Milksharing etiquette tips

There are many situations where a mother wants to breastfeed but other factors prevent it. Did you know donor milk is an option and is considered by the World Health Organization to be superior to formula?  Human breastmilk is available through milk banks as well as informally through mother-to-mother sharing. Either can be a safe option with proper precautions. The incidence of babies receiving donor milk is unknown, in part because moms are understandably reluctant to disclose this to their pediatrician, and in part because of the popularity of informal milksharing between friends or via groups such as Human Milk 4 Human Babies or Eats on Feets.

Because milksharing (unlike formula) is relatively foreign to most of us, we have not developed societal rules governing the relationship between donor and recipient. It is intensely personal to both moms, one who wants the very best for her child and is brave enough to seek it out, and one who is literally giving of her body out of the desire to honor another life.  My years of milk donation have helped me identify some areas where things can go wrong.

If you are pumping for donation:

  • The first rule is obviously to make sure you have no bloodborne diseases. You should have received testing for HIV, hepatitis, etc, during your prenatal care – of course everything should be negative and I’m just going to say that you should be in a mutually monogamous relationship to prevent your acquiring and transmitting diseases unknowingly. Anything less is morally repugnant in the danger it poses to the recipient of your milk.
  • Handle all milk, pump parts, bottles, etc with clean hands.  If you touch your face, change a diaper, or answer the phone, wash your hands again before you touch anything that will touch the milk. Wash and sterilize pump parts after use. Keep storage bags at room temperature, not in a hot car where their integrity can be compromised. Use common sense and don’t contaminate the milk.
  • It is unnecessary to sterilize your nipples but shower daily and wash your bra daily as well. A wet bra breeds thrush and no one needs that.
  • Store the milk properly. Ideally it should go straight into a chest freezer or if you are sharing fresh milk, the refrigerator. If you forget and leave it out on the counter all day, sorry – toss it out. It’s not nice to take risks with someone else’s baby.
  • Eat a clean diet. Do not smoke or use illegal drugs. Disclose all medications you are taking to the recipient family. Ideally your doctor will have cleared your medications for your own baby but your recipient family may have different standards for their baby and that’s ok.
  • Let her know she’s a great mom.  After all, she is seeking the best nutrition available to her – your milk.  Let her know you think she’s doing a great job!

If you are receiving donor milk for your baby:

  • Provide the containers. Remember that without this milk you would be buying formula, and this milk is far superior and costing you nothing. So cheerfully buy bags of your donor’s choosing.
  • If your donor is pumping for you on an ongoing basis, it might be more economical for you to provide storage bottles instead. When you pick up the filled bottles, you can provide a clean empty set. Note I said “clean”. It is amazingly, horribly rude to bring dirty bottles that have had milk sitting in them for a week, and ask your donor to wash them before she fills them up with her pumped breastmilk. You’d be surprised to know that people actually do this.
  • We don’t need to say that this is a million times more disgusting if you are bringing the donor dirty bottles you got from a *different* donor. It is never ok to tell a donor that she will “need” to wash someone else’s breastmilk out of the bottles you are asking her to fill for your baby. Remember the only thing she HAS to do is feed her own baby.
  • Don’t act entitled. Helping you feed your baby is a privilege, but that doesn’t translate to an obligation on the donor’s part.  Say thank you. If there is something you can do in return, do it, whether that means making her something or offering your skills as a computer repairperson or photographer or landscape designer. Yes, you have a new baby to care for – but so does your donor, and in addition to feeding her own baby, she is taking time away from that baby to sit and pump (while scheduling pumping sessions around her own baby’s feeding), wash pump parts, properly store milk, and meet up with you to deliver that milk. She wouldn’t be doing any of this otherwise.  So make her happy to do it for you.
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When choosing a childbirth class…

This AWESOME pic comes from, created in honor of HER single mother!

This AWESOME pic comes from, created in honor of HER single mother!

.. what is important to you?

There is something that has been bothering me for a while, ever since I was pregnant with my oldest, actually, and taking natural childbirth classes to prepare for the unknown.  Namely, the glut of natural childbirth methods that cater specifically to married couples while ignoring the fact that over half of all women giving birth are unmarried.

What does it say about a childbirth class that teaches, “You’re married, good!  You deserve a great birth!”  What is the corollary to that statement?  “You aren’t married, too bad. Go figure it out for yourself.  And if you can’t, tough.  You should have thought of that before you got pregnant.”

I mean, seriously.  Is that really a class that anyone, married or not, should be taking?  I know that there are many of these classes that are very good – as long as you fit the exclusive criteria required for entry.  But it marginalizes and ostracizes everyone else, and that is something I can’t tolerate.

In looking at my past doula clients and Lamaze students, I see women in a variety of life situations.  Yes, some are married and wanting a doula because they see the value of having professional labor support even though their husband will be at the birth.  Some are married and wanting classes because they are savvy enough to know how much they don’t know about birth (yet.)  But plenty of my past clients and students have been single moms who are having a baby without a husband to coach them through it.

There’s only one way to fertilize an egg.  But women come to pregnancy in a variety of ways, only one of which is get-married-then-decide-to-have-a-baby.

  • Maybe the couple is engaged but decided to postpone a wedding until after the baby is born and the mama can fit into a smoking-hot wedding dress.
  • Maybe it’s an on-again, off-again relationship with a man who is unsuitable for raising a child, so the mother chooses to have little or no involvement from the baby’s father.
  • Maybe the baby’s father left her when she became pregnant.
  • Maybe the mother has decided that she doesn’t want or won’t ever find “Mr Right”, but chooses to use a sperm donor so that she can still have a child.
  • Maybe the mother was widowed during the pregnancy.

What about these women?  Whether they chose to be single mothers, or whether the circumstance was forced on them, don’t they deserve their best possible birth too?

I believe that every woman deserves to know exactly what her birth options are, and the chance to knowingly choose what is right for her and her baby.  Childbirth classes are a huge piece of this puzzle.  Just reading a popular pregnancy book isn’t going to cut it. No Facebook page or birth blog can give women the same richness of information as a good childbirth class.   Nothing can replace the human connection gained in a birth class – between teacher and student, between each woman and her birth team, and from one expectant mother to another.  A birth professional’s local knowledge is invaluable. And the ability to reach out for information at any time you need it – I can’t even begin to think what that is worth.

Don’t all women deserve this?  I think so, which is why my classes have the most diverse set of students of any non-hospital class in North Alabama.  I love working with all mothers, whether their birth partner is their husband, boyfriend, sister, mother, or me as the doula.  :) My goal is to give women the tools they need to achieve their safest and most satisfying birth possible.

*Disclaimer: Of course I teach Lamaze, which is not a method per se, but a philosophy of pregnancy, birth, and early parenting.  By providing evidence-based information, Lamaze education empowers women to gain confidence in their bodies, trust their inner wisdom and to make informed decisions about pregnancy, birth, breastfeeding and parenting. All this without bias, pressure to birth a certain way, or judgement of your choices.  If your childbirth class doesn’t do that, shouldn’t you look elsewhere?

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Do: be sure your care provider meets your needs

Advice to pregnant women often centers on things we shouldn’t do in labor: don’t have a convenience induction, don’t lie on your back, don’t do any number of things.  I think it’s really important to give moms options of things they *can* do.  Anyone can not do something, it’s what you *do* instead that matters.  So with that in mind, I want to look at a few things that women should do.

Do: switch to a care provider who meets your needs, whatever those needs are.

Look at your care provider and your prenatal appointments. Do you see a different practitioner every time? Is your provider a 2-minute, in and out, doesn’t really care about you or your family, kind of provider?  Is that the kind of person in whose hands you really want to place your life, and your baby’s life?  Is that the kind of person who will do their best for you, or their best to avoid a lawsuit?  I’m sorry to say that there are plenty of care providers who do practice this way.  The good news is that there are also those who don’t.  While I believe strongly in the midwifery model of care, I also know that respectful caregiving has little to do with a caregiver’s credentials, and everything to do with putting the laboring mother’s needs first.  We are fortunate to have some very good, respectful OB/GYNs in our state who understand that birth is healthy and normal, not a medical event.

Especially if you are a first-time mother, you will do well to choose the kind of care provider who will do everything in their power to help you have a physiologically normal vaginal birth.  While c-sections are lifesaving when needed, the risks are high for you, baby, and future pregnancies so it only makes sense to avoid one.  Is your care provider going to decide that a c-section is less time-consuming, more fun, and more profitable?  Often the first sign that your provider is planning to perform an unnecessary c-section on you is evident in your prenatal appointments.  Dr Johnathan Weinstein, OB/GYN, says it far better than I could – This should be required reading for all pregnant women.

We all have things that are especially important to us, while we are less particular on other things.  So where does your caregiver line up with your beliefs?  If you are adamant on not having an episiotomy, make sure you choose a provider who rarely performs them.  (There are some who do them on just about every woman – which is both unsupported by the evidence *and* just plain wrong, especially if the woman prefers her perineum intact.)  Other issues that might be on your shortlist are physiological third stage, pushing in an upright position, food/drink in labor, etc.  Whatever you particularly value for your labor, make sure your provider is on board.  If they begin to add statements like, “Well, that’s a great goal but remember that very few women can do that in their birth” or “Insurance (or hospital) policies don’t allow us to do that” or “In my experience many first-time moms need [x, y, or z that you’ve just said you didn’t want]…”  it’s probable that you’re not going to get what you want.  Caveat emptor.

Often it can be hard to break up with your care provider, even when you know you deserve better care than you’re getting. We worry that they’ll be mad at us.  We feel like bad patients who have let them down or somehow defaulted on a contract. Sometimes we rationalize that probably nothing will go wrong. Look at it this way:  if your gut tells you something is wrong, it probably is.  And you have too much on the line – your body, your baby, your future health – to gamble on a care provider who doesn’t respect you.

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Ten questions to ask your OB or midwife

Have you heard of the Coalition for Improving Maternity Services?  They have developed a list of 10 questions to ask care providers, to be sure that the offered care is mother-friendly.  Go on, ask your OB or midwife these questions, and then comment below and let us know what they said!




Have you decided how to have your baby? The choice is yours!

Evidence based information from CIMS, Coalition for Improving Maternity Services:

First, you should learn as much as you can about all your choices.  There are many different ways of caring for a mother and her baby during labor and birth. Birthing care that is better and healthier for mothers and babies is called “mother-friendly.” Some birth places or settings are more mother-friendly than others.

A group of experts in birthing care came up with this list of 10 things to look for and ask about. Medical research supports all of these things. These are also the best ways to be mother-friendly.  When you are deciding where to have your baby, you’ll probably be choosing from different places such as:

  • birth center,
  • hospital, or
  • home birth service.

Here’s what you should expect, and ask for, in your birth experience. Be sure to find out how the people you talk with handle these 10 issues about caring for you and your baby. You may want to ask the questions below to help you learn more.

1. Ask, “Who can be with me during labor and birth?”

Mother-friendly birth centers, hospitals, and home birth services will let a birthing mother decide whom she wants to have with her during the birth. This includes fathers, partners, children, other family members, or friends.

They will also let a birthing mother have with her a person who has special training in helping women cope with labor and birth. This person is called a doula or labor support person. She never leaves the birthing mother alone. She encourages her, comforts her, and helps her understand what’s happening to her. They will have midwives
as part of their staff so that a birthing mother can have a midwife with her if she wants to.

2. Ask, “What happens during a normal labor and birth in your setting?”

If they give mother-friendly care, they will tell you how they handle every part of the birthing process. For example, how often do they give the mother a drug to speed up the birth? Or do they let labor and birth usually happen on its own timing?  They will also tell you how often they do certain procedures. For example, they will have a record of the percentage of C-sections (Cesarean births) they do every year.  If the number is too high, you’ll want to consider having your baby in another place or with another doctor or midwife.

Here are numbers we recommend you ask about.

  • They should not use oxytocin (a drug) to start labor for more than 1 in 10 women (10%).
  • They should not do an episiotomy (ee-peezee-AH-tummy) on more than 1 in 5 women (20%). They should be trying to bring that number down. (An episiotomy is a cut in the opening to the vagina to make it larger
    for birth. It is not necessary most of the time.)
  • They should not do C-sections on more than 1 in 10 women (10%) if it’s a community hospital. The rate should be 15% or less in hospitals which care for many high-risk mothers and babies. A C-section is a major operation in which a doctor cuts through the mother’s stomach into her womb and removes the baby through
    the opening. Mothers who have had a C-section can often have future babies normally. Look for a birth place in which 6 out of 10 women (60%) or more of the mothers who have had C-sections go on to have their other
    babies through the birth canal.

3. Ask, “How do you allow for differences in culture and beliefs?”

Mother-friendly birth centers, hospitals, and home birth services are sensitive to the mother’s culture. They know that mother and families have differing beliefs, values, and customs.  For example, you may have a custom that only women may be with you during labor and birth. Or perhaps your beliefs include a religious ritual to be done after birth. There are many other examples that may be very important to you. If the place and the people are mother-friendly, they will support you in doing what you want to do. Before labor starts tell your doctor or midwife special things you want.

4. Ask, “Can I walk and move around during labor?  What position do you suggest for birth?”

In mother-friendly settings, you can walk around and move about as you choose during labor. You can choose the positions that are most comfortable and work best for you during labor and birth. (There may be a medical reason for you to be in a certain position.) Mother-friendly settings almost never put a woman flat on her back with her legs up in
stirrups for the birth.

5. Ask, “How do you make sure everything goes smoothly when my nurse, doctor, midwife, or agency need to work with each other?”

Ask, “Can my doctor or midwife come with me if I have to be moved to another place during labor? Can you help me find people or agencies in my community who can help me before and after the baby is born?”  Mother-friendly places and people will have a specific plan for keeping in touch with the other people who are caring for you. They will talk
to others who give you birth care. They will help you find people or agencies in your community to help you. For example, they may put you in touch with someone who can help you with breastfeeding.

6. Ask, “What things do you normally do to a woman in labor?”

Experts say some methods of care during labor and birth are better and healthier for mothers and babies. Medical research shows us which
methods of care are better and healthier. Mother-friendly settings only
use methods that have been proven to be best by scientific evidence.

Sometimes birth centers, hospitals, and home birth services
methods that are not proven to be best for the mother or the baby. For
example, research has shown it’s usually not helpful to break
the bag
of waters.

Here is a list of things we recommend you ask about. They do
help and may hurt healthy mothers and babies. They are not proven to
be best for the mother or baby and are not mother-friendly.

  • They should not keep track of the baby’s heart
    rate all the
    time with a machine (called an electronic fetal monitor). Instead, it
    is best to have your nurse or midwife listen to the baby’s
    heart from
    time to time.
  • They should not break your bag of waters early in labor.
  • They should not use an IV (a needle put into your vein to
    give you fluids).
  • They should not tell you that you can’t eat or
    drink during labor.
  • They should not shave you.
  • They should not give you an enema.

A birth center, hospital, or home birth service that does
things for most of the mothers is not mother-friendly. Remember, these
should not be used without a special medical reason.

7. Ask, “How do you help mothers stay as comfortable as they can be? Besides drugs, how do you help mothers relieve the pain of labor?”

The people who care for you should know how to help you cope with
labor. They should know about ways of dealing with your pain that
use drugs. They should suggest such things as changing your position,
relaxing in a warm bath, having a massage and using music. These are
called comfort measures. Comfort measures help you handle your labor
more easily and help you feel more in control. The people who care for
you will not try to persuade you to use a drug for pain unless you need
it to take care of a special medical problem. All drugs affect the

8. Ask, “What if my baby is born early or has special problems?”

Mother-friendly places and people will encourage mothers and
families to touch, hold, breastfeed, and care for their babies as much
as they can. They will encourage this even if your baby is born early
or has a medical problem at birth. (However, there may be a special
medical reason you shouldn’t hold and care for your baby.)

9. Ask, “Do you circumcise babies?”

Medical research does not show a need to circumcise baby boys. It is painful and risky. Mother-friendly birth places discourage circumcision unless it is for religious reasons.

10. Ask, “How do you help mothers who want to breastfeed?”

The World Health Organization made this list of ways birth
services support breastfeeding.

  • They tell all pregnant mothers why and how to breastfeed.
  • They help you start breastfeeding within one hour after
    your baby is born.
  • They show you how to breastfeed. And, they show you how to
    your milk coming in even if you have to be away from your baby for work
    or other reasons.
  • Newborns should have only breast milk. (However, there may
    be a medical reason they cannot have it right away.)
  • They encourage you and the baby to stay together all day
    and all night. This is called “rooming-in.”
  • They encourage you to feed your baby whenever he or she
    wants to nurse, rather than at certain times.
  • They should not give pacifiers
    (“dummies” or “soothers”) to
    breastfed babies.
  • They encourage you to join a group of mothers who
    breastfeed. They tell you how to contact a group near you.
  • They have a written policy on breastfeeding. All the
    employees know about and use the ideas in the policy.
  • They teach employees the skills they need to carry out
    these steps.

Would you like to give this information to your doctor,
midwife, or
nurse? This information is taken from the Mother-Friendly Childbirth
Initiative written for health care providers. You can get a copy of
the Initiative for your doctor, midwife, or nurse by mail, e-mail, or
on the Internet.

To Get a Copy by Mail For a copy of both this brochure and the
Mother-Friendly Childbirth Initiative by mail, send a stamped,
self-addressed envelope with $5 (US) to help cover the costs ($6 Canada
or Mexico, $10 all others). Bulk prices are available. Mail to:
Coalition for Improving Maternity Services 1500 Sunday Drive, Suite 102
Raleigh, NC 27607

To Get a Copy on the Internet Log on to to

Contact CIMS Tel: 888-282-CIMS (2467) • Fax:
919-787-4916 E-mail:

© 2000 Coalition for Improving Maternity
Services (CIMS).

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Class series beginning April 1

Seats are going fast and there are just a couple left! More information, including a link to register online, at the “Lamaze classes” link above.

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Question of the Day:

Q. “If I take your Lamaze class and then later hire you as my birth doula, do I have to pay your full fee on top of what we spent on the class?”

A.  Glad you asked – of course not!  Class fees can be applied towards my doula fee if you hire me later, meaning you get both a full-length Lamaze class and skilled doula care for only $550.  That’s a considerable bargain!  Not only do you get the cost savings, but after spending 5 class nights working together to prepare you for birth, we’ll already have a great rapport that will carry over into your labor.  I love when my Lamaze students hire me to be their doula!

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Continuous fetal monitoring – is it right for you?

The evidence shows that intervening in the normal physiological process of labor carries a host of risks that, in a healthy woman carrying a healthy baby, are not justified by the  benefits.  (It should also be noted that many of these “benefits” are for the caregivers and not the laboring woman, but that’s another post altogether.)

By far the most common labor intervention is the use of continuous fetal monitoring.  According to Childbirth Connection’s Listening to Mothers Survey II, 2006, 94% of mothers were given EFM and of those, 93% were monitored continuously (76%) or most of the time (17%).  If you will be giving birth in a hospital, the chances are that you will be offered continuous monitoring in your labor.  Sounds great, right?  You can make sure that your baby is doing well every second of your labor!

But there’s something you should know: the evidence shows that continuous monitoring does not improve outcomes for mothers and babies.  In fact, for a low-risk woman, it can increase risk of an unnecessary c-section or instrumental delivery. It is estimated that continuous monitoring results in 1 additional c-section for every 58 women monitored.  I’m thinking of one local hospital that does probably 60 deliveries a day.  That’s something like 1 extra cesarean every single day.   Think about that.

We’ve known for at least 20 years that intermittent auscultation, where fetal heart rates are monitored with a fetoscope or handheld doppler for a few minutes every hour, is at least as safe as continuous monitoring with EFM. There are no differences in newborn mortality, admission to the NICU, Apgar scores, or cerebral palsy between women who are monitored intermittently and those who are monitored continuously.  Nearly every professional birth-related medical organization (the American College of Obstetrics and Gynecologists, The Association of Women’s Health, Obstetric, and Neonatal Nurses, The American College of Nurse-Midwives, the American Academy of Family Physicians, as well as the US Preventative Services Task Force) recommends intermittent auscultation over continuous monitoring and publishes guidelines for its use. (See the references for links that you can print out and take to your care provider.)


One main drawback to EFM use is that it severely restricts mobility.  The internal version uses a monitor screwed into the baby’s scalp and a catheter placed in the uterus to measure the strength of the contractions, and requires artificial rupture of membranes and mom staying in bed.  The external version fastens around the mother’s abdomen with wide elastic belts and in theory allows mom to get up and move around (at least as far as her “leash” allows.)  The information from both internal and external EFM is fed to video screens and a strip recorder at the bedside.

In practice, what normally happens is that (being a large elastic belt, heavy monitors, and trailing wires) EFM is bothersome to many moms, like having a scratchy tag or a rock in your shoe.  That’s if it stays in place, which often it doesn’t if the woman is laboring normally and is moving around.  Sometimes they’re very fiddly and slip at the slightest movement.  Then the monitor starts squawking and the nurse comes in with varying degrees of frustration and disapproval to adjust it.  The laboring mother feels chastened or guilty for having to make her nurse stop what she was doing to come in and fix the monitor. Because the nurse has to make the adjustments, she’s not in charge of what she’s wearing on her own body.  (How empowered would you feel in your daily life if you couldn’t zip your own pants or tie your own shoes?)  The monitor is most accurate when she doesn’t move, and so to avoid making problems for others she finally gets back in bed. Lack of movement leads to more pain, a willingness to receive more interventions, and increased likelihood of a cesarean.  Not good.

The other big pitfall with EFM (and this might just be a function of the medical model of care) is that it is looking for problems – and makes it more likely to find them.  Interpretation of the strips varies widely from caregiver to caregiver and even reading to reading.  Check out this quote from George A. Macones, MD, who headed the development of the ACOG Practice Bulletin on EFM.

“One of the problems with FHR tracings is the variability in how they’re interpreted by different people. The ACOG guidelines highlight a case in which four obstetricians examined 50 FHR tracings; they agreed in only 22% of the cases. Two months later, these four physicians reevaluated the same 50 FHR tracings, and they changed their interpretations on nearly one out of every five tracings.”

Whoa.  The natural conclusion to many is that, since we can’t be 100% accurate in our readings, anything that looks “nonreassuring” should be treated as an emergency just in case it really is.  This is a great way to avoid a hefty malpractice suit but not so good for mothers and babies.  One Cochrane systematic review even found in increase in perinatal deaths when CFM was used – definitely not what we are all going for.

From a support professional’s experience, I can also say that there is a definite tendency to watch the monitor instead of the laboring woman.  And a laboring woman needs and deserves to be the focus of everyone’s attention.  Women are not simply a thing in the corner to be ignored while her loved ones are caregivers are fascinated with the thing that goes “beep”.

As with any intervention, there are times when CFM is indicated.  These situations may include, but are not limited to, previous c-section, fetal growth restriction, induced or augmented labor (Pitocin is a strong risk factor for fetal distress), and pre-eclampsia.  In the absence of risk factors, intermittent auscultation is the better choice for most women.  I recommend you discuss monitoring with your care provider.  If CFM is recommended, ask why, and be wary if the answer is not that you have a condition requiring CFM, but “so we can keep an eye on your baby.”



Lamaze for Parents – guide to EFM

ACOG announces new fetal monitoring guidelines

ACOG guidelines for fetal monitoring

practice guidelines for fetal monitoring from the American Academy of Family Physicians

Association of Women’s Health, Obstetric, and Neonatal Nurses fetal monitoring guidelines

American College of Nurse-Midwives fetal monitoring guidelines

US Preventative Services Task Force on EFM

Cochrane summary on CTG/EFM

Alfirivic, Z. et al. (2006) Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour.

Grivell, R. et al. Antenatal cardiotocography for fetal assessment. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007863

Evidence Based Birth

Goer H, Leslie M. S, Romano A. The Coalition for Improving Maternity Services: Evidence basis for the ten steps of mother-friendly care. Step 6: Does not routinely employ practices, procedures unsupported by scientific evidence. The Journal of Perinatal Education. 2007;16(Suppl. 1):32S–64S.

Thacker S. B, Stroup D. F. Continuous electronic heart rate monitoring for fetal assessment during labor. 2001. Cochrane Database Systematic Review (2): CD000063.


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Avoiding perineal damage, part 3

Yay!  You’re finally in labor!  Don’t forget about your perineum – you’re going to have to live with it for the rest of your life, so keep it happy during your birth.  In no particular order, here are some steps you can take during birth to avoid tearing.


Being upright and mobile will help keep your perineum intact.  Aside from the other problems caused by birthing in the stranded-beetle position, you are much more likely to tear on your back and especially if your legs are in stirrups.

As Henci Goer says in her excellent and highly-recommended book, The Thinking Woman’s Guide to a Better Birth:

“Give birth upright, or at least avoid giving birth in a position that stretches the legs wide apart.  If your perineum is already under tension, it has nowhere to go.”

Makes sense, right? Keeping the thighs closer together means the perineum has more slack available to accommodate baby’s head and shoulders.  Also remember that in birth, gravity is your friend.  It helps your perineum stretch gently and slowly, which is the key to avoiding tears.  If you are exhausted or just not feeling like being upright, a side-lying position is a good choice.

Pushing technique

If I had a pet peeve regarding birth, directed pushing would be the big one somewhere on my top five list.  By “directed pushing” I mean valsalva pushing, aka “Purple Pushing” where you hold your breath and push hard while nurses shout, “1-2-3-4-5-6-7-8-9-10-and-right-back-into-it-1-2-3″ in your face.  On the other hand, spontaneous pushing is just that, pushing controlled by your own body’s urges.  The Royal College of Midwives has this to say about spontaneous pushing:

“Furthermore, the natural blowing out between breaths that occurs encourages her pelvic floor muscles to relax and reduces the risk of tearing.”

We bring a lot of preconceived notions to the birthplace, and the idea that we have to push hard to give birth is one of them.  Don’t get me wrong, it feels wonderful to push.  But if we slow down or don’t push at all, the baby will still come.

Directed pushing may be necessary in an emergency or when you can’t feel anything due to an epidural (though if it were me I’d choose to watch my contractions on a monitor so I could direct my own pushing.) In a normal, nonmedicated birth it’s not indicated, so feel free to request that the cheerleaders back off and let you do your own thing.

Timing of pushing

It’s best to wait until you feel the urge to start pushing.  The need to push is triggered by baby’s head hitting a specific cluster of nerves.  It only happens when baby is in the right position to be born.  Until then, even though your cervix may be dilated 10 cm, it’s probable that baby is not yet lined up correctly. Remember that baby is an active part of the birth process. Pushing prematurely is not going to make your baby be born faster, it’s just going to put you on the clock (setting you up for a “failure to progress” cesarean) and exhaust your energy.

Often moms who are encouraged to push before they’re ready are made to feel like they’re weak and their pushing is ineffective.  They push and push for hours, yet nothing happens.  They become too tired to carry on with upright positions, and end up in stirrups.  The nurse begins to suggest directed pushing techniques “to see if it helps you progress”.  Then when mom is exhausted and willing to accept the directed pushing, the nurse assures her that “now you’re making progress!”  when in fact absolutely nothing is happening, still. After a while of this, mom’s confidence in herself is completely shattered.  She feels like she must not be good at giving birth, because how else could she be giving 110% and still her baby isn’t born?  At this point, the situation begins to frustrate mom, partner, and caregivers.  Caregivers are more likely to intervene and mom is ready to accept things she never would have accepted 12+ hours ago because she just wants this baby out!  And mom’s perineum becomes collateral damage.

Also consider that every care provider measures dilation a little differently.  One nurse’s 10 cm might be another nurse’s 8 cm.  So being told you are fully dilated doesn’t mean you immediately have to push.  If you’re not feeling the urge, it might be better to lie down and take a quick nap to store up some energy while your uterus and baby finish their work of  lining baby up to navigate the bony passages of your pelvis.  Don’t worry, you won’t sleep through it.  (Don’t we all wish, right?)

Avoiding episiotomy

Episiotomy is a cut made at the perineum to enlarge the vaginal opening.  It is a second-degree incision (cuts through the skin and muscle.) Many caregivers perform this intervention routinely as they mistakenly believe this prevents more severe tears from occurring.  The evidence shows that what actually happens is that the incision often splits further toward the anus and a 3rd or 4th degree tear is the result.  If you think about it, that makes sense – if you make a cut at the edge of a piece of fabric, then pull, the fabric will tear at the cut, right?  The structural integrity is already weak at that point, so that’s where it gives.  Avoid the episiotomy and you have taken steps toward avoiding a severe tear.

Choose a caregiver who rarely performs episiotomy.  Make your wishes known in advance.  Remember that you can always refuse consent or withdraw consent if you had previously given it.  Some moms line-item things like episiotomy on their general consent form -eg, “I do not consent to episiotomy.”

Avoiding instrumental delivery

The evidence shows that instrumental delivery (ie, vacuum or forceps extraction) increases the rate of perineal trauma.   This makes sense as most caregivers will also cut an episiotomy before extraction of the baby. The evidence also shows a dramatic reduction in severe perineal trauma when using vacuum extraction as opposed to forceps, but this benefit to mothers carries the tradeoff of greater risk to the baby in the form of hematomas and retinal hemorrhage.  The good news is that having continuous support in the form of a doula is proven to reduce the rate of instrumental delivery.  Have professional labor support and your perineum just might thank you.

Refuse “ironing it out”, or massage during labor

As we said last time, extremely gentle perineal massage during pregnancy = good.  Perineal massage during labor = bad.  Why? Short answer, it makes the perineum swollen and more likely to tear.  This is not the same type of swelling that occurs with engorgement during arousal, it’s the swelling that happens as a result of trauma.

The evidence on massage during labor is mixed – some studies have shown no harm, others have shown the primary benefit to be a decrease in the use of episiotomy, and many have shown an increase in lower-degree spontaneous tears when massage is used.  All state that it is best left up to  the mother to decide.  Personally I’m in the “don’t massage” camp, as I’ve only seen it associated with tearing.

The massage I often see performed in my local hospitals is aggressive.  The normal method is to insert a gloved and lubricated finger into the vagina alongside the baby’s head, then to rapidly run the finger from side to side while pulling the perineum away from the baby’s head. Alternately two fingers are used in a spreading motion. Usually this stretches the perineum farther than the baby’s head would normally push the tissues.  Sound painful?  I think it’s safe to say that most of us don’t yank on our own perineums (or ask our partners to touch us) in this way.  Generally when we touch ourselves and something hurts, we stop.  If someone else is touching us, they obviously can’t feel when it hurts us.  Not being able to adjust the massage to the body’s signals can lead to small lacerations that will only split further when baby’s head is born.

An example I heard once was to recall your days of making faces as a child, and put a finger in each side of your mouth and pull hard while massaging the insides of your cheeks. Do this for 30 minutes or more.  What happens?  Do your lips become pliable and stretchy?  Or does your mouth start to crack and bleed?  Now extrapolate.  (Ouch.)

Besides all that, there is the issue of the laboring mother still being an autonomous person and deserving of as much personal space as is possible to give her while safely assisting her in birthing her baby.  In no other situation would it be acceptable to touch someone else’s genitals without permission/invitation; why is it suddenly ok just because a woman is giving birth?  At the very least, perineal massage is a procedure that should require informed consent just like any other.  Sadly, I’ve never seen that happen.  It behooves you to let your nurse know your preferences before you get to that point, then have your partner or doula watch out for signs that your nurse is about to iron you out and intervene if necessary.

Warm compress/oil

Some moms appreciate the sensation of a warm compress placed on their perineum during crowning.  It is thought by many to hydrate the tissue and increase blood flow, and so to lessen tearing.  I am not aware of good studies to back this up, but if you want to try it, there is no risk and only potential benefit.

Likewise, adding an oil such as olive, sweet almond, or coconut can reduce the stinging sensation of crowning.  Some midwives like to do this to add a dimension of slipperiness and to protect against chafing, and also to help the tissue stretch slowly.  Again, no good studies on this, but if you want to do it, feel free.

Stay nourished/hydrated

You probably have noticed that when you get dehydrated, your skin becomes dry, cracked, and easily irritated.  Your perineum is no different.  If you want your perineum to be stretchy and elastic, eat and drink in labor if you want. One very important function of your birth partner is to offer a drink between every contraction and to be sure you empty your bladder at least once an hour.  I always tell the partners in my classes not to ask, just to hold it out to her.  And use a straw.

Your hospital probably has policies against consuming anything other than ice chips.  Of course I would never recommend you go against medical advice, but some mothers find themselves eating the snacks they packed for their husbands.  Just saying.

And if you do get hungry in labor and decide to eat – light snacks like honey sticks, crackers and nut butter, broth, fresh or dried fruit, etc, are nourishing and will keep you energized as well as being sure that your skin has adequate blood flow and nutrition.  In one of my labors I was so hungry that I ate several packets of oatmeal, and in another I didn’t want a thing besides orange juice and water.   Your body knows what it needs to get you through this work – go with its cues.


The complicated interplay of hormones that drive normal birth is too vast a topic to cover adequately here, but suffice it to say that when birth is undisturbed and mom’s normal birth hormones are in balance, blood flows to the perineum and her skin is more elastic.  This is another benefit of laboring without intervention in a quiet, dark place.  It’s a great reason for a laboring woman to have continuous support from a loved one, friend, or doula.

Avoid vaginal exams

Ok, vaginal exams are also a contender for the top spot on my “annoying birth interventions” list.  With regards to the perineum and potential tears, cervical checks are irritating to the perineum (as well as the cervix, but that’s another blog post of its own.)  Irritation = tears.  Unless there is a terribly compelling reason to check dilation (and charting ‘progress’ doesn’t count), it’s not worth the chafing.  VEs by themselves probably won’t cause a tear, but combined with other factors, it can be enough to tip the scales.

Remember that you matter, too

I see a tendency for moms to be pressured into accepting pain, emotional trauma, and long-term effects to their health as “part of birth”.  Some people feel that if you have a healthy baby, that should be enough.  Well, I disagree.  Your baby needs you to be healthy so you can hold him, love him, feed him, and spend hours looking into those amazing eyes.  Your partner needs you to be healthy so that you can grow into your role as parents together.  And you deserve to spend the first few days of parenthood taking pictures, feeling blissful, and feeling confident in your role as a parent – not suffering every time you sit/go to the bathroom/move the wrong way.  You matter.  Make sure your birth is an experience you will be satisfied with for your whole life.  Demand the best care you can get.  And take care of your perineum.  You’ll be glad you did.


Rockner G, Jonasson A, Olund A. The effect of mediolateral episiotomy at delivery on pelvic floor muscle strength evaluated with vaginal cones. Acta Obstet Gynecol Scand 1991;70:51-4.

Evidence Report/Technology Assessment No. 112, The Use of Episiotomy in Obstetrical Care: A Systematic Review (AHRQ Publication No. 05-E009-2)

Altman, D, Ragnar, I, Ekstrom, A & al, e 2007, ‘Anal sphincter lacerations and upright delivery postures – a risk analysis from a randomized controlled trial’, International Urogynecology Journal and Pelvic Floor Dysfunction, vol. 18, no. 2, pp. 141-6.

Goer, H.  The Thinking Woman’s Guide to a Better Birth. Perigee Books, 1999.

Enkin M, Keirse M, Renfrew M, Neilson J. 2000. A guide to effective care in pregnancy and birth (Rev. ed.). New York: Oxford University Press.

Kettle C. Tohill S.  Perineal care.  Clin Evid (Online). 2008; 2008: 1401.

Perineal massage in labour and prevention of perineal trauma: randomised controlled trial.
Stamp G, Kruzins G, Crowther C  BMJ 2001 May 26;322(7297):1277-80

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Avoiding perineal damage, part 2

Last post, I discussed the need to have a plan for avoiding damage to the perineum during labor. Don’t wait until labor to start thinking about it! While the perineum is designed to give way when necessary, and then to heal afterward, why not do everything you can now to avoid serious damage?

These are some things you can try before giving birth:


A varied, nutrient-rich diet of unprocessed foods is the best way to make your skin supple and healthy.  There are a few foods you can add to your diet if you’re trying to improve your skin’s health. And of course, better nutrition can only benefit you and your baby!

Perineal Massage

Massaging and gently stretching the perineum before birth (NOT to be confused with the “ironing it out” some caregivers perform during labor) can help the perineum stretch during birth. The idea is to gently stretch the perineum gradually over a period of time, just like people who gauge their ears increase the size of their gauges very, very slowly. Doing daily massage increases the blood flow to the perineal tissues and makes tears less likely. It will make you aware of the “ring of fire” feeling that usually accompanies crowning so that in labor, you can relax the pelvic muscles and know when to stop pushing and let the baby ease out gently.  An excellent pdf instruction sheet produced by the American College of Nurse-Midwives can be found here.

The Cochrane says that “Antenatal perineal massage helps reduce both perineal trauma during birth and pain afterwards.” and, “Women should be informed about the benefits of antenatal perineal massage.”

It also goes without saying that you are the best person to massage your own perineum, since only you know how it feels and when enough stretch is enough. Alternately, your partner can also do this massage. It has been proven effective with a first baby, although if you’ve already given birth,there are norisks so you certainly can massage if you choose.


When baby is posterior (back of baby’s head faces mom’s spine), tears are more likely because the position increases the diameter of the part of the baby’s head that is coming out.  If you’ve been told your baby is posterior, there are a series of exercises you can do, plus changing the way you normally sit, that can help your baby rotate around to an anterior position.  I reference often because it’s such a wonderful resource for helping moms to understand their baby’s position in the womb, and also for techniques to help get baby lined up in the best position possible for easier birth.


Positions such as squatting and tailor-sitting stretch the perineum gradually over a period of time.  If you wait until labor to try squats, you are more likely to tear.  This may be one reason why midwives report more tears when a birth stool is used – women are unused to squatting in daily life.  It only makes sense to begin gently stretching your perineum earlier in pregnancy.  I recommend you try sitting in a squat, half-squat, or cross-legged while reading or watching tv, at least 30 minutes a day total or more if you’re comfortable.


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Avoiding perineal damage, part 1

After giving birth, nearly every mother feels somewhat bruised and sore.  For most moms who have had their baby vaginally, a large portion of this discomfort is in the genital area, and most specifically the perineum, the diamond-shaped area between the vagina and anus.  There are varying degrees of perineal trauma after childbirth:

  • Intact:  There is no injury.  A red, swollen appearance is normal for a day or two.
  • Grazed/scraped:  Just as it sounds – there may be a few tiny tears similar to anal fissures or the miniscule chafing you get as a kid when you stretch your mouth open with your fingers to make a silly face. It is also common for the labia to have tears or abrasions. These require no repair, only good hygiene, and heal well and quickly.
  • First degree:  The skin and underlying tissue are torn.  This probably requires no repair, or at most 1-2 stitches are placed.
  • Second degree:  The skin, underlying tissue, and muscle are torn.  An episiotomy – a deliberate surgical incision of the perineum – is at least a second degree injury in nature.  Repair is usually recommended but with a natural tear is up to the woman to decide.
  • Third degree:  The skin, underlying tissue, and muscle are torn across the perineum and up to the anus.  Interestingly, these tears often start with an episiotomy that continues to split further.
  • Fourth degree:  The skin, underlying tissue, and muscle are torn across the perineum and on into the anus and rectum.  Third and fourth degree tears are extremely rare and require extensive repair.

It should be noted that the perineum normally tears and heals during birth.  In women who are adequately nourished, hydrated, and supported in normal birth (therefore with her normal hormones present), the perineum is elastic and rich in oxygen-carrying blood vessels.  Severe tears are less likely and healing is faster.  However, you can pretty much expect to have some degree of laceration because that is what your body is designed to do – tear.  The goal is to minimize this as much as you can.

When making plans for your birth, what is your goal for your perineum?  It may seem strange, but this should be part of every mother’s birth plan.  Here’s why:

  • Perineal management varies widely from caregiver to caregiver.  If you don’t make a plan, you’re going to get your caregiver’s plan, and it may not be what you want.
  • Tiny lacerations heal in a day or two and can be ignored, but an episiotomy or larger tear can take weeks to heal.
  • While healing from a larger repair, most women experience significant pain, itchy stitches, discomfort when sitting, burning during urination, and a tough time defecating.
  • In the long term, the evidence shows that compared with a natural tear, episiotomy takes longer to heal, causes incontinence, and is associated with painful sexual intercourse for months afterward.
  • It’s your perineum and you have to live with it.

Next post, things you can do before giving birth to avoid perineal damage.

Goer, H.  The Thinking Woman’s Guide to a Better Birth. Perigee Books, 1999.

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