Keeping perineum intact

Hi there

This might be a question for the midwives - I'm currently doing the childbirth education classes at my maternity hospital and they showed us the stats for the month of July. There were only 15 intact perineums, and 66 were either unsutured tears (I remember it was 11 for that category), sutured tears or episiotomies. I was quite shocked by this and asked if this was a "bad" month - to which I was told it was actually pretty good, and better than June.

The one thing that does worry me about labour is tearing/episiotomy. I always believed that since a woman's body is designed to give birth, tearing or episiotomy would be the exception rather than the rule, rather than the other way around, and that I would be "unlucky" if this happened to me. So I'm feeling a bit unsettled at the thought that it's quite unlikely I'll get through labour with an intact perineum - at least, according to those stats!

So...my question is - does perineal massage really help? I know they say they have no hard scientific evidence that it does, but I thought the midwives out there might be offer an educated opinion or some anecdotal experience...?

Rates of tearing and episiotomies are much higher in hospitals than they are at homebirth where the woman's body is left to do it's thing. Private hospitals are also worse for this than public. Being flat on your back on bed is not helpful to this yet this is what most women do for some or all of their labour, which is certain if you have an epidural. Not only does the chance increase from this, but once you have the epidural which can then lead to ineffective pushing (can't feel it properly if at all) then forceps may be used which often means an episiotomy.

Hospitals are there to control and manage the process of childbirth which doesn't run in our favour as birthing women. They have policies to protect themselves, speed things up and this often means these interventions. So you have to inform yourself about what you don't want, your rights etc.

Giving birth in water is brilliant for supporting the perineum as is birthing upright. Warm compresses can be used, and Ina May Gaskin has a manuvure she successfully uses which is discussed in one of her books.

Also when in fear, or anxious, some women don't relax their pelvic floor/perineum and the pushing fights against this - so educate yourself outside the hospital (New Active Birth by Janet Balaskas or The Thinking Woman's Guide to a Better Birth), get great support and trust your body!!! It is capable of blowing those stats out the water.

Jules I had a 4.13k bub (9lb1oz) & did no masage with no tearing at all. I think when you logically conclude that passing a medium watermelon (for want of a better object) through a hole designed for a lemon some women will inevitably tear & some wont.

This goes to variables like skin elasticity, size of the baby etc. Experienced & patient midwifes can minimise risk by asking you to wait, stop pushing (which can be a big ask at that point) & realigning skin/bubs head etc.

If perenial massage will give you a sense of mental preparedness then go for it, that can only be a benefit but my personal opinion is that, as with all statistics, it is truly a numbers game. Some tear & some dont.

I read somewhere that rubbing Almond Oil daily on the perineum from 32wks on can help?!?! :dunno:

hi
i think it depends on the way the baby is sitting, when i had my dd 3 weeks a go i needed one as she got stuck he had a ring around her head when she was born

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I think when you logically conclude that passing a medium watermelon (for want of a better object) through a hole designed for a lemon some women will inevitably tear & some wont.

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I think apart from the other things I mentioned, the psychological aspect can be a biggie too. If you think about the above comment in labour, you are only going ot be less reluctant to let the baby come freely as you are waiting to tear. One mum said that she envisaged a walnut coming through a toilet seat to relax the area and baby was born fine and well.

Also, if you take a look at the stats I posted for tearing / episiotomy for homebirth, it's a massive difference to that in hospital. So it's not something to expect to tear. Do your research and find ways to minimise intervention which relate to tearing and episiotomy. It's amazing that many, many midwifes with tens of years of experience never perform them or have had to perform them once. Doesn't this say something? ;)

:confused: we are talking about a piece of flesh either being able to stretch to accommodate, or alternatively unable to stretch to accommodate (and hence tearing). I don't see how psychology enters into it. That would be like saying that women get stretch marks on their belly because psychologically they are reluctant to allow their skin to stretch to accommodate the baby bump. Some women have more collagen and their skin is more pliable (lucky ducks!) whereas others are bound to stretch and tear. Of course having a forceps delivery will virtually guarantee tearing, but I don't think that's what Melody is talking about. BTW Melody you lucky duck not tearing at all with such a big bub!!

Until you support women at birth Sal, you just wouldn't understand :) You need to try to relax the perineum - and come on, how many of us do because we don't get told, or we are so scared of tearing, the 'ring of fire' etc if you haven't had an epidural. Fear of birth and pain is an absolute epidemic and psychological blocks are a big problem - I have seen many of them first hand in births where there has been past sexual abuse, generally feeling 'unsafe' and fear of 'tools'. It is possible to be so tense and fearful that you tighten up in places you never thought possible and nor-adrenaline kicks in and the whole process stops or as observed by midwives and doulas, even goes backwards. My teacher has been studying it for years, based on books written on the topic by further experts on the psychology of birth and the way it's changing.

If for a moment you can think with an open mind for a second and take into account the experience of many, many midwives who trust in a womans body to stretch (and know how to help naturally), they are the keepers of normal birth and have NEVER had to perform an episiotomy or perhaps once in their life you will be open to new things and realise the system is less than ideal, infact hideous compared to countries like NZ, Holland, Europe... rather than have blind faith in the medical system. How come a country so well, healthy and abundant has such poor ratings in the outcomes for birth reports? We are well down the list. You can be happy with a great outcome in terms of baby being safe, but who goes into birth wanting their OWN body to be cut, forced and pulled about? Thats not our idea of a peaceful, beautiful birth perhaps romantacised about prior to. Look at it from a textbook perspective if you may but I'm sorry, thats not the way real-life is.

So I can blame my multiples tears on my psychological state? No way! I tore because Miles had a big head (37cm) and because my skin doesn't have all the pliability that I'd like it to have, which runs in my family. I also got stretch marks on my belly because it runs in the family to get stretch marks.

I'm just not sure that it's helpful for women to think that if only they have the right mindset that they will definitely remain tear-free. It actually sets up for feeling worse about the experience afterwards...how easy for others to then just say 'oh well you weren't relaxed enough'.

I am not saying this is the case for all women but I definitely think this is something to consider given so many of us are fearful about birth - someone made a comment about a watermelon out of something the size of a lemon. Doesn't paint a nice picture. So try to picture a walnut going through a toilet seat and give it your best shot. But many women do have an episiotomy when it is not required. Hear examples all the time of the scissors being suggested or gotten out and the baby is born fine or even shoots out quickly - another thing to do with fear called the 'ejection reflex' has a place too in the birth room... there is just not one answer for everything, or one problem, I like to start with the least interventive, first.

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I'm sorry, thats not the way real-life is.

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Hmmmm. Real life, in African countries with third-world medical facilities, leaves a frightening number of women with horrific obstetric injuries (and deaths of mother and/or baby) and complications (eg obstetric fissures). It is nice to do the 'back to nature' thing and encourage women to try for as natural a birth as possible, but how lucky that it can be done with a first-world medical safety net.

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someone made a comment about a watermelon out of something the size of a lemon. Doesn't paint a nice picture

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That would be me and as far as a common-sense, logical example of your probability to tear vs. getting through tear-free goes..... it is spot on. No emotive 'la la' language used at all. The question was "Does perineal massage really help?" & you responded with all sorts of IMO 'fear based' language around high interventions & episiotomies in private hospitals.

I very much doubt that a woman at the 'business end' of labor is going to be thinking of watermelons.... so my clear response about skin elasticity & the size of the baby seems as relavent as any response anyone else made AND YET you still chose to come in & "one-up" me....

"Anyone who is pleased with a highly intervented birth is kidding themselves"
I had an epi in a private hospital with a team of midwives & a wonderful obstetrician & he had forceps at the ready.... if Hunter was in danger I would beg him to use them.... I am in no way delusional about my satisfaction at holding a healthy baby in my arms, we can't all give birth in the bush under the stars.....

In the context of whether or not perenial massage helps? the answer is debatable but the contributing factors are not. Skin elasticity, size of baby & attending Ob/Midwife.
All the emotive & condascending language in the world won't change that.

You are comparing third world to Australia? Please.... They have no support there - no midwives to guide them or help them, no medicine, no nothing... sorry but I wont change my mind. :) These women have nothing, poor nutrition, poor health, we have education about birth, midwives who are prepared to be by their side and we have books to read about active birth to help us avoid all that. They too are probably scared out of their brain knowing what happens to women before them. Why don't you do further study or reading and specialise in birth psychology - you might find it interesting and helpful to so many women...

Ladies, our bodies are amazing and designed to stretch, open and give birth to babies. It just shows how far we have to go if you truly believe otherwise.

I think you took my comment out of context - we wouldnt care if intervention saved our baby, but no-one willingly wants to be cut, forceps etc if its not necessary.

So little confidence in women's bodies as it is, I am trying to help reduce that fear and keep things as normal as possible (while still saying some intervention is needed), but too many continue to feed it...

Again, we are in the top few of the healthiest, welthiest countries, but in terms of outcomes and intervention at birth, we are waaaaay down the list. It's KNOWN that we have far too much intervention and we aren't going to change things unless angry mothers get loud voices and say that this isn't what we want. But the amount of women truly confident in their bodies, their rights and willing to do that is very low.

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Fear of birth and pain is an absolute epidemic and psychological blocks are a big problem - I have seen many of them first hand in births where there has been past sexual abuse, generally feeling 'unsafe' and fear of 'tools'. It is possible to be so tense and fearful that you tighten up in places you never thought possible and nor-adrenaline kicks in and the whole process stops or as observed by midwives and doulas, even goes backwards.

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Kelly (and anyone else who could help), I don't want to hijack this thread at all, but I have a question regarding this comment and any advice you can give as I find myself in this situation (past sexual abuse). So much so that I have trouble relaxing enough to let my husband 'in', so to speak, when we make love (and we have been together for almost 6 years!). I am not sure that my fear will allow me relax enough to let the baby pass through, although I realise that a lot of that is out of my control anyway.

I have looked into waterbirth as I think that will really help a lot and feel I could do it then (maybe in combination with dimmed lights), but unfortunately the only place that does waterbirths where I live is fully booked. The private birthing suite of my public hospital does have a bath but I dont think they allow birthing in the water, only labouring, and besides I am a public patient.

Do you have any advice on how I could best prepare myself? I would really like to try for a vaginal birth as I think it will be very empowering, and besides I have issues with csearean anyway and lack of feeling and control of that area - and feel like the only way I would cope would be if my husband were to be able to 'stand guard' for me in the theatre! So sorry about this, but this is my greatest fear, more so than then pain of labour etc.

Babydustplease....I'll be giving birth to my first soonish enough, and in terms of best preparing myself I firstly read all the birth stories on BB, read up all of the threads in labor and birth, and best of all, read 'New Active Birth' by Janet B.....it is such an encouraging book for us preggies to read.....so much so that I'm looking forward to labor and birth without any fear (that might come in a few weeks time though!). This may sound naive, but as they say, 'knowledge is power' and the more positive you are about your bodies capabilities, the better off you are.....
You can also find solace in the fact that I should be giving birth seven weeks ahead of you, and if I can do it then you can too!

ps: Kelly, I love that walnut/toilet seat thing!

babydust, what state are you in? I would recommend HypnoBirthing for you as a possibility but you might find that it makes you feel vulnerable. If you are in Melbourne, contact Diane Gardiner - she has a website of her own name and has some great results. :) Past sexual abuse can be tricky, you need to do lots of work on you and lots of healing - there is a great book, 'When Survivors Give Birth' I think by Penny Simkin - grab a copy of that too. I also have some women's healing course details that has been forwarded to me not long ago, so let me know what state and I will give you more info.

Kelly - I just googled her name (Diane) and couldn't find anything... I am quite interested in hypnobirthing (even though ity might be a little late!)

Sorry - typo! http://www.dianegardner.com.au/ - she may do one on one with you or a crash course if you ask nicely :) Say you are from BB ;)

Kelly I don't want to hijack this thread either, but I just have a quick question regarding the perineum, There was a lip of my cervix caught on Cooper's head, and therefor the Obs had to have his hand "up there" pushing it back as I pushed down with each contraction for the first couple of pushes. I ended up having an episiotomy, which I assume was in order for his hand to fit whilist pushing my cervix back.

Firstly - have you seen this, and does it always require you to be cut?

Secondly, I am really interested in getting a copy of my notes from both births, do I go straight to the hospital or do I have to go via the Obs and do the hospital have to get his permission to release the information to me? :help:

Relle, the lip occurs with your cervix (not the perineum which is the skin on the outside below your vagina) and is a tiny amount of cervix that hasn't opened. I've not heard of anyone having to be cut for this, but perhaps you can ask why he did it. There are some things you can do apart from an internal to get the lip to go, by using positional changes, lunge type of positions where there is a bit of movement in different directions to get the last bit to dilate. Most doctors will just know to push it back.

To get your notes, you can go direct to the hospital I believe. You can have access to your own notes.

Thanks Kelly, will look into getting a copy of them!

Hi Relle, I also have never seen anyone perform an episiotomy to push an anterior lip over the babies head. Most often, if a lip will not slip over easily the practitioner will suggest position change (as Kelly said) and wait for a period of time for the lip to go away.
Obviously the issues within this thread are touchy and i can see everyone's point of view. I think there are lots of ways in which labour and birth can be a 'mind over matter' kind of thing but i also know that sometimes that just isn't enough. No woman wants to tear and no woman wants to have an episiotomy but sometimes it's necessary. It doesn't matter how experienced a midwife is, he or she is stil able to help women through second stage to avoid perineal trauma, i haven't been doing this for years and years but i have caught my fair share of babies and i have only ever had 1partial third degree tear and this was related to being positioned on the birth stool and having a shoulder dystocia with a 4.9kg baby, i have only had maybe 5 second degree tears at the most. I have had intact perineums with previous third degree tears and that is due to a good working relationship between myself and the woman so i do argue the fact that "experienced midwives" can help to prevent perineal trauma. (I mean they can, but experience doesn't necesarily have anything to do with it IMO)
I have also been in a birth with a very 'natural' midwife who was caring for her friend in the birth center. Unfortunately this womans perineum just didn't stretch up. This woman was extremely active throughout her labour and repeated positive mantras to herself throughout 2nd stage. As bubs head was begginning to crown a pinhole appeared, the midwife asked for the scissors but before she was able to perform an episi the perineum shattered and the woman ended up with a 4th degree tear. So positive thinking and visualisation doesn't always work and hence the reasons for episiotomies being around in the first place. I am an absolute believer that episotomies should only be used when truely needed and i don't think there would be many midwives who would think differently from me. Doctors, of course, are a different story.
It is absolutely 100% true that womens bodies were designed to give birth. But as with everything in this world even the best laid out plans go to the dogs. I am 100% a midwife. Yes i do work in a hospital BUT i also believe in womans choice and womans ability and i will not have that belief challenged by anyone, however with that belief and faith in woman also comes the knowledge that things DO go wrong and without medical intervention we would have a significantly higher mortality rate. I guess where i'm going with this is to say that just because a woman has an a birth that involves medical intervention, this doesn't mean that she has had a "less than ideal birth experience". Maybe she hasn't had your ideal birth experience or my ideal birth experience but who are we to judge what her ideal birth experience is? We are all individuals. I personally would never in a million years go through an obstetrician for pregnancy and birth care as i know there is no way my ideal birth experience would be fulfilled, however many women love their obstetricians and wouldn't have their birth any other way. I have looked after all sorts of women - some women want birth as natural as possible where other women want an epidural as soon as they feel their first contraction! Other women have elective cesarean's for any number of reasons and it is my job as a midwife to support women in whatever birth they desire to the best of my ability.
I see the flaws within our system, i know they're there, i know the intervention rates are too high and i know that we ned more one-on-one midwifery care but i do think it's wrong to judge any womans birth experience as less than perfect because she had intervention and i think statements such as this have the ability to promote guilt amongst women who have had intervention during labour and birth. Some things just are out of everyones control.

Sorry to ramble guys - and i hope i haven't offended anyone :)

I've reworded my post because I didn't put it right - I often post in between disruptions... I am not saying that one birth is better than the other but what I mean is that we all don't want to have anything that in unnecessary - I am pretty sure that is universal and I don't mean caesareans just anything. And what ideal birth is to one woman varies between the next, absolutely. We all have to support women for the birth they want, so it's important to make sure you trust your care provider and do your research into what's important to you. Also the psychological aspect was just something I added and I am not saying it's the only cause, but it got drawn out as it was questioned as a valid option. But I believe that too does happen from time to time - again not the only reason why but can be a contributing factor.

To address the main question, yes the rates are high and that is of concern to me as a woman.

I totally hear you about the high rates but look at how far we have come already!! You know those births where the mothers or mother-in-laws are support people and you can almost always be guaranteed to hear the famous words: "i remember when i had (insert name) and i had to lay on the bed with my feet in stirrups"(and lets not get me started on the whole separation from babies in the postnatal period) In some cases this was only 20 years ago. So we have come a long way. And with higher numbers of midwives and midwifery led services, not to mention websites like this that help inform and empower women, things can only get better. I'm not sure about other states but here in NSW we curently have two stand alone midwifery services and many other midwifery group practices, and NSW Health is in the process of introducing a 'homebirth policy' which i think is a great move forward.
It's kinda nice to see these sort of debates don't you think? Shows how passionate we all are about women and childbirth and that can only be a good thing :D

Chelleg, well said sweety :)

ETA What a shame I missed out on their HB policy. But a fantastic thing that they are implementing it :)

Chelleg, well said sweety :)

I totally agree Trish, it was well said and covered everyone's point of view!

My 2nd birth did have medical intervention, but it was my choice and ultimately I had the delivery I was after (Bar the cut!)

Hi Kelly,
I am in the ACT. I will try and get a hold of a copy of the book you mentioned.
I am not sure about hypnobirthing, but I will do some research and find out a bit more about it.

Babydustplease,
you are in a great place for hypnobirthing!
Peter Jackson is in Bowral and does the best! When I did his course, there were lots of midwives who came from ACT.

He has a website called calmbirth and runs courses on weekends as well as through the week. GL

Hi all

I haven't had computer access for the last 4 days and I was certainly surprised to see the debate I triggered in my absence...

There are a lot of useful comments in here though - and it sounds like that I'm really just going to have to take my chances! I don't have my heart set on a completely natural birth, even though that is my ideal, because I've read in other posts how devastated some women are if that didn't happen - which I think is a great shame, because in the end, as long as Bubs comes out okay with a minimum of damage to mum - that's really all that matters. I would have every intervention procedure under the sun, if I had to, in order to ensure my baby boy is okay.

It's a first baby, so I do find the idea of perineal trauma a bit frightening, but the hospital I am going to is actually very supportive of active birth, and the beds fold in such a way that gravity can still be used if the woman has an epidural. I have New Active Birth and some other natural birth type books, so I shall go in there fairly educated anyway. I'm planning on having a chat with my obstetrician beforehand and the midwives on duty and I've worded up DH - so I feel that really, I'm doing all I can do and the rest I shall leave to the angels!

I have heard the "watermelon through lemon sized hole" comment many times before so I wasn't fazed by it. I do however like the "walnut through the toilet seat" analogy and will keep it in mind!

My mother has been very interested in the changes in childbirth policy in hospital (eg no stirrups, using gravity/not lying on back, getting to hold the baby straight away) and thought it was absolutely wonderful. I agree that while childbirth may still be over-managed medically - the pendulum certainly seems to be swinging the other way, thanks to passionate childbirth advocates and midwives, and rather than wish things were "perfect", I am simply very glad to be giving birth in a first world country at a time when natural birth is far more accepted than it has been in a very long time, but the best medical assistance will be available to me and my baby, should I need it. I think I'm a very lucky girl!

As for perineal massage....can't say that I was too keen on giving it a go to be perfectly honest, I'll try it out, but if I don't like it - I won't stress!

Thanks ladies.