of touch between midwives and women?
For the past few years, it has become common for student midwives to undertake a module or course in massage, whether as a compulsory or optional part of their programme. These courses can be really valuable, not least in helping students explore some of the issues surrounding touch in general. Yet I have recently heard student midwives talk about how they feel unsure about rubbing women’s sacrums in labour, because they “haven’t done the massage module yet”. These students have seen enough births to have watched their mentors rubbing women’s backs and using other kinds of touch in labour, yet they somehow feel the need for classroom instruction before they can try it out for themselves. This situation appears to be confounded by the combination of professional guidelines which outline how midwives need to be appropriately qualified before using complementary or alternative therapies, the growth of massage as a separate professional discipline with a growing evidence base and expert practitioners, and, of course, the ever-present concept of risk.
As Faye Thompson (2004) discusses, there is a crucial ethical difference between “being with” and “doing to”. Touch can often be about “doing to” women, and I would argue that it is mainly in this context that it should be thoroughly examined and weighed up; there is no doubt that some of the ways in which labouring women are touched are unacceptable. Yet we might need to take care to clarify these issues. Do we really want to perpetuate the idea that it is not OK to rub women’s sacrums unless we have a certificate that says we are qualified to do so? If we do not combine our efforts to protect women with a bit of common-sense, we might soon have to add “sacral-rubbing” to the ever-growing list of updates we have to attend each year…
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A version of this article was originally published as Wickham S (2004). Professionalisation of the sacral rub. TPM 7(4):25.
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Faye Thompson (2004). Mothers and Midwives: The Ethical Journey. Books for Midwives, Oxford. Søren Ventegodt (2004)
Medicine and the past. Lesson to learn about the pelvic examination and its sexually suppressive procedure, British Medical Journal Rapid Responses, 20 February 2004. Can be accessed at: http://bmj.bmjjournals.com/cgi/eletters/328/7437/0-g#50997