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.

Position

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.

Hormones

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.

References:

http://summaries.cochrane.org/CD005123/antenatal-perineal-massage-for-reducing-perineal-trauma

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.

http://www.rcmnormalbirth.org.uk/stories/if-at-first/second-stage-pushing/

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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