Coaching a slow birth with the woman in an empowered position may be less harmful than routine hands-on practice to protect against severe tears in birth - A discussion paper

Background: Different hands-on interventions to protect women from severe perineal tears after birth have been widely implemented. Evidence to support the routine use of hands-on interventions to reduce severe tears is mainly based on aggregated data from observational studies. Aim To critically discuss the current evidence for the implementation of hands-on intervention as a routine practice to protect women from severe tears after birth.

Discussion: Observational studies have been used to justify the routine use of hands-on intervention to protect women from severe perineal tears despite randomized controlled trials and systematic reviews showing lack of benefit. There is strong evidence supporting the slow speed at the time of birth to prevent severe perineal tears. While hands-on intervention does reduce the speed of birth, it may have a negative effect on the birth process, on neonatal outcomes and women's agency.

Conclusion: Evidence-based practice requires sufficient evaluation of interventions before being implemented in clinical practice as well as valuing the level of evidence when making clinical decisions. Evaluation of hands-on interventions to protect women from severe perineal tears must include not just one outcome of interest, but also an assessment of how the intervention interferes with the normal mechanism of birth, and how it affects neonatal outcomes and the autonomy of women.