This post, "But my vagina!" by Jennifer Block is a beaut.
There's heaps of great advice, and research studies, from the experienced midwives of the USA Gentle Birth Archives - Avoiding Tears and Episiotomies
Here's another excellent article by Midwife Gloria Lemay - A Midwife's Guide to an Intact Perineum
Here's a post about good nutrition to support skin integrity and elasticity: Protecting Your Perinuem From the Inside Out - Vitamin C, Vitamin E, healthy fats, selenium, silica and cysteine.
A thoughtful perspective by Dr. Rachel Reed of Midwife Thinking: Perineal Protectors
Here is my personal experience:
All four times I gave birth, I was in some kind of a kneeling position. This just happened to be my preferred position, but there is research that suggests it is associated with less perineal damage. The first and third time I did not tear. I did have a little tear with the second birth, due to it being pretty fast and I forgot to 'back pedal' (she was born in a hurry in a shopping mall!) The fourth time, I was in a birth pool and did have a small tear that did not require suturing, and healed well.
Some women just have lovely stretchy vaginas. All vaginas are designed to stretch, are tough, strong, stretchy and tensile, and heal beautifully from minor tears. Yay, the vagina!
Here's my thoughts on supporting optimal wellbeing for the birthing vagina and perineum:
* Grab a copy of My Pelvic Flaw to learn about really good pelvic floor exercises.
* Consider perineal massage and gentle vaginal exploration. I don't believe you need to stretch or condition your tissues. They're naturally designed to stretch. But, gentle massage and exploration might be good for a mumma to get in touch with her body and *discover* just how awesome, strong and stretchy it is. That was my experience, anyway. Jenny Blyth's book, Birth Work, has some wonderful wisdom on vaginal exploration and preparation. If you are one of my clients, let me know if you'd like photo-copies of the relevant pages, or would like to borrow the book.
* Use a birth pool & give birth in water! The gold star standard for perineal care.
* Listen to your body and ban 'Directed Pushing'.
* Gravity, uterine contractions, the foetal ejection reflex, and volitional pushing are 4 different forces that are involved in the expulsion of the baby. You rarely need all 4 forces happening at once. In an uncoached, un-coerced birth, the FER is really strong. When the mother just goes with it, she rarely needs to push and strain.
* Wait until the urge to push is absolutely overwhelming. Don't start pushing because you've been *told* you're fully. Don't start pushing as soon as you first start feeling pushy. Welcome and celebrate when you first start feeling that unmistakeable pushy feeling. But if you can, keep breathing through the pushiness until it's just so overwhelming that you can't hold off any longer. Blow out forcefully if you have to. I watched one first timer mama do this in a strong rhythm: "puff-puff BLOW! Puff-puff-BLOW!" The rhythm really helped her stay in control and resist that urge. Then - just go with it! Mischief can be caused by *telling* a woman to 'push', or if you're an impatient mama and you give into that litle demon whispering in your ear that if you push heaps now you can get this over. Tell that imp to shut up and go away. Heaving and shoving and pushing too hard too soon could be counterproductive and set you back. Keep breathing ... be patient ... trust your body ... kinda boycott the pushing thing for a while ... eventually it will be so full on, it will be undeniably the real thing. As Gloria Lemay says in her beaut article, Pushing for First Time Mothers, "Wait till you're '11 cm dilated' before starting to push."
* Get gravity on your side and make sure you have the freedom, and the motivation, to follow what your body is compelling you to do. A very few women actually do like to push on their backs or on their sides. But make sure you're not doing that because of the subconscious influence of The Bed, the instructions of the staff, or the influence of images you've seen in books and the media.
* This study of 1068 women showed that 70% of women planning a homebirth had an intact perineum, without serious tears requiring stitches. In first time mothers, it showed that if you give birth either kneeling or on hands and knees, and your perineum is supported manually by the midwife, you are less likely to tear; and that perineal massage while you are pushing out the head actually increases the likelihood of damage to the perineum. For mothers who have given birth before, these factors increased the likelihood of damage: being aged 40 or over; weight gain over 18 kg; previous episiotomy; and the use of oils or lubricants.
So, if you are keen to avoid tears and damage to your perineum and vagina, consider these factors:
- birth at home
- give birth on hands and knees or kneeling (I would also suggest in a birth pool)
- don't bother using oils or lubricants
- have your midwife support your peri if you're a first timer (the water does this for you if you're in a birth pool.)
* Consider using only one or two of the 4 forces. Such as, gravity and the FER, but not pushing. Or, pushing gently between contractions rather than during contractions. That's when you're trying to ease bub's head out really gently. (I nailed this with birth #3). Or, eliminate the gravity factor if it's coming too fast, by kneeling into a knee-chest possie, or lying down in the birth pool or on your side, for example. You may not need to use all the 4 forces all at once, especially if the birth is progressing well and the baby's head is advancing. Some women find kneeling, then dropping their head down into a knee chest, helpful to slow down a fast second stage to a manageable speed.
* When you can feel that burning ring of fire, you're as good as done. That burning is your signal to BACK-PEDAL. In most cases, strenuous pushing efforts are no longer needed. It's time to stop pushing, and just b-r-e-a-t-h-e your baby out. Don't be tempted to rocket that wee bub across the room. It's better to gently ease your bub out over the length of a couple of contractions than give into the urge to 'just get it out' (through gritted teeth)!
* Watch the shoulders! Congrats, you just birthed the head - awesome! Now, gently does it with the shoulders. Unless the shoulders are sticky and there are concerns about possible dytocia, there's NO RUSH! Sometimes large heads are born with no tear, then little shoulders cause a rip because of too much rush.
* Reach down and feel inside your vagina, and touch your baby's head. You can feel just how close your baby is. As the head starts to emerge, a little more each contraction, reach down and feel whenever you want to, if it helps you connect with how your body is stretching and how you're progressing. This tactile approach helps some women know 'where they're at'. Other women would rather shut their eyes and do it all by feel. But your fingers belong there more than anyone else's fingers.
* Watch that second birth! If you had a long arduous first time labour, you might not realise how much quicker your next birth could be - especially if bub #2 comes along within about 3 yrs of the first.
* As a special treat for your healing body after giving birth, try the Post Natal Bliss bath herbs, lovely for the tender healing tissues and ideal for taking the baby in the bath with you for skin-to-skin cuddles.
Some Victorian Statistics from the Perineal Data Collection Unit
In 2005, 222 women in Victoria gave birth at home.
Intact perineums:
40% of Victorian women who gave had vaginal births in hospital that year had intact perineums.
80% of women who had vaginal births at home had intact perineums (this includes minor tears and grazes not requiring suturing.)
Sutured Tears:
38% of women having vaginal births in hospital had perineal or vaginal tears that required suturing.
16% of women who had homebirths required suturing.
Episiotomies:
22% of women having vaginal births in hospital had episiotomies.
4% of women who had homebirths had episiotomies (after transfering to hospital)
Epidurals:
26% of women having vaginal births in hospital had epidurals.
None of the 222 women who planned homebirths had epidurals, including those who transfered during labour.
Instrumental Vaginal Extractions:
13% of women who had vaginal births in hospital had forceps or ventouse extractions.
6% of women who planned homebirths had ventouse or forceps extractions after transfering to hospital.
In 2008, 560 women in Victoria had planned homebirths.
Here is an article from Mama Birth's blog, "How To Push - your official guide"
When and How To Push - Providing the Most Current Information About Second-Stage Labor to Women During Childbirth Education.
Another useful article: Birth Sensations and protecting the perineum through it all
Be aware that there are differing schools of thought on the benefits of pelvic floor exercises versus squats - read more here
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