No Pushing: Perineum Tears
No Pushing: Perineum Tears
PUSH! BREATHE! COUNT! REPEAT!
Before our first was born, my husband had terrifically incorrect ideas about childbirth. He thought that my water would break, we would rush to the hospital, there would be lots of yelling about pushing and counting and breathing and then, POP! Our baby would scream her way into the world while the doctor, holding the baby upside down by her feet, paddled her little tushie and we would all go home. All in about thirty minutes, or the length of a standard sitcom, which is where he learned everything he knew about childbirth. Until we took birthing classes, he had no concept of the excruciating pain, contractions, epidural, monitoring, positioning, tearing, after-birth, gooey mess that would accompany our daughter’s entry into the world. I had a concept, but believe me, the reality was much different and more personal.
Perineal tearing often accompanies childbirth, with an estimated 95% of women experiencing this unintended, spontaneous tearing. Perineal tearing is tearing of the flesh between the vagina and anus and is measured in degrees of severity, from one to four. A first-degree tear is the slightest tear, involves the lining of the vagina, and often requires no, or little, suturing. Fourth-degree tearing extends to the anal sphincter and rectal lining, is the most complicated tear to repair, and is thankfully the least common. It is seen mostly with births where the baby gets stuck and the use of forceps or a vacuum is necessary. Second and third-degree tearing are in the middle and make up the majority of tears. If you’ve never experienced perineal tearing, trust me, you don’t want to; it is as painful as it sounds. There are several factors that can lead to tearing such as: first births, as the skin has never been stretched to such magnitude; a birth that progresses very quickly, not giving the mother’s body time to stretch and adjust; pushing too hard, too fast, or for too long; the baby’s position during the birth; and size of the baby relative to the size of the birth canal.
What’s the Backstory?
Perineal tearing is nothing new and medical science has been trying for a long time to lessen tears, or at least the effects of tears. In a mostly bygone era, obstetricians used to intentionally cut the perineum, in a procedure called an episiotomy, to avoid tearing. This procedure was carried out with medical grade scissors and I have heard stories that it sounded like cutting thick denim material. In the 1970s, 80% of first time births were accompanied by an episiotomy. However, this procedure was not all it was cracked up to be and did not deliver (pun intended) on the promises of maintaining the integrity of the female anatomy, reducing the pain of recovery, and pain reduction of post-recovery intercourse. Luckily, according to the Mayo Clinic (2015), episiotomies are no longer recommended except in very specific cases. Thank heavens!
Hot Off the Press
England’s Medway NHS Foundation Trust’s maternity team recently received an award for their STOMP program, a trauma prevention method that focuses on position, speed, and coaching techniques during childbirth. STOMP has reduced both the amount and severity of injuries that women endure during childbirth, such as perineal tearing. The team was able to reduce third and fourth degree tearing from 6% nationally down to 1%!
Local doula, Katie Lamb, was asked about not pushing. “Well, it's more that we encourage women to allow their bodies to do it for them. In an unmedicated labor, during the pushing phase, there's a feeling that's described as an ‘urge to push’. Instead of using that feeling to bear down with all your might and count for a certain amount of time, like in a coached pushing, it's recommended that you let your body naturally bear down with the contractions as much as it's going to do anyway. Your body will push pretty much on its own. Resisting any attempt at making it harder, faster, or timed a certain way is what you're going for.” Some doctors call this mother-led practice of pushing with the urge “laboring down”.
Lauren Standridge, a local doula with Baton Rouge Birth Services, said that she has never been with a mother who could resist that natural urge to push! She has seen that many providers are starting to let the mothers follow their instincts and go with their urge to push, but notes that some mothers need guidance to figure out how to push effectively. She has experienced births where the physician has encouraged mom to actually stop and take a break from pushing to allow the perineum time to stretch on its own. Birthing professionals try to encourage mothers to ease the baby through the perineum, not tear through it. She recommends warm compresses to the perineum, which can help soften and gently stretch this tissue and reported, “Between pushes mom should absolutely rest. Rest, breathe and try to take your mind off of everything that is going on.”
Position of the mother can also play a role in preventing perineal tearing. Let gravity play its part. Lying flat on your back to labor does not take advantage of gravity, and the force of the baby’s head to push on the cervix, to help birth. “A supported squat definitely helps, as does hands and knees. A side lie with help supporting a leg up is also good for opening the pelvis. In fact, many birth professionals will use a peanut ball (think yoga ball but peanut shaped) between their knees in a side lie for resting, or if they have an epidural and it is challenging to assume other positions because of reduced feeling. It works very well!” added Lamb. Trying different positions can also help with babies who are misaligned and whose head is not applying enough pressure to the cervix.
Help the Healing
The first thing you can do to avoid inflicting trauma on these delicate parts is to not wipe after using the restroom. Most hospitals and birthing centers will provide a small water squirt bottle use to clean your perineal area, then gently pat dry. Tip for the new mom: use warm (NOT hot, NOT cold) water. Pain relievers may be used in spray form (this was my personal favorite). Avoid pushing too hard to go to the bathroom. Ask for a stool softener if you aren’t given them after giving birth. Avoid sexual intercourse until you are healed. Sitz baths, warm shallow baths that cleanse the perineum, can also provide needed relief.
As long as mother and baby are fine, there shouldn't be any hurry in pushing. If a mother is fully dilated but has no urge to push, don't push. Patience here can change the game! One mom reported that she took her time with contractions and did not push until she felt the urge, “If I had been with a professional less patient than my midwife, that would have been a c-section, but she (baby) came on her own terms!”