Midwifery 87 (2020) 102712

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Midwifery
journal homepage: www.elsevier.com/locate/midw

Review Article

The effects of hands on and hands off/poised techniques on maternal

outcomes: A systematic review and meta-analysis
Jing Huang a, Hong Lu a,∗, Yu Zang a, Lihua Ren a, Chunying Li b, Jianying Wang c
a
School of Nursing, Peking University, Beijing 100191, China
b
Health Science Library, Peking University, Beijing 100191, China
c
The Xibei Hospital for Women and Children, Xian 710061, China

a r t i c l e i n f o a b s t r a c t

Article history: Background: Negative maternal outcomes such as perineal trauma and related perineal pain may cause
Received 19 September 2019 both long-and short- term morbidities. Hands on and hands off/poised technique are two kinds of tech-
Revised 9 March 2020
niques to protect perineum during the second-stage of labor. Hands on technique has been the routine
Accepted 27 March 2020
midwifery practice for a long time; nevertheless, the effects of hands on technique on protecting per-
ineum has been doubted. Hands off/poised as a promising technique seems prevalent in clinical practice.
However, there is no consensus on use of hands off/poised technique and hands on technique. The effects
of these techniques on maternal outcomes have not been fully investigated.
Objective: To evaluate the effects of hands on hands off/poised technique on maternal outcomes during
the second-stage of labor.
Design: Systematic review and meta-analysis of relevant quantitative studies.
Data sources: Seven databases: PubMed, EMBASE, The Cochrane Library, CINAHL, WanFang Data, China
National Knowledge Infrastructure (CKNI), SinoMed were systematically searched from inception to July
23,2018 for relevant quantitative studies comparing the effects of hands on and hands off/poised tech-
nique on maternal outcomes.
Review methods: Quantitative studies were retrieved for relevant studies. Two reviewers independently
screened the studies, evaluated the methodological quality using JBI appraisal checklist tools and ex-
tracted the data. The included studies were divided into two groups for analysis according to study types.
Results: Nine RCTs with a total of 7112 participants and eight non-RCTs with 37,786 participants were
included for meta-analysis. Based on the results from RCTs, this study did not find difference between
hands on and hands off/poised technique regarding the risk of 2nd perineal tears, 3rd /4th degree per-
ineal tears, duration of second-stage labor and incidence of postpartum hemorrhage (PPH>500 ml). The
results from 9 non-RCTs were similar with that of RCTs, except for showing less 2nd degree perineal tears
in hands off/poised technique than in hands on technique.
Conclusion: Evidence in the present study indicated that hands off/poised technique may be a promising
delivery technique to maintain intact perineum, and reduce perineal pain and episiotomy use among
women with low-risk pregnancy undergoing vaginal delivery. In addition, hands off/poised technique
might be safe to use as it did not increase the risk of severe perineal trauma, postpartum hemorrhage,
and longer duration of second-stage labor when compared with hands on technique. More studies with
stringent study design, especially large randomized controlled trial, should be conducted before strong
recommendation of the hands off/poised technique.
© 2020 Elsevier Ltd. All rights reserved.

Introduction

Childbirth is a major life event for women and their fam-

∗
Corresponding author. ilies. Globally, about 140 million women give birth every year
E-mail addresses: 1811210232@bjmu.edu.cn (J. Huang), luhong@bjmu.edu.cn (H. (United Nations, Department of Economic and Social Affairs, 2019).
Lu), renlihua@bjmu.edu.cn (L. Ren), leecy@bjmu.edu.cn (C. Li).

https://doi.org/10.1016/j.midw.2020.102712
0266-6138/© 2020 Elsevier Ltd. All rights reserved.
2 J. Huang, H. Lu and Y. Zang et al. / Midwifery 87 (2020) 102712
However, unfavorable maternal outcomes frequently happen dur-
ing childbirth. Perineal trauma and related postnatal perineal pain
are two common negative outcomes. About 53–79% of women will
sustain some type of perineal trauma at vaginal delivery, with the
third- and fourth- degree perineal tears being the most serious
ones (Smith et al., 2013).East et al. (2012) also reported that 90%
of women experienced some perineal pain, with 37% having mod-
erate or severe pain. These negative outcomes can lead to both
long- and short-term morbidities. Severe perineal trauma may give
rise to urinary or anal incontinence, dyspareunia and long-term
sexual dysfunction (Stedenfeldt et al., 2014; Jangö et al., 2018;
Marsh et al., 2011; OʼShea et al., 2018), while the related perineal
pain affects women’s daily activities and mood (East et al., 2012).
With growing awareness of significant morbidities that perineal
trauma brings about, various perineal protective techniques have
been tried to promote better maternal outcomes.
Hands-on versus hands-off/poised techniques are different
kinds of perineal supports. The major difference between hands-
on and hands off/poised techniques is the hand placement over
course of delivering the newborn. Although varied in description,
generally, the hands-on technique is defined as the flexion of fe-
tal head and manual support of the perineum. In general, hands
off means midwife does not touch the fetal head and perineum at
all during the delivery, while hands-poised technique refers to ap-
plying slight pressure on fetal head to avoid rapid expulsion and
not supporting the perineum. Many studies combined the results
of both hands off and hands poised techniques while reporting, so
now the hands off and hands poised techniques are categorized as
hands off/poised technique.
The traditional routine management of perineum during the
second-stage labor has been hands-on technique (Trochez et al.,
2011), which has been thought to promote spontaneous vaginal
delivery and reduce perineal trauma. However, since the publi-
cation of the first randomized study, which compared the hands
on and hands poised technique and found no difference in per-
ineal outcomes between these two techniques (McCandlish et al.,
1998), there has been a trend to apply hands off/poised technique
in midwifery practice (Ampt et al., 2015). In China, 55.8% of the
midwives prefer to apply the hands off/poised technique during
the second-stage labor (Zhou et al., 2019). About 63% of the mid-
wives working in Norther Sydney Local Health District of Australia
reported they prefer to use hands off/poised technique while as-
sisting at a low-risk nonwatery birth (Ampt et al., 2015). A sur-
vey conducted in UK revealed that a lightly higher proportion of
midwives use this technique to manage the late second-stage la-
bor(49.3% compared to 48.6% hands on) (Trochez et al., 2011).
Although hands off/poised technique seems prevalent in clinical
practice and many doubted the protective effects of hands-on tech-
nique for reducing perineal trauma, there is no consensus on use
of hands off/poised technique and hands on technique. Debate is
fueled by divergent conclusions from literature with regard to the
impacts of these techniques on maternal outcomes. In terms of
perineal outcomes, Mayerhofer et al. (2002) reported that there
was no difference in perineal trauma between hands off/poised
and hands-on technique. Their findings are in accordance with that
of other two studies (McCandlish et al., 1998; de Souza and Gon-
zalez Riesco, 2006) . However, some studies supported the use
of hands off/poised techniques as they found a comparatively in-
creased perineal trauma with hands on techniques (Rezaei et al.,
2014; Fahami et al., 2012). Due to the varied conclusions of per-
ineal outcomes with hands on and hands off/poised techniques,
conflicts concerning related perineal pain have been described.
A few systematic reviews and meta-analysis have investigated
the effectiveness of hands on and hands off/poised technique on
perineal outcomes. However, some limitations exist in the method-
ology, number and quality of included studies. For example, Pierce-
Williams et al. (2019) included five randomized trials in their
study, in which the hands on technique was defined as involv-
ing one hand on the fetal head and with the other hand applying
pressure on the perineum, but the clear description of hands off
technique was not given. Their findings that hands on technique
was associated with a similar rate of third- and fourth degree per-
ineal tears in comparison with hands off/poised technique should
be interpreted with caution because the included studies are of
low quality. Aasheim et al. (2017) conducted a Cochrane review to
examine the effects of different perineal techniques during second-
stage labor on reducing perineal trauma. They arrived at a conclu-
sion that hands off the perineum resulted in fewer episiotomies,
but no difference to perineal trauma, which based on the results
from four randomized and quasi-randomized controlled trials with
considerable heterogeneity existing.
Five randomized controlled trials and seven non-randomized
controlled trials were included in the systematic review conducted
by Bulchandani et al. (2015). In this study, the meta-analysis from
RCTs showed that the protective effect of hands on technique
(termed as manual perineal support) on reducing the obstetric anal
sphincter injury(OASIS) was not statistically significant, while the
results from non-RCTs demonstrated a significant decreased risk of
OASIS with routine hands on technique. However, none of the RCTs
designed with primary aim of examining the effect of hands on
technique on OASIS, and most of the included observational cohort
studies focused on the effectiveness of training program of hands-
on technique. Hu et al. (2016) also conducted a systematic re-
view and meta-analysis focusing on the effects of hands off/poised
technique on primiparous women, where the hands off technique
was defined as exerting slight pressure on fetal head and not sup-
porting perineum, and the hands on technique were described as
guarding the perineum with the thenar muscle in the right palm
when the fetal head visible on the valvul gapping and perineum
stretches, and exerting inner and upper pressure on perineum dur-
ing contractions, putting pressure on fetal head. Based on the re-
sults from twelve randomized controlled trials, they reported that
hands off/poised technique reduced the rate of episiotomy and
shortened the duration of second-stage labor. They did not find any
difference in the rate of neonatal asphyxia and perineal trauma be-
tween hands on and hands off/poised techniques.
To date, there is insufficient evidence to draw a compelling con-
clusion about which perineal technique is more favorable since the
results from extant literature are inconsistent. Given that the ef-
fects of hands on and hands off/poised techniques on maternal
outcomes have not been fully investigated as well as more rele-
vant evidence is available on this topic, it is necessary to conduct
a comprehensive systematic review and meta-analysis to gain more
insights on the effects of hands on and hands off/poised technique.
Method
This systematic review and meta-analysis was guided by
the Preferred Reporting Items for Systematic Review and Meta-
analysis(PRISMA) Statement (Liberati et al., 2009)
Search strategy
The search strategy was developed with the support from a
subject librarian. Seven electronic databases were searched from
inception to July 2019. The international databases used for search
included: PubMed, EMBASE, The Cochrane Library, CINAHL, Chinese
databases: WanFang Data, China National Knowledge Infrastructure
(CKNI), SinoMed.
The search terms are a set of Mesh terms or Emtree
terms in combination with text terms using Boolean opera-
tor, which includes populations and interventions. The following
 J. Huang, H. Lu and Y. Zang et al. / Midwifery 87 (2020) 102712
terms were used for searching international databases: “hands
on”, “hands off”, “hands poised”, “Rigten maneuver”, “modified
Rigten maneuver”, “manual perineal protection”, “manual assis-
tance”, “manual control”, “manual support”, “perineal support”,
“perineal technique∗ ,” “perineal method∗ ”, “perineal control”, “per-
ineal protection”, “perineal care”, “perineal management”, “delivery
technique∗ ” and “parturient∗ ”, “multipara∗ ”, “nullipara∗ ”, “Women”,
“mother∗ ”, “primiparous women”, “nulliparous women”, “Vaginal
deliver∗ ”, “Labor”, “Birth”, “Childbirth”. The full search strategies
for seven databases are presented in Appendix1.
In order to gather as wide a range of best available evidence as
possible, no restrictions were put on languages. The reference lists
of finally included studies and relevant reviews were screened to
identify potentially relevant studies.
Eligibility criteria
Quantitative studies evaluating hands off/poised versus hands
on techniques for women with vaginal delivery were included.
Studies involving full term parturient women who had single-
ton pregnancy in cephalic presentation were included. Randomized
controlled trials were excluded if enrolled women with high-risk
pregnancy, special medical conditions or previous perineal scar.
Hands on techniques in this study were defined as “ only guard-
ing the perineum”, “controlling the head and guarding the per-
ineum” or “hands-on controlling the head and/or promoting flex-
ion”. Hands off/poised technique refers to “not guarding perineum
at any time of the delivery, applying no pressure or only applying
minimal pressure on the fetal head to control expulsion rate when
rapid expulsion and perineal tears are likely to occur.”
Studies were included if 1) having clear description of hands
on and hands off techniques 2) meeting the definition described
above. Studies were excluded if meeting at least one of the fol-
lowing criteria: 1)studies which examined the effects of hands on
and hands off/poised technique combined with other interventions
were excluded(e.g., hands on with perineal massage versus hands
off with perineal massage). 2)Studies applied hands off techniques
with other auxiliary treatment as intervention group without con-
trolling for the additional effect(e.g., hands off technique with lu-
bricant versus hands on) 3) applying routine episiotomy.
Studies were eligible if they provided the evidence on one of
the six outcomes addressing important maternal outcomes: epi-
siotomy, intact perineum, perineal tears, postnatal perineal pain
within 24 h, postpartum hemorrhage (blood loss>500 ml) , dura-
tion of second-stage labor.
Studies of poor methodological quality were excluded for final
data synthesis in order that the best available evidence could shed
light on the effects of hands off/poised and hands on techniques on
maternal outcomes. Eligibility standard in regard to methodological
quality is based on the guideline of Joanna Briggs Institute.
Study selection
All the potentially relevant studies from each database were
pooled into Endnote × 9. Titles and abstracts were screened by
two reviewers independently to yield relevant studies based on el-
igibility criteria after the removal of duplicates. Studies were re-
trieved and assessed for eligibility in next round of full text screen-
ing if there was insufficient information to draw a decision. The
full texts of remaining studies were also screened by two reviewers
independently for relevance. Any discrepancies or disagreements
throughout study selection process were resolved by consulting se-
nior reviewers until a consensus was reached.
3
Quality appraisal of relevant studies
To assess the methodological quality of relevant studies af-
ter full text screening, Joanna Briggs Institute (JBI) critical ap-
praisal checklist tools were used. These tools have been used by
many previous systematic reviews (Lee et al., 2016; Sinclair et al.,
2015; Whitehead et al., 2019). Quality appraisal were performed
by two reviewers independently. All discrepancies were resolved
through consultation with senior reviewers until the consensus
was reached.
Specific JBI critical appraisal checklist tools were chosen ac-
cording to study designs. In the present study, checklist for an-
alytic cross-sectional studies, quasi-experimental studies and ran-
domized controlled studies were used. The JBI checklist requires
the reviewers to select “yes”, “no” and “not applicable” for each
question. For analytic cross-sectional studies, the checklist con-
sists of eight questions .These eight questions focus on clearly de-
fined criteria, clear description of setting and participant, reliable
and valid measures of exposure, objective, standard criteria for
measurement of the condition, identification of confounding fac-
tors, strategies to control confounding factors, reliable and valid
measures of outcomes and appropriate statistical analysis. The JBI
checklist for quasi-experimental checklist consists of nine ques-
tions, which focus on clear causality, comparability identical treat-
ment except intervention, establishment of control group, pre-post
multiple measurements, complete follow-up, identical measures,
reliable measures, appropriate statistical analysis respectively. The
checklist for randomized controlled trial consists of thirteen ques-
tions, which focus on random sequence generation, allocation con-
cealment, comparability, blinding of participants, blinding of per-
sonnel, blinding of outcome assessment, identical treatment except
intervention, complete follow-up, analysis of all randomized partic-
ipant, identical measures of treatment groups, reliable measures,
appropriate statistical analysis and appropriate trial design.
Data extraction
The data of included studies were extracted by two viewers
independently with pre-designed data collection forms. The data
extracted comprised of: first author, year of publication, country
where the study was conducted, period for gathering data, charac-
teristics of participants, sample size, major outcomes(episiotomy,
intact perineum, perineal tears, blood loss, duration of second-
stage labor, postnatal perineal pain within 24hours) and relevant
measures, description of hands on and hands off/poised techniques
in each study.
Data synthesis
All the data from included studies were divided into two groups
for meta-analysis according to study design: randomized controlled
trials and non-randomized controlled trials. when data was only
reported in one study or could not be extracted for meta-analysis,
descriptive analysis was conducted. For study where the out-
comes of hands poised and directed pushing, hands on and di-
rected pushing, hands poised and undirected pushing, hands on
and undirected pushing were reported respectively, the data of
hands poised & undirected pushing and hands on & undirected
pushing were chosen to increase comparability. when results were
reported differently in independent group in a study, such as three
categories of hands on technique, the groups were combined for
analysis.
Reviewer Manager Software 5.3 (Revman 5.3)was used to syn-
thesize data, which was developed by Cochrane Collaboration. Two
reviewers inputted the data into RevMan 5.3 independently and
cross-checked it later to ensure accuracy. The odds ratios were
4 J. Huang, H. Lu and Y. Zang et al. / Midwifery 87 (2020) 102712
calculated for dichotomous variables(episiotomy, intact perineum,
perineal tears, blood loss>500 ml) using Mantel-Haenszel method.
The mean difference was calculated for continuous variables (dura-
tion of second-stage labor, postnatal perineal pain) measured with
the same instrument, otherwise the standardized mean difference
was used. Cochran’s Q test and I2 were applied to assessing hetero-
geneity among studies. The studies were considered as low hetero-
geneity If P ≤ 0.10 in Cochran’s Q test and I2 >50%, and random-
effects model was then applied. Otherwise, fix-effects model was
used. Sensitivity analysis were performed to test the reliability and
stability of results by consecutively excluding one study once at a
time. A two-tailed P valve<0.05 was regarded as statistically in all
test. Funnel plot analysis were applied to evaluate publication bias
if comparison consists more than 10 studies.
Results
Search process
A total of 4698 records were yielded from 7 databases and rel-
evant reviews. After the removal of duplicates, 2949 records were
retained and were screened by titles and abstracts. 2353 records
were excluded for not meeting the eligibility criteria. The reasons
are as follows: 1886 Irrelevant records 241records combined other
interventions, 80 Other types of publications (reviews, conference
abstract, comments, protocol, etc.), 64 records had no comparison
of interest. 3 records had duplicate data, 2 records did not meet
criteria of participants(have previous perineal scars or serious di-
abetes), 4 records focused on models rather than human,1 record
did not have outcomes of interest. About 578 records were further
excluded after screening by full text and quality appraisal. Among
the excluded records, 518 records were excluded due to the fol-
lowing reasons: 240 records did not meet the description of hands
on and hands off techniques in this study, 152 records had no
clear description of intervention, 161 records did not control the
additional effect of certain group, 29 records involved routine epi-
siotomy, 4 records had no outcomes of interest, 2 records did not
have available full text, 1 record had no primary data, 1 record
enrolled women with preterm labor. 61 records were further re-
moved for poor methodological quality after quality appraisal.
Of the remaining 17 studies included in quantitative studies,
5 studies were identified from international databases (Lee et al.,
2018;Tunestveit et al., 2018;Rezaei et al., 2014; Fahami et al.,
2012; McCandlish et al., 1998), and 12 studies (Zhang et al., 2014;
Wu and Yan, 2016; Wu et al., 2016; Wang et al., 2013; Lu, 2017;
Liu et al., 2015; Lin, 2014; Huang, 2014; He, 2016; Guo et al., 2016;
Fu et al., 2014; Ding et al., 2016) were obtained from Chinese
databases.
The PRISMA flowchart of study selection is showed in Fig 1.
Characteristics of included studies
Nine RCTs with a total of 7112 participants and eight non-RCTs
with 37,786 participants were included in this study. The sample
size of RCTs ranged from 66 to 5505, for non-RCTs183 to 26,393. Of
the included studies, twelve trials were conducted in China, two in
Iran, one in United Kingdom, one in Australia, one in Norway. Most
of the studies (k = 15) were published between 2013–2018.
All included studies characterized the participants as low-risk
pregnancy women though specific eligibility criteria varied. In re-
gard to the parity of participants, ten studies involved primiparas,
and the rest seven studies enrolled both primiparas and multi-
paras. The characteristics of participants and description of hands
on and hands off/poised techniques of each study are described in
detail in Table 1, Table 2, respectively.
Methodological quality
Methodological quality of RCTs
The JBI quality appraisal checklist for randomized trials was
used to evaluate the internal and external reliability and validity of
RCTs. Of the included nine RCTs, all studies applied randomization
methods. Five studies applied random number table; two studies
used computer generated random allocation; one study random-
ized participants by drawing; the randomization of another trial
was in a ratio of 1/1 within balanced blocks of 4 to 8, stratified by
center. Four studies concealed allocation with opaque, sealed en-
velopes, other five studies did not mention allocation concealment.
The groups in all studies were comparable in age, BMI, gestation
weeks, etc. Blinding of participants and personnel is impossible
due to the nature of hands off/poised and hands-on technique. Of
the included RCTs, McCandlish et al.(1998) intended not to tell par-
ticipants the information about allocation. All the included studies
did not report the blinding of outcome assessment. All the studies
applied identical treatment except intervention of interest. Ques-
tion about complete follow-up is not applicable in these trials for
all the outcomes are acute outcomes. Eight studies analyzed par-
ticipants in the groups to which they were randomized or used
“intention-to-treat”, one study failed to do this. All studies ap-
plied identical measures of treatment groups, appropriate statisti-
cal analysis, appropriate trial design. Six studies used reliable mea-
sures to access outcomes of interest.
Methodological quality of non-RCTs
The included non-RCTs comprise of six quasi-experimental
trials and two analytic cross-sectional studies. For six quasi-
experimental trials, clear causality was well demonstrated in all
studies. Groups in all trials were comparable in age, parity, gesta-
tion, BMI, etc. All the studies set a control group. None of the stud-
ies mentioned pre-post multiple measurements. Question about
complete follow-up is not applicable in these trials. All the six
trials applied identical measures to both groups, and appropriate
statistical analysis. All the quasi-experimental studies used reliable
measures to evaluate outcomes of interest. For two analytic cross-
section studies, all the studies have clearly defined criteria, clear
description of setting and participant, objective, standard criteria
for measurement of the condition, reliable and valid measures of
outcomes and appropriate statistical analysis. All the studies iden-
tified confounding factors by applying relevant strategies. Question
about the reliable and valid measures of exposure is not applicable
in these studies.
Episiotomy
Seven RCTs reported the rate of episiotomy between hands
off/poised and hands-on technique groups. The result of meta-
analysis indicated that women in hands off/poised group were less
likely to receive episiotomy when compared with those in hands
on group, and the difference was statistically significant (random-
effects model, OR:0.27, 95%CI:0.14–0.49,p<0.0 0 0 01,n = 902). The
difference remained significant after sensitive analysis where the
OR ranged from 0.23–0.38. There was high heterogeneity among
studies(I2 =83%). (Appendix Fig 1)
Five non-RCTs provided data on the rate of episiotomy between
groups of interest. The results of meta-analysis also suggested that
women in hands off/poised group received less episiotomy in com-
parison with those who received hands on technique to protect
perineum during delivery, the difference was significant(random-
effects model, OR:0.47,95%CI:0.39–0.57, p<0.0 0 0 01, n = 24,534).
The difference remained significant after sensitive analysis where
the OR ranged from 0.43–0.51. High heterogeneity was found
among studies(I2 =70%). (Appendix Fig 2)
J. Huang, H. Lu and Y. Zang et al. / Midwifery 87 (2020) 102712 5
6 J. Huang, H. Lu and Y. Zang et al. / Midwifery 87 (2020) 102712

Table 1
Characteristics of included studies.

First author Study Outcomes

Year country design Data collection Characteristics of participants Sample size reported Measures

Zhang et al. RCT 2013.7–10 

1 Primiparas with low-risk pregnancy 216 Rate of –
(2014) China who undergo vaginal birth; 2 without episiotomy
any obstetric or medical
complications; 3 singleton pregnancy
Rate of Intact –
perineum∗
b
Perineal tears –
Duration of unknown
second-stage
labor∗
Wu and Yan RCT 2013.1–2015.1 
1 Primiparas with low-risk pregnancy 140 Rate of –
(2016) China who plan to have vaginal birth; episiotomy
2 well- developed perineum;  3 no
pregnancy complications;  4 singleton
pregnancy;  5 cephalic presentation;
6 normal pelvis, no cephalopelvic
disproportion  7 no serious diseases of
heart, liver, kidney,etc. no special
medical conditions in immune system
and hematopoietic system;  8 healthy
fetus without malformation or
congenital diseases
Rate of intact –
perineum a
b
Perineal tears –
Duration of unknown
second-stage
labor∗
Hemorrhage c Weighting
method
Volumetric
method
Perineal pain VAS
Lu (2017) RCT 2015.3–2016.3 1 Primiparas with low-risk pregnancy 90 Rate of –
China who plan to have vaginal birth; 2 episiotomy
cephalic presentation; 
3 term labor;
4 no pregnancy complications;
Rate of intact –
perineum∗
b
Perineal tears –
Ding et al. RCT 2015.3–2016.6 
1 Primiparas 2 cephalic presentation; 605 Rate of –
2017 China 
3 term labor;4 singleton pregnancy episiotomy

5 normal fetal position; 6 perineum:
no inflammation and
well-developed; 7 cooperate to
instructions; 
8 no obstructed labor,
dystocia, preterm labor, fetal distress,
pregnancy complications;  9 fetal
weight no more than 4kg
Duration of unknown
second-stage
labor d
Perineal pain VAS
Fu et al. (2014) RCT 2013.1–7 
1 Primiparas undergo vaginal birth; 190 Rate of –
China 2 cephalic presentation; 
3 singleton episiotomy
pregnancy 4 term labor 5 the
absence of any risk factors or
contradictions to vaginal birth
Rate of intact –
perineum∗
b
Perineal tears –
Wu et al. RCT 2014.2–6 
1 normal thinking and talking, no 200 Rate of –
(2016) China communication barriers; episiotomy
2 the absence of any risk factors or
contradictions to vaginal birth3 term
labor;

4 singleton pregnancy;
5 cephalic
presentation;

6 no labor induction before

7 anticipated a vaginal birth

8 healthy fetus without
malformation or congenital diseases
(continued on next page)
 J. Huang, H. Lu and Y. Zang et al. / Midwifery 87 (2020) 102712 7

Table 1 (continued)

First author Study Data collection Characteristics of participants Sample size Outcomes Measures
Year country design reported

Rate of intact –
perineum∗
b
Perineal tears –
Duration of –
second-stage
labor∗
RCT 1994.12–1996.12 1 cephalic presentation; 2 anticipated 5005 Perineal tears b
–
McCandlish et al. a normal birth; 3 no waterbirth;
(1998) UK 4 had no elective episiotomy
prescribed; 5 term labor
Duration of unknown
second-stage
labor ∗
Hemorrhage c unknown
Fahami (2012) RCT 2011.11–2012.2 
1 18 to 35 years old; 
2 primiparous; 66 Rate of intact –
Iran 
3 singleton pregnancy; 4 gestational perineum a
age from 37 to 41 weeks, estimated
fetal weight of less than 4000 gs;  5
no embryo water, spontaneous
rupture of the bag before the active
phase of labor;  6 the lack of perineal
preparation during pregnancy
(perineal massage in the last 4 weeks
of pregnancy, attending classes in
preparation for labor, doing regular
exercise or sport as a professional),
the probability of difficult delivery,
7 no indications for cesarean section,
no mental disorders;  8 no chronic
disease of the mother (maternal
health, with questions and case
studies), the risk of preeclampsia;
9 no obvious lesions such as severe
varicose veins or hematoma in the
vulva or perineal, symptoms of
vaginal infections and genital herpes
(in the case of painful sores or lesions
on the vulva and perineal, genital
herpes diagnosis was possible),
nonprescribed opioids, the use of
Entonox gas for no-pain delivery;

10 no need for episiotomy (rigid and
resistant perineal).
Excluded: 1 the lack of progress in
labor; 2 fetal distress; 3 using
vacuum or forceps in delivery;
4 perineal edema or rash occurrence
b
Perineal tears –
Duration of unknown
second-stage
labor ∗
Perineal pain visual scale of
McGill
questionnaire
Rozita et al. RCT 2012.5–2013.8 1 primiparous healthy 600 Rate of –
2014 Iran women 2 15–35 years old; 3 singleton episiotomy
pregnancy; 4 fetus weights
2500–4000 g;  5 Amniotic membranes
were intact at the time of admission
and the labor duration was less than
12 h after the individuals were
admitted. 6 Oxytocin was not used at
the first and second stage of delivery
neither was the preparation of the
perineal done during pregnancy;  7 no
special medical conditions of fetus
and women
b
Perineal tears –
Wang et al. Quasi- Ex- 2010.1–2011.12 1 Primiparas undergo vaginal birth; 8165 Rate of –
(2013) China perimental 2 cephalic presentation; 
3 term episiotomy
trial labor; 
4 no pregnancy complications;

(continued on next page)

8 J. Huang, H. Lu and Y. Zang et al. / Midwifery 87 (2020) 102712

Table 1 (continued)

First author Study Data collection Characteristics of participants Sample size Outcomes Measures
Year country design reported

Perineal tears∗ –
Lin (2014) Quasi- Ex- 2013.1–2013.5 1 no medical or pregnancy 918 Rate of –
China perimental complications  2 cephalic episiotomy
trial presentation; 3 term
labor;
4 singleton pregnancy 
5 normal
soft birth canal and bony birth canal,
no cephalopelvic disproportion
Rate of intact –
perineum ∗
∗
Perineal tears –
Hemorrhage∗ weighting
method
volumetric
method
Liu et al. Quasi- Ex- 2011.10–2012.10 1 Primiparas undergo vaginal 183 Rate of intact
(2015) China perimental birth;2 no indication for perineum a
Trail episiotomy; 3 normal pelvis; 4 no
prolonged labor; 5 no fetal distress;
6 no perineal lesion7 no special
medical conditions or pregnancy
complications; 8 no fetal macrosomia
or fetal growth restriction.
b
Perineal tears –
Duration of –
second-stage
labor d
Neonatal APGAR score
asphyxia e
Hemorrhage∗ unknown
Huang (2014) Quasi- Ex- 1 18–35years old;2 no pregnancy 200 Rate of –
China perimental complications;3 normal pelvis; no episiotomy
Trail cephalopelvic
disproportion; 4 cephalic presentation;
5 singleton pregnancy;
6 well-developed perineum;  7 normal
thinking and talking; 8 healthy fetus
without malformation or congenital
diseases;
Excluded: 1 fetal malpresentaion,
premature rupture of fetal membranes
2 fetal macrosomia; post-term birth;
preterm labor; labor induction
history;  3 serious diseases of heart,
liver, kidney or special medical
condition in immune system and
hematopoietic system;
4 communication barriers, metal
illness;  5 immobility of limb;  6 labor
analgesia;  7 use of oxytocin or
Artificial rupture of membranes;
8 stillbirth or fetus with congenital
diseases
Rate of intact –
perineum a
b
Perineal tears –
Hemorrhage c –
Duration of unknown
second-stage
labor d
Perineal pain VAS
He (2016) Quasi- Ex- 2013.1–2014.12 1 Primiparas  2 term labor;3 cephalic 428 Rate of
China perimental presentation; 4 singleton pregnancy; episiotomy
Trail 5 no any risk factors for pregnancy
complications;  5 no mental disorders,
no communication barriers
Excluded: 1 premature rupture of
fetal membranes  2 with infectious
diseases or immune system diseases;
3 disorders of important organs such
as liver and kidney;
∗
Perineal tears –
Duration of unknown
second-stage
labor ∗
Hemorrhage ∗ unknown
Guo et al. Quasi- Ex- 2013.10–2014.3 
1 no fetal malpresention; 
2 no fetal 742 Rate of –
(2016) China perimental malposition; 
3 no serious medical episiotomy
Trail conditions or pregnancy
complications4 no cephalopelvic
disproportion
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 J. Huang, H. Lu and Y. Zang et al. / Midwifery 87 (2020) 102712 9

Table 1 (continued)

First author Study Data collection Characteristics of participants Sample size Outcomes Measures
Year country design reported

Rate of intact –
perineum ∗
b
Perineal tears –
Lee et al. Analytic Unknown 
1 No cesarean section, gestation < 37 26,393 Rate of intact –
(2018) cross weeks; 
2 no twin births, 3 no episiotomy
Australia sectional malpresentations (e.g. breech, brow,
studies face); 
4 no operative (vacuum and
forceps) births
∗
Perineal tears –
Analytic 2007.12–2008.9 1 non-instrumental vaginal births; 757 Rate of intact –
Tunestveit et al. cross 2 Norwegian or English speaking perineum a
(2018) Norway sectional women; 3 older than 16 years;
studies 4 singleton pregnancy;  5 cephalic
presentation;  6 gestational age of 37
weeks or longer
b
Perineal tears –

Abbreviations:
a:intact perineum: no injury to the perineal skin or/and vaginal muscosa, perineum remains intact.
b:Perineal tears: First-degree tear: Injury to perineal skin and/or vaginal mucosa; Second-degree tear: Injury to perineum involving perineal muscles but not
involving the anal sphincter; Third-degree tear: Injury to perineum involving the anal sphincter complex; Fourth-degree tear: Injury to perineum involving the
anal sphincter complex (EAS and IAS) and anorectal mucosa. and anorectal mucosa.
c:hemorrhage:blood loss>500 ml.
d:second-stage labor: beginning with complete dilation of cervix and ending with expulsion of the fetus.
VAS: visual analogue scale.
∗
:undefined.

Intact perineum
Six RCTs showed the rate of intact perineum between hands
off/poised and hands-on technique group. Of the six RCTs, two
study specified intact perineum as: no injury to the perineal skin
or/and vaginal muscosa, and perineum remains intact. The result
of meta-analysis demonstrated that women who received hands
off/poised technique during delivery were more likely to have
intact perineum, the difference of rate of the intact perineum
between two groups was statistically different(fix-effects model,
OR:2.94,95%CI:1.82–4.77, p<0.0 0 0 01,n = 902). The difference re-
mained significant after sensitive analysis and the OR ranged from
0.23–0.38. No heterogeneity was observed in these studies(I2 =0%).
(Appendix Fig 3)
Four non-RCTs compared the rate of intact perineum be-
tween hands off/poised and hands on techniques. Three of four
studies defined intact perineum as no injury to the perineal
skin or/and vaginal muscosa, perineum remains intact, while one
study did not give clear description of intact perineum. Accord-
ing to the results of meta-analysis, there was a non-significant
higher rate of intact perineum in the hands off/poised group
than hands on group(random-effects model, OR:3.10, 95%CI:0.46–
21.02, p = 0.25,n = 1994). After the removal of the study
of Huang (2014), the difference between hands on and hands
off/poised group was statistically significant(OR:10.42, 95%CI:6.89–
15.78,p<0.0 0 0 01). The heterogeneity among studies was high
(I2 =91%) (Appendix Fig. 4)
Perineal tears
Of eight RCTs which provided data on perineal tears, seven of
them have clear description of perineal tears: First-degree tear: In-
jury to perineal skin and/or vaginal mucosa; Second-degree tear:
Injury to perineum involving perineal muscles but not involving
the anal sphincter; Third-degree tear: Injury to perineum involv-
ing the anal sphincter complex; Fourth-degree tear: Injury to per-
ineum involving the anal sphincter complex (EAS and IAS) and
anorectal mucosa.
The meta-analysis from six RCTs revealed that the inci-
dence of 1st perineal tear was higher in hands off/poised group
than in hands on group, the difference between two groups
was significant(random-effects model, OR:3.22, 95%CI:1.72–6.03,
p<0.0 0 0 01,n = 6973). The difference remained significant af-
ter sensitive analysis where the OR ranged from 2.59 to 3.88.
There was high heterogeneity among studies(I2 =92%). The re-
sults of eight RCTs showed that there was no significant dif-
ference in the incidence of 2nd degree perineal tear(random-
effects model, OR:0.59, 95%CI:0.30–1.17, p = 0.13,n = 6973). Af-
ter the removal of the study of Zhang et al. (2014), the differ-
ence regarding the incidence of 2nd degree perineal tears be-
tween hands on and hands off/poised techniques became signif-
icant (OR:0.44, 95%CI:0.22–0.86,p = 0.02). The heterogeneity was
high among studies(I2 =87%). In regard to 3rd and 4th degree per-
ineal tears, no difference was found between hands off/poised and
hands on techniques(random-effects model, OR:0.49, 95%CI:0.09–
2.75, p = 0.42,n = 6161). When the study of McCandlish et al. was
excluded, the difference between hands on and hands off/poised
technique was significant(OR:0.16, 95%CI:0.03–0.94, p = 0.04),
which favored hands off/poised technique. The heterogeneity was
high(I2 =63%).(Appendix Figs. 5–7)
Eight non-RCTs compared perineal tears between hands
off/poised and hands-on. Four of them presented classification
of perineal tears: Perineal tears: First-degree tear: Injury to per-
ineal skin and/or vaginal mucosa; Second-degree tear: Injury to
perineum involving perineal muscles but not involving the anal
sphincter; Third-degree tear: Injury to perineum involving the anal
sphincter complex; Fourth-degree tear: Injury to perineum involv-
ing the anal sphincter complex (EAS and IAS) and anorectal mu-
cosa.
The results from non-RCTs demonstrated that women was
more likely to sustain 1st degree perineal tears with hands
off/poised techniques(fix-effects model, OR:5.19, 95%CI:4.20–6.42,
p<0.0 0 0 01,n = 2471). The difference between hands on and hands
off/poised technique remained significant after sensitive analy-
sis where the OR ranged from 4.36–5.54. The heterogeneity was
low among studies((I2 =31%). With regard to 2nd degree per-
ineal tears, the results of meta-analysis from seven non-RCTs in-
10
Table 2
Interventions of included studies.
Author& Year
Randomized controlled trial
1 Zhang et al. (2014)
2 Wu et al. (2016)
3 Lu (2017)
4 Ding et al. (2016)
5 Wu and Yan (2016)
6 Fu et al. 2017
J. Huang, H. Lu and Y. Zang et al. / Midwifery 87 (2020) 102712
intervention
Hands on
Midwife guards the perineum with the
thenar muscle in the right palm, and
exerts inner and upper pressure on it
during contractions. Meanwhile, applying
pressure toward fetal vertex to maintain
flexion and facilitate extension with left
hand. Reducing the pressure on the
perineum in the period between
contractions. As fetal head is delivered, the
midwife wipes fluid from neonate’s face,
nose and mouth with left hand, facilitates
restitution and external rotation. Gentle
downward traction is applied to affect the
descent of anterior shoulder. Then, applying
upward traction to deliver the posterior
shoulder. When the shoulders are delivered,
stop guarding perineum.
When the fetal head visible on the valvul
gapping and distends vulva and perineum
to open the vaginal introitus to
2 cm × 3 cm, Midwife guards the
perineum with the thenar muscle in the
right palm, and exerts inner and upper
pressure on both perineum and hip
during contractions. Meanwhile, executing
pressure toward fetal occiput to maintain
flexion and slow the rate of expulsion of
fetal head with left hand. Reducing the
pressure on the perineum in the period
between contractions. Other steps are the
same as hands off
When the fetal head visible on the valvul
gapping and perineum stretches, midwife
guards the perineum with the thenar
muscle in the right palm. Meanwhile,
applying downward pressure on fetal
occiput with left hand.
Midwife guards the perineum with the
thenar muscle in the right palm, and
exerts inner and upper pressure on it
during contractions. Meanwhile, applying
downward pressure on fetal occiput with
left hand to maintain flexion and facilitate
extension. Reducing the pressure on the
perineum in the period between
contractions. Keep guarding the perineum
after the delivery of fetal head. Stop
guarding the perineum when shoulders
are emerging. Assist women to give birth to
the rest of the body with both hands.
Hands on: Midwife guards the perineum
with right hand, and maintains the flexion
of fetal vertex. Reducing the pressure on
the perineum in the period between
contractions. Keep guarding the perineum
after the delivery of fetal head.
Midwife guards the perineum with the
thenar muscle in the right palm, and
exerts inner and upper pressure on both
perineum and hip during contractions.
Meanwhile, executing downward pressure
toward fetal occiput to maintain flexion
and slow the rate of expulsion of fetal
head with left hand. Reducing the
pressure on the perineum in the period
between contractions.
Hands off
When the fetal head visible on valval gapping,
midwife controls the rate of expulsion of fetal vertex
with left or right hand (keep expulsion rate<1 cm
during each contraction). During delivery, midwife
neither guards the perineum with right hand nor
maintains flexion nor facilitates extension of fetal
head. As soon as the fetal head is emerging, midwife
wipes fluid form neonate’s face, nose and mouth and
waits for the next contraction or few seconds to assist
women to give birth to the anterior shoulder. Gentle
traction is applied with both hands along with women’s
gentle pushing efforts to deliver the anterior shoulder.
Then, midwife exerts gentle downward traction with
both hands to deliver the posterior shoulder.
When the fetal head visible on the valvul gapping
and distends vulva and perineum to open the vaginal
introitus to 2 cm × 3 cm, midwife places the thumb
and fingers of left hand on either side of labia minora
or fetal head during contractions to control the rate
of expulsion, but neither maintains flexion of fetal
head nor supports perineum with right hand. As fetal
head is emerging, midwife wipes fluid from neonate’s
face, nose and mouth, waits for the restitution, external
rotation and spontaneous delivery of the shoulders.
Then, midwife holds the shoulders to assist women to
give birth to the rest of the body.
When the fetal head visible on the valvul gapping
and perineum stretches, midwife controls the
expulsion rate with bent fingers of left hand (keep
expulsion rate<1 cm during each contraction) .
Midwifes neither supports perineum during delivery
nor maintains flexion of fetal head.
When the head visible on the valvul gapping and
distends the vulva and perineum to open the vaginal
introitus to 5 cm × 4 cm, midwife begins to control
the expulsion rate with one hand (keep expulsion
rate<1 cm during each contraction). As fetal head is
emerging, midwife wipes fluid from the neonate’s face,
nose and mouth, waits for the restitution and external
rotation. Applying gentle traction with both hands to
assist women give birth to shoulders. During the
delivery, midwife neither touches perineum nor
maintains flexion.
When the cervix reaches to full dilation and fetal
head visible on valvul gapping, midwife controls the
rate of expulsion with one hand, but neither supports
perineum nor maintains the flexion. At crowning,
midwife slow the rate of expulsion with both hands.
As soon as fetal head is emerging, midwife wipes fluid
from neonate’s face, nose and mouth and assists
restitution and external rotation. Assist the women to
give birth to the shoulders with both hands then.
When the head visible on the valvul gapping and
distends the vulva and perineum to open the vaginal
introitus to 2 cm × 3 cm, midwife places the thumb
and fingers of left hand on either side of labia minora
or fetal head during contractions to control the rate
of expulsion, but neither maintains flexion of fetal
head nor supports perineum with right hand. As the
head is emerging, midwife wipes the fluid from the
neonate’s face, nose, mouth, waits for the restitution
and external rotation and the delivery of shoulders.
Hold the shoulders to assist women to give birth to the
rest of the body then.
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 J. Huang, H. Lu and Y. Zang et al. / Midwifery 87 (2020) 102712
Table 2 (continued)
Author& Year
Randomized controlled trial
7 McCandlish et al.
(1998)
8 Fahami et al. (2012)
9 Rozita et al. 2014
Quasi-experimental trails
1 Lin (2014)
2 Liu et al. (2015)
3 Huang (2014)
4 Guo et al.
5 Wang et al.
intervention
Hands on
Midwife puts pressure on the baby’s head
in the belief that flexion will be increased,
and supports(guards)the perineum
When the baby’s head was distended the
vulva and perineal(vaginal opening was
open with a diameter of 5 cm or
more),through the perineal and just in
front of sacroiliac joint(lumbar vertebrae),
with a hand within the glove and a towel
thrown on it, a forward direction pressure
would be applied onto the fetus chin.
During this action the left hand controlled
the speed of the crowning of the baby’s
head.
Midwife places the index, ring and little
fingers of her left hand close together on
the fetus’s occiput, with the palm turned
toward the anterior region of the
perineum. Expulsion is controlled by
maintaining the flexion of head protecting
the anterior region of the perineum,
providing support to the ischio-cavernous
and bulbo-cavernous muscles, the urethral
introitus and the labia major and minor.
Simultaneously, the right hand is flatted
and placed on the posterior perineum,
with the index finger, and the thumb
forming a “U” shape, exerting pressure.
All region of the perineum, particularly
the fourchette, remained protected.
When the fetal head visible on the valvul
gapping and perineum stretches, midwife
guards the perineum with the thenar
muscle in the right palm, and exerts
upward pressure on hip with fingers.
Keep guarding the perineum with right
hand during delivery. Other steps are the
same as hands off.
Midwife guards the perineum, exerts
pressure on fetal occiput or vertex with
palmer side of left hand to control
extension and maintain flexion.
Midwife guards the perineum with the
thenar muscle in the right palm.
Maintaining flexion and controlling
extension. Reducing the pressure on the
perineum in the period between
contractions.
At crowning, midwife does not guard the
perineum, only controls the rate of
expulsion of fetal head
When the fetal head visible on the valvul
gapping and distends vulva and perineum
to open the vaginal introitus to
2 cm × 3 cm, midwife keeps the fingers
of right hand close together and guards
perineum with the gloved right hand
covered by a towel. Exerting slight
pressure on fetal occiput with the index,
middle, ring fingers of left hand covered
by a towel to maintain flexion. Reducing
the pressure on perineum in the period
between contractions. Keep guarding the
perineum with right hand at any time
during delivery. At crowning, facilitating
extension with left hand.
11
Hands off
Midwife keeps her hands poised, prepared to put
light pressure on the baby’s head in case of rapid
expulsion but not to touch the perineum otherwise
Midwife would not touch any part of the perineal
during the crowning of the baby’s head and with the
left hand prevented the sudden exit of the baby’s
head
Midwife only observes the successive movement of
restitution, external rotation, delivery of the
shoulders and the remainder of the body. Midwife
rotates the head and helps in the delivery, when this
does not occur spontaneously within 15 min after the
delivery of head or the new born appears hypoxic.
When the fetal head visible on the valvul gapping
and perineum stretches, midwife controls the
expulsion rate with one hand (keep expulsion
rate<1 cm during each contraction), neither guards
the perineum nor maintains flexion during delivery.
While waiting for the restitution and external rotation,
midwife wipes fluid from neonate’s nose, face and
mouth. Then midwife applies gentle downward traction
on neck with one hand to assist women to give birth to
the anterior shoulder. Midwife holds the head and neck
with right hand and supports the rest body with left
hand, then deliver the posterior shoulder.
At crowning, midwife controls the rate of expulsion
with bent fingers of left hand exerting slight pressure
on fetal vertex and fetal occiput, neither guards the
perineum or anus with right hand nor maintains
flexion.
Midwife neither guards the perineum nor maintains
flexion, only controls the rate of extension to avoid
raid expulsion.
Midwife controls extension of fetal head with one
hand, while guards the perineum with another hand
At crowning, midwife controls the rate of expulsion
to avoid rapid expulsion, but neither guards the
perineum nor facilitates flexion during delivery. Then,
midwife exerts gentle downward pressure on head with
both hands to deliver the anterior shoulder, and applies
gentle upward pressure with both hands, lifting head to
deliver the posterior shoulder.
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12 J. Huang, H. Lu and Y. Zang et al. / Midwifery 87 (2020) 102712

Table 2 (continued)

Author& Year intervention

Hands on Hands off

Randomized controlled trial

6 He (2016)
Analytic cross-section studies
1 Lee et al. (2018)
2 Tunestveit et al. (2018)
When the fetal head visible on the valvul
gapping and perineum stretches, midwife
guards the perineum with the thenar
muscle in the right palm, and exerts
upward pressure on hip with fingers.
Keep guarding the perineum with right
hand at any time during delivery
Midwife controls the head and/or
promotes flexion. Midwife controls the
head and guards the perineum. Midwife
only guards the perineum.
Midwife supports perineum with straight
fingers, support against the perineum.
Midwife supports the perineum with
bended fingers, collects the tissue when
support. Midwife supports perineum with
thumb and index finger, the three other
fingers support the chin.
Midwife neither guards the perineum nor maintains
flexion nor facilitates extension. When the fetal head
visible on the valvul gapping and perineum stretches,
midwife only controls the rate of expulsion with one
hand(keep expulsion rate<1 cm during each
contraction). While waiting for the restitution and
external rotation, midwife wipes fluid from neonate’s
nose, face and mouth. Then midwife applies gentle
downward traction on infant’s neck with one hand to
assist women to give birth to the anterior shoulder. To
delivery the posterior shoulder, midwife uplifts the head
and neck with right hand and supports the rest body
with left hand.
Midwife only applies pressure to the vertex when
judged to be advancing rapidly and likely to tear the
perineum.
Midwife does not apply any kind of manual supports.

dicated that there was less 2nd degree perineal tears in hands
off/poised group than in hands on group, the difference was
statistically significant(random-effects model,OR:0.38,95%CI:0.23–
0.63,p<0.0 0 0 01,n = 32,363). When the study of Wang et al.
was excluded, there was no difference between hands on and
hands off/poised technique(OR:0.40, 95%CI:0.15–1.03, p = 0.06) .
The heterogeneity was high among these studies(I2 =98%). There
was no difference in the incidence of 3rd and 4th degree per-
ineal tears between hands off/poised and hands-on groups based
on the results from two non-RCTs(random-effect model, OR:0.46,
95%CI:0.10–2.20,p = 0.33,n = 15,516). The sensitive analysis could
not be done for the limited number of studies. The heterogeneity
was high between these studies(I2 =64%).(Appendix Figs. 8–10)
Postnatal perineal pain within 24 h
Three RCTs reported the postnatal perineal pain within 24 h
with continuous variables. Two studies measured the pain level
with VAS, and one study used visual scale of the McGill question-
naire.
The result of meta-analysis revealed that women in the hands
off/poised group had less postnatal perineal pain within 24 h
when compared to those in hands-on groups(random-effect model,
SMD:−0.99, 95%CI:−1.82 to-0.17,p<0.0 0 0 01,n = 781). The het-
erogeneity was high(I2=94%).There was no difference between
hands on and hands off/poised technique when the study of
Fahami et al. (2012)(MD:−1.60, 95%CI:−3.80–0.59, p = 0.15) or Wu
and Yan(2016)(SMD: −1.39, 95%CI:−3.28–0.49,p = 0.15) was ex-
cluded. (Appendix Fig. 11)
Only one non-RCT provided data on postnatal pain us-
ing VAS within 24 h, for this reason, a meta-analysis could
not be done. This study showed that hands off/poised tech-
nique was associated with less perineal pain in the previous
24hous.(4.78±1.56vs7.52±2.13,p<0.05)
Duration of second-stage labor
Five RCTs provided evidence on duration of second-stage of la-
bor between hands off/poised group and hands-on group. Only
one study specified the duration of second-stage labor as begin-
ning with complete dilation of cervix and ending with expulsion
of the fetus. There was no difference between hands off/poised and
hands on techniques in duration of second-stage labor (MD:−0.19,
95%CI:−6.04–5.66, p = 0.95,n = 1197). The difference remained
non-significant after sensitive analysis. High heterogeneity was
found within these studies (I2 =93%) .(Appendix Fig. 12)
The conclusion drawn from the results of three non-
RCTs is the same with that of RCT(MD:−0.52,95%CI:−5.37–
4.33,p = 0.83,n = 811). The difference remained non-
significant after sensitive analysis. The heterogeneity was also
high(I2 =70%).(Appendix Fig. 13)
Postpartum hemorrhage(blood loss>500 ml)
Two RCTs reported the incidence of blood loss>500 ml. One
study used weighting method and volumetric method to evaluate
blood loss, while another study did not specify the measures. The
results of the meta-analysis indicated that there was no difference
in the incidence of postpartum blood loss>500 ml (random-effects
model, OR:0.44, 95%CI:0.05–3.82, p = 0.46,n = 5611) .The hetero-
geneity was high between two studies((I2 =87%).(Appendix Fig. 14)
Based on the results from two non-RCTs, no difference was
found in the incidence of PPH>500 ml (fix-effects model, OR:0.71,
95%CI:0.31–1.60,p = 0.41,n = 1118) ,the heterogeneity was low be-
tween studies(I2 =48%). Sensitive analysis could not be done for the
limited number of studies.(Appendix Fig. 15)
Discussion
This meta-analysis includes the relevant quantitative studies
that published in both English and Chinese. The inclusion of non-
RCTs strengthened the external validity of this review, while the
RCTs provided better internal validity. In addition, multiple mater-
nal outcomes were evaluated in this study to gain a more com-
prehensive understanding of both hands on and hands off/poised
technique.
In this study, we present results of nine RCTs(7106 women) and
nine non-RCTs(26,218 women) across six countries. Meta-analysis
 J. Huang, H. Lu and Y. Zang et al. / Midwifery 87 (2020) 102712
of RCTs revealed that the hands off/poised technique had more
protective effects on perineum and was safe to use. This technique
involved fewer episiotomies, higher rate of intact perineum and
less perineal pain. Although hands off/poised technique was asso-
ciated with more 1st perineal tears, but this kind of slight injuries
do not cause serious morbidities. Based on the results from RCTs,
this study did not find difference between hands on and hands
off/poised technique regarding the risk of 2nd perineal tears, 3rd
/4th degree perineal tears, duration of second-stage labor and the
rate of blood loss over 500 ml. The results from 9 non-RCTs were
similar with that of RCTs, except for showing less 2nd degree per-
ineal tears in hands off/poised technique than in hands on tech-
nique.
The results from our studies regarding the severe perineal
trauma agree with other systematic reviews, which demonstrated
that the hands off/poised was not associated with higher risk
of 3rd /4th degree perineal tears when compared with hands
on technique (Aasheim et al., 2017; Pierce-Williams et al., 2019).
Furthermore, the presenting findings of episiotomy seem to
be consistent with the findings of previous research, showing
that hands off/poised technique reduced the rate of episiotomy
(Aasheim et al., 2017; Hu et al., 2016). The episiotomy use has been
consistently related with severe perineal trauma (Marschalek et al.,
2018; Yamasato et al., 2016), perineal discomfort (Karaçam and
Eroǧlu, 2003; Sartore et al., 2004), dyspareunia (Sartore et al.,
2004) and lower pelvic floor muscle strength (Sartore et al., 2004).
Accordingly, the reduction in episiotomy that brought by hands
off/poised technique can avoid the episiotomy-related morbidities
thereby improving maternal outcomes. Our results also suggested
that women were more likely to have intact perineum when re-
ceiving hands off/poised technique, which has been proved by pre-
vious studies(Wu et al., al.,2016; Lin, 2014). However, Cochrane
review conducted by Aasheim et al.(2017) did not find any dif-
ference in rate of intact perineum between hands off/poised and
hands on techniques. The results of intact perineum from this
Cochrane review which conducted the meta-analysis of 2 stud-
ies using random model, may be affected by unreliable error es-
timate(Borenstein et al., 2009)
Our study suggested a protective effect of hands off/poised
technique against perineal trauma. Several explanations for this
finding are possible. Firstly, hands off/poised technique allows
gradual extension of perineum by not exerting manual pressure
on it(Fahami et al., 2012), which may help to distribute the per-
ineal tension over a larger area thereby preparing the perineal tis-
sue to accommodate fetus at crowning. Secondly, the absence of
additional pressure on perineum could prevent perineal ischemia.
It has been reported that perineal ischemia may make perineum
more vulnerable to severe perineal tears (Mayerhofer et al., 2002;
Foroughipour et al., 2011).
However, earlier findings suggested that hands on tech-
nique may reduce severe perineal trauma (Laine et al.,
2009; Samuelsson et al., 2000, 2008; Pirhonen et al., 1998).
Bulchandani et al.(2015) reported that routine hands on technique
led to a significant reduction in the risk of obstetric anal sphincter
injuries based on the meta-analysis from 3 non-RCTs. Despite the
fact that the results from non-RCTs demonstrated good external
validity, these results should be interpreted with caution as many
confounding factors may exist. For example, since demographic
and intrapartum factors such as maternal position, parity and
ethnicity (Smith et al., 2013; Wheeler et al., 2012), could influence
the incidence of perineal trauma, the absence of randomization in
non-RCTs might not control the confounding effects brought by
these factors thereby reducing comparability between groups and
leading to a biased conclusion.
Hands on technique has been commonly described as maintain-
ing the flexion of fetal head and guarding the perineum. The use
13
of flexion technique was considered to present the smallest diam-
eter of fetal head through the perineum. Nevertheless, the possible
benefits of flexion technique may not be explained by actual mech-
anism.
Flexion is a part of cardinal movement of labor, which refers to
the normal flexion of descending fetal head to meet the resistance
from cervix or pelvic wall. With complete flexion, the suboccipito-
bregmatic diameter, the shortest anteroposterior diameter of the
fetal head, is passing through the pelvic inlet (Cunningham et al.,
2018). After the inner rotation, the flexed head reaches the vulva
and undergoes extension. Extension is a must for fetal head to
emerge. As there is 90° curve in the birth canal at the level of
ischial spine, the fetal head must negotiate to emerge from the
vagina. With the posterior force exerted by uterus and the ante-
rior force supplied by the resistant pelvic floor and the symph-
ysis, the fetal head moves toward the vulvar opening and the fe-
tus’s neck have to extend, which is a normal course of delivery
(Cunningham et al., 2018; Myrfield et al., 1997). However, if pres-
sure from outside was put on the fetal head to maintain flexion in
the hope of presenting the smallest diameter of fetal head through
perineum, it will not only impede the natural process of labor,
but impinge on the posterior of perineum and eventually force the
head through the perineal tissues (Cunningham et al., 2018). There-
fore, the perineum may either stretch more to accommodate fetal
head, or rupture if the head does not extend but is driven down-
ward (Myrfield et al., 1997) . Both can lead to higher risk of the
perineal trauma.
With regard to the protective effects of supporting the per-
ineum, this was believed to reduce the strain on the perineum.
Zemčík et al. 2012) found that the highest tissue strain occurs at
the posterior fourchette and in transverse direction during the fi-
nal stage of delivery, so they concluded that manual support by
fingers of right hand can be proposed to reduce the tension in
the midline. Jansova et al.(2014) used a biomechanical model to
simulate hands-on and hands off technique. In their study, hands
on technique was described as placing the thumb and index finger
alongside the fourchette and vaginal opening and squeezed against
each other, which is also called modified Viennese method. They
reported that the hands-on technique reduced the maximum ten-
sion in perineal structure by 39%. It is noteworthy that their find-
ings are both based on the data of stereophotogrammetry, which
may need further evidence to support the clinical significance of
effects of hands on technique on reducing tension on perineum.
In this study, hands off/poised technique was associated with
slightly reduced perineal pain within 24 h when compared with
hands on technique. Since perineal pain is closely related to the
use of episiotomy and perineal trauma, the higher possibility of
intact perineum and lower likelihood of episiotomy use may ex-
plain the association between hands-off technique and less per-
ineal pain. However, the sensitive analysis revealed that the re-
sults of perineal pain between hands off and hands on technique
may not be robust enough, because the difference was not statisti-
cally significant when the study of Fahami et al. (2012) or Wu and
Yan (2016) was excluded.
The current study did not find difference in duration of second-
stage labor and the rate of blood loss more than 500 ml be-
tween hands on and hands off/poised technique, which revealed
that hands off/poised did not increase the risk of longer duration
of second-stage labor and postpartum hemorrhage when taking
hands on technique as a reference. These findings are in line with
several studies (Wu and Yan, 2016; Lin, 2014; Huang, 2014) and
demonstrated that hands off/poised technique was safe to use.
Childbirth is a natural process. Undertaking unnecessary in-
tervention without medical indications may disrupt the physiol-
ogy of birth, which might pose adverse impact on maternal and
neonatal outcomes and exhaust physician or midwife (Çalik et al.,
14 J. Huang, H. Lu and Y. Zang et al. / Midwifery 87 (2020) 102712
2018) . The routine episiotomy has been the standard midwifery
practice for a long time for the possible benefits of reducing
the length of second-stage labor (Maimburg and De Vries, 2019).
However, with the compelling evidence from scientific studies,
the widespread use of episiotomy has proved to be harmful to
women (Maimburg and De Vries, 2019). Just like episiotomy, the
effect of exerting additional pressure on fetal head and manipu-
lating perineum have been questioned. The call for fewer unnec-
essary interventions during childbirth may make hands off/poised
technique more favorable than hands on technique. Nevertheless,
hands off/poised technique requires midwife’s close attention to
watch the perineum. This means midwives should recognize the
signs of rapid expulsion and take measures to slow down expul-
sion in time. For the less experienced midwife, hands off/poised
technique can be a hard task. Therefore, more training programs
and theoretical education is needed to qualify practicing midwives.
Overall, the results from present study indicated that the use
of hands off/poised technique may bring better maternal outcomes
among women with low-risk pregnancy undergoing vaginal deliv-
ery in comparison with hands on technique. However, these results
should be interpreted with caution due to the high heterogeneity
among studies. Therefore, more studies with stringent study de-
sign, especially large randomized controlled trial, should be con-
ducted before strong recommendation of the hands off/poised
technique.
The current study has several limitations. First, most of the in-
cluded studies failed to blind participants and intervention per-
formers. The blinding of outcomes accessors was not reported. For
the nature of such intervention, the blinding of participants and
personnel is impossible. As to the blinding of outcomes accessors,
no related details were given in most of the studies, which may
influence the reliability of the results. Second, given lack of data,
some confounding factors that can affect perineal outcomes, such
as maternal positions, parity and ethnicity, could not be controlled
through subgroup analysis. Still, the groups of interest were com-
parable in most of the studies. Third, as the terminology of hands
on and hands off/poised technique has not been specified in the
literature, we only presented the general description in the current
study. For example, the hand placement of “guarding” or “control-
ling the expulsion speed” has not been defined in detail.
Conclusion
This study suggested that hands off/poised technique may be
a promising delivery technique to bring better maternal outcomes
among women with low-risk pregnancy undergoing vaginal de-
livery. Hands off/poised technique entailed more intact perineum,
fewer episiotomies and less perineal pain when compared with
hands on technique. In addition, hands off/poised is safe to use be-
cause it did not increase the risk of severe perineal trauma, post-
partum hemorrhage, and longer duration of second-stage labor.
However, due to the high heterogeneity among included studies,
further evidence is needed to confirm these findings.
Ethical approval
The systematic review was not subject to ethical review.
Funding
None.
Declaration of Competing Interest
The authors declare no conflicts of interest.
Supplementary materials
Supplementary material associated with this article can be
found, in the online version, at doi:10.1016/j.midw.2020.102712.
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