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Perineal Protection / Avoiding Tears and Episiotomy

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See also:

Subsections on this page:


See also: Pelvic Floor Exercises / Kegels

Protecting the perineum during operative vaginal delivery - Free CMEs

Epino is effective, if used correctly, where there is a desire to prevent perineal damage at birth [April 2016] by Judy Slome Cohain - BJOG 2016 review of EPINO (1) found Epino Birth Trainer not to be effective, but the study uses non-evidence based protocols like episiotomy and the women used the Epino incorrectly. I am the only EPINO researcher without conflict of interest (2). Episiotomy is medically obsolete.(3) All Perineal tears are preventable. (4) Over 2 million people have watched the technique for how to deliver vaginal births without a tear. (5) 500 scientists registered on ResearchGate…

Perineal tears can be eliminated. The protocol that results in no tears on first births or subsequent births, regardless of birth weight:

Consider the fact that a horse vagina delivers a 100 pound foal without tearing, same for cows, and their vaginas are more or less the same diameter in width as human vaginas. The horse penis is about the same diameter as human penis, just longer.
If you push the head out slowly the skin does not tear. Pretty simple, it is a question of an extra minute: Judy's birth and placenta birth

The Epino helps women learn what it will feel like to push slowly. Using the Epino once for 5 minutes at 38 weeks, results in zero second degree perineal tears. The Swedish population described here - has 70% epidural rate and those women, if you don't let the epidural wear off, won't feel how to push slowly. But it can be explained to them not to push at crowning.

The Epi-No birth trainer makes it easier to accomplish 100% ...

Episiotomy is Obsolete: Cinnamon gel applied after episiotom...

Testing the Epi-No birth trainer where episiotomy is not practiced

Minimizing Genital Tract Trauma and Related Pain Following Spontaneous Vaginal Birth
Leah L. Albers, CNM, DrPH, and Noelle Borders, CNM, MSN
J Midwifery Womens Health 2007;52:246–253

"The following techniques and care measures are associated with lower rates of obstetric lacerations and related pain following spontaneous vaginal birth: antenatal perineal massage for nulliparous women, upright or lateral positions for birth, avoidance of Valsalva pushing, delayed pushing with epidural analgesia, avoidance of episiotomy, controlled delivery of the baby’s head, use of Dexon (U.S. Surgical; Norwalk, CT) or Vicryl (Ethicon, Inc., Somerville, NJ) suture material, the “Fleming method” for suturing lacerations, and oral or rectal ibuprofen for perineal pain relief after delivery. Further research is warranted to determine the role of prenatal pelvic floor (Kegel) exercises, general exercise, and body mass index in reducing obstetric trauma, and also the role of pelvic floor and general exercise in pelvic floor recovery after childbirth."

Factors Related to Genital Tract Trauma in Normal Spontaneous Vaginal Births
Leah L. Albers, CNM, DrPH1*, Kay D. Sedler, CNM, MN1, Edward J. Bedrick, PhD1, Dusty Teaf, MA1, and Patricia Peralta1
Birth, Volume 33 Page 94  - June 2006

Conclusions:Delivery technique that is unrushed and controlled may help reduce obstetric trauma in normal, spontaneous vaginal births. (BIRTH 33:2 June 2006)

Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: a randomized trial.
Albers LL, Sedler KD, Bedrick EJ, Teaf D, Peralta P.
J Midwifery Womens Health. 2005 Sep-Oct;50(5):365-72.

1) warm compresses to the perineal area, 2) massage with lubricant, or 3) no touching of the perineum until crowning of the infant's head were found to have equal distribution genital tract trauma.

See also: Significance for Normal Birth from the Lamaze Institute for Normal Birth

This is a fabulous article from Mothering Magazine:

Saying No to Episiotomy: Getting through Labor and Delivery in One Piece
By Elizabeth Bruce
Issue 104, January/February 2001

Midwife's Guide to an Intact Perineum by Gloria Lemay. Originally appearing in Midwifery Today Magazine, Winter 2001.

Honoring Body Wisdom by Pamela Hines-Powell, CPM, LM - about pushing and tear prevention

Intact PerineumMidwifery Today E-News, Volume 4, Number 9 [may not be available until April, 2002]

Tear Prevention - Midwifery Today E-News, Volume 1, Number 17

Perineal Injury in Nulliparous Women Giving Birth at a Community Hospital: Reduced Risk in Births Attended by Certified Nurse-Midwives
Browne M, Jacobs M, Lahiff M, Miller S
J Midwifery Womens Health. 2010;55:243-249

Study Summary

Perineal injury occurring with labor and delivery is associated with a variety of short- and long-term consequences. Previous research suggests that postpartum perineal pain, sexual dysfunction, and delayed time to resume sexual intercourse are frequent byproducts of perineal injury, with some women still experiencing significant problems up to a year after giving birth. The resulting perineal pain and sexual problems have also been linked to postpartum depression.

Objective. The study sought to determine whether rates of perineal injury sustained by nulliparous women who were attended by obstetricians differed in comparison with births attended by certified nurse-midwives (CNMs) at one US community hospital.

Methods. The study involved a retrospective cohort analysis of 2819 women who spontaneously gave birth in community hospitals to singleton, vertex, term, live infants between 2000 and 2005. The independent variable was attendant type (obstetrician or CNM). The main outcome variables were intact perineum, episiotomy, and spontaneous perineal lacerations. The literature suggested that certain factors might influence the incidence of perineal injury; thus, multivariate logistic regression was used to adjust for 6 potential confounding variables: macrosomia, maternal age, epidural anesthesia, oxytocin administration, medical insurance status, and ethnicity.

Results. The prevalence and severity of perineal injury, both from spontaneous lacerations and episiotomy use, were significantly higher in obstetrician-attended births. The odds ratio (ORs) for obstetrician-attended births vs CNM-attended births were significant for a spontaneous minor perineal laceration vs intact perineum (OR, 0.82; 95% confidence interval [CI], 1.33-2.48); spontaneous major laceration vs intact perineum (OR, 2.29; 95% CI, 1.13-4.66); and episiotomy vs no perineal injury, with or without extension (OR, 2.94; 95% CI, 2.01-4.29).

Discussion. This study differs from others in the literature in 2 major ways: (1) it collected data from births in a community hospital rather than a teaching hospital or a maternity care center; and (2) it adjusted for variables that are known to be associated with perineal injury. The large sample size and collection of data over a 6-year period are strengths of the study. A weakness of the study is that no information about the birth attendant’s years of practice experience was provided. Evidence that less perineal injury is associated with more experienced birth attendants, regardless of profession, suggests the importance of this variable.


The findings of this study agree with other research on this topic. This research was conducted in northern California by an interdisciplinary team of 2 registered nurses (including one with a PhD who was also a CNM), a physician, and a PhD statistician. When comparisons are made between care of different providers, an interdisciplinary research team helps in crafting research designs that are seen as both credible and unbiased. When research findings can be generalized, the team often helps disseminate findings to other professionals so that changes in practice are more likely.

What the research does not identify are the differences in birth practices between CNMs and obstetricians that result in fewer perineal injuries in CNM-attended care. The investigators suggest that CNMs typically encourage the mother to be in a nonsupine position for the second stage of labor and birth and also promote noncoached pushing. But no research has yet examined whether these techniques reduce the risk for perineal injury.

My own observations of CNM deliveries suggest that CNMs as a group tend to spend significant time during the later stages of labor massaging the perineum, sometimes employing lotions or ointments, and attempting to gradually stretch the perineum before the final stage of labor. CNMs tend to suggest to mothers that an intact perineum is possible and that they will work to help achieve it.

Additional research might help identify the factors responsible for lowering the rate of perineal injury. The next step would be to share with obstetricians the findings about CNM practices that avoid perineal injury.

About Episiotomy

New Yahoo! Group: episiotomy_is_sexual_assault · Episiotomies are SEXUAL ASSAULT

The role of episiotomy in prevention and management of shoulder dystocia: a systematic review.
Sagi-Dain L1, Sagi S2.
Obstet Gynecol Surv. 2015 May;70(5):354-62. doi: 10.1097/OGX.0000000000000179.

CONCLUSIONS AND RELEVANCE: Our systematic review found no evidence supporting the use of episiotomy in the prevention and management of shoulder dystocia. This observation carries major clinical and legal implications for the obstetricians. Higher-quality studies are needed to evaluate this important issue.

Woman Forced Into Episiotomy Fights Back With Lawsuit [6/4/15] - “This is a big step for women who have been silenced,” plaintiff Kimberly Turbin, of Los Angeles, said Thursday in a statement about the suit against Dr. Alex Abbassi, an obstetrician at Providence Tarzana Medical Center in California. “Every time I hear one of these stories about women being ignored when they complained about how they were treated in the hospital, it reminds me of why I’m doing this. It took a lot of people to get this far, but this is the proof that you can do something.”

Doctor Who Abused Birthing Mother Denying Medical Rights Surrenders Medical License [7/21/16]

ACOG Recommends Restricted Use of Episiotomies [3/31/06] - "The best available data do not support the liberal or routine use of episiotomy."  If your midwife or doctor still does routine episiotomy for first babies, show them this bulletin.  If they continue to practice this way, discuss it with their supervisor or licensing body.

[3/7/13] - At the recent North American Primary Care Research Group, a tribute to Dr. Klein’s significant contribution to research on episiotomies was presented to those in attendance.  Lucky for us, this presentation was also recorded.  Clever, accurate and incredibly funny . . .

If you're a healthcare provider and need motivation to stop cutting episiotomies and to work to prevent tears, consider that this is an opportunity to do a great deal of good for new mothers and babies!

Postpartum Pain May Linger for Weeks After Vaginal Delivery

"Also the percentage of women who reported perineal pain up to one week after childbirth varied among the women depending on the degree of perineal trauma. For example:

  a.. 75% of women with an intact perineum reported pain one day after childbirth, and 38% a week later.
  b.. 95% of women with 1st or 2nd degree tears in the perineum, involving skin and muscle of the vagina, reported pain one day after delivery, and 60% one week later.
  c.. 97% of women who had an episiotomy reported perineal pain 1 day after childbirth, 71% 7 days later.
  d.. 100% of women who had 3rd or 4th degree tears, an extension of the episiotomy to or through the rectum, reported pain 1 day following vaginal delivery, and 91% 7 days later."

Incidence, severity, and determinants of perineal pain after vaginal delivery: a prospective cohort study.
Macarthur AJ, Macarthur C.
Am J Obstet Gynecol. 2004 Oct;191(4):1199-204.

"CONCLUSION: Acute postpartum perineal pain is common among all women. However, perineal pain was more frequent and severe for women with increased perineal trauma."

Ed: This is a very odd comment, that "Acute postpartum perineal pain is common among all women". It leaves one with the impression that "there's nothing you can do about it", in part because the word "acute"  leaves the impression that the pain was severe, when it really means that it happened suddenly and didn't last that long.  I'd also be curious to know whether the women with an intact perineum who were still feeling pain were really reporting tailbone pain, which is much more common for women birthing in the semi-reclining or prone position that is standard at most births.

As a midwife who has a VERY low tear rate, I find that most women are comfortable in a sitting position when I return for the 24 hour visit - heck, many of the ones who birth in the water are comfortable sitting immediately after the birth!  This allows them to breastfeed in a variety of positions with great ease and comfort.  I see a huge difference in the comfort levels for women who have tears requiring a few sutures - these women are still having to take measures to ease perineal discomfort at the ten-day visit, which is a real drag when they're trying to care for a newborn.  This is what motivates me to work really hard to prevent tears!

Trends in the use of episiotomy in the United States: 1980-1998.
Weeks JD, Kozak LJ.
Birth 2001 Sep;28(3):152-60

New Mother Dies from Episiotomy Infection

Aug. 2, 2001 - El Paso, Texas - Eight days after giving birth, a new mother died from toxic shock, due to an infection at the site of the episiotomy done while she was giving birth.  Treatments were unable to halt the progress of the infection, resulting in kidney failure, pneumonia and ultimately heart failure.  She leaves a grieving husband, baby daughter and other family.

From a physician consulting for the NIH Office of Rare Diseases in a letter to the mother of the deceased new mother:  " . . . it is a rare, but often fatal infection and does often affect young women who have given birth and had an episiotomy."

Much ado about a little cut: Is episiotomy worthwhile? - ACOG says "Routine episiotomy is no longer advisable."  Dhuh.

Research Shows Routine Episiotomy Dangerous

Woolley, Robert J. "Benefits and Risks of Episiotomy: A Review of the English-Language Literature Since 1980." OBSTETRICAL AND GYNECOLOGICAL SURVEY vol. 50, num. 11, CME Review Articles # 32 & 33, pp. 806-835. Nov., 1995.
This article concludes that the risks of episiotomy far outweigh the benefits: Quoting from the abstract: "It is concluded that episiotomies prevent anterior perineal lacerations (which carry minimal morbidity), but fail to accomplish any of the other maternal or fetal benefits traditionally ascribed, including prevention of perineal damage and its sequelae, prevention of pelvic floor relaxation and its sequelae, and protection of the newborn from either intracranial hemorrhage or intrapartum asphyxia. In the process of affording this one small advantage [reduction of anterior perineal lacerations], the incision substantially increases maternal blood loss, the average depth of posterior perineal injury . . . , the risk of anal sphincter damage and its attendant long-term morbidity, the risk of improper perineal wound healing, and the amount of pain in the first several postpartum days."

Episiotomy Revisited -- Contemporary evidenced-based  research leads to the conclusion the we should " reduce dramatically the use of this injurious procedure." Brody 1981. from Faith Gibson's goodnewsnet.org

Why some doctors still cut an episiotomy?

How Episiotomy Hurts the Baby

Episiotomy Resources at Childbirth.org.

Any medical procedure that a person says "I do not consent to _______." in Texas is considered assault if the provider does the procedure in spite of the patient.  It's a great sentence to teach moms about epis.

In 1998, the national episiotomy rate in the United States was 40% overall.  [Birth, Sept., 2001, p. 154]

If you've ever suspected that a lot of standard medical birthing practices are wrong, you'll find proof in Henci Goer's essential book, Obstetric Myths Versus Research Realities. The website includes the entire chapter on episiotomy.

There's also a section on Pain and Dyspareunia, about painful sexual intercourse and dysfunction after an episiotomy.

The Tragedy of Routine Episiotomy - a summary of Henci Goer's research - from Jock Doubleday's site, Natural Woman, Natural Man, Inc.

Episiotomies -- Medical Myth versus Reality by Cheri Van Hoover, C.N.M.

Intrapartum Lacerations Improvement Project at the Arkansas Foundation for Medical Care, Inc.  [Good Bibliography.]

Collection of episiotomy abstracts

World Health Organization on Episiotomy Rates

Dr. Marsden Wagner says that WHO recommendations are that episiotomy should be around 10%, and no more than 20%. He also flat-out states that episiotomy is MD-sanctioned female genital mutilation, and states there is no difference between it and female circumcision. 

From a World-Renowned Expert on Episiotomy Research

Frankly, I think I know as much about the scientific literature on episiotomy as anybody in the world.

There is no sound research that supports more than a 0% rate of episiotomy.

Advocating for a 0% episiotomy rate isn't realist. I guess those midwives and OBGYNs at the WHO office figured out what good indications there exist to act and in how many cases statistically those conditions might occur and that they took into account whatever parameter to come to a scientifically based result. Anyway, just saying 'the lower the rate, the better' isn't wise. If one has good arguments one can of course question the 10% rate. Maybe it should be lower. The research the study group at the WHO did figured out 10% was a well-balanced rate. I'm convinced they base this not only on their personal and shared experiences but also on, what many consider as, sound research.

You are willing to assume where I am not. Since there are no indications for episiotomy (that is, problems for which it has been shown to be beneficial, or more beneficial than the results of not doing one), how could the WHO folks have determined that the proper conditions happen in 10% of births? What, exactly, are they considering indications for which there is, in your words, "sound research" demonstrating benefit? I know of none--and believe me, I've looked.

Call for abandonment of routine episiotomies published.

(Reuters)Dr. Roberto L. Lede of Rosario, Argentina, and colleagues have called for physicians to abandon the routine use of episiotomy during labor. Dr. Lede conducted a study that showed "...a lower incidence of severe perineal tears in the group with restrictive use of episiotomy than in the liberal use group." Moreover, the long-term effects of episiotomy included higher rates of urinary and fecal incontinence, weaker pelvic muscle strength and poorer future sexual function compared with long-term effects in women on whom the procedure was performed selectively. Dr. Lede reports that women in who sustain spontaneous perineal tears resume sexual intercourse sooner (within one month of delivery), have less pain and are more sexually satisfied than women who undergo episiotomy.
Am J Obstet Gynecol 1996;174;1399-1402.

Importance of Reducing Postpartum Infection by Reducing Episiotomy

About 10,000 women give birth in the United States every day. That's a lot of chances to prevent opportunities for infection by preventing perineal trauma instead of intentionally inflicting a wound in an environment known to harbor the deadliest germs.

In case anyone missed the news from last week's First International Conference on Emerging Infectious Diseases, hosted by the CDC, here's a summary of a statement about hospital-acquired infections:

"The rate at which patients pick up an infection while being treated in a U.S. hospital has increased 36 percent in the past 20 years.  Dr. William Jarvis of the Centers for Disease Control and Prevention (CDC) told researchers at an international conference on emerging infectious diseases, "We estimate that today 2 million patients develop a hospital-acquired infection in the United States each year. Of that number, 90,000 die as a result of those infections."

90,000 people die every year in the U.S. from infections acquired in hospitals.  Doesn't it make sense to support efforts to reduce both episiotomies and tearing that can occur in childbirth?

Is routine use of episiotomy justified?

Episiotomy Trials

How to Cope with Fears about Episiotomy or Tearing

Episiotomy Repair and Sewing Analogy

There are many reasons why a natural tear heals faster, with less pain, and better than an episiotomy. First, a tear is generally smaller, often occurring only in the skin, rather than going through skin and muscle, as an episiotomy does. Secondly, because the tear isn't a perfectly straight line, the repair will have to be more precise. It's difficult to suture swollen tissue in any case, and it's not always obvious how to line up the two sides. Especially with an episiotomy where the two sides are relatively straight, it's not always clear what lines up with what. (Kind of like doing a jigsaw puzzle where all the pieces are perfect squares. Who knows what you'll end up with?) So an episiotomy repair doesn't always connect the right muscles on both sides. However, a tear tends to have more landmarks to help match up the two sides. Also, since there's more "surface area" to a tear, it's easier for the two sides to reconnect themselves more quickly.

For a home demonstration of the difference, cut a piece of paper with a straight-edge scissors and a zigzag scissors (or pinking shears). Notice how much easier it is to line up the two pieces properly and how much more "surface" you would have to hold the tissue together on the zigzag tear.

While you've got your sewing materials out, try the following experiment. Get a piece of scrap material that has an intact selvage, or even a cut edge. Try tearing the cloth from the edge. Now make a little cut and apply the same force to the cut and see how much more it rips? This is also what happens with episiotomies.

Basically, I don't think anyone finds the thought of either an episiotomy or a natural tear very pleasant. How to avoid it altogether? Good birth attendants will have a tear rate down around 10-15%, i.e. only 10-15% of women tore badly enough that they needed any sutures, and many of these will be "superficial" first-degree tears, i.e. through the skin only. 


[NOTE - 7/20/09 - I've been told that the FDA is prohibiting sale of the Epi-No in the U.S.  I can't imagine why!]

As I'm fond of saying, "There's no shortage of creativity in the world." The EPI-NO Childbirth and Pelvic Floor Trainer has received US FDA approval as a class 1 Device. 1-866-863-7466.

Here are their international distributors:

epharmacy.com.au - As of Aug. 2013, they won't ship outside Australia

Canadian Retailers of EPI-NO Products - these are said to stock the EPI-NO Delphine Plus

Places that used to sell it:


Testing the Epi-No birth trainer where episiotomy is not practiced by Judy Slome Cohain - Among 80 consecutive primiparous vaginal births delivered by practitioners who never performed episiotomies, 99 % were delivered without the need for suturing.

they have to send money to someone out of the states, whom purchases it, wraps it, and labels it as a pelvic trainer or sex toy to get through customs.

I ordered one from a pharmacy in Canada. As you have probably heard, nobody in other countries will ship it to an American address, so I had to use a re-routing service. I found a website called Your Canadian Address (Canadian Address- your real address & virtual mailbox in Canada.). This is a service that will provide you with an address inside Canada that will accept packages and then mail them to the US (for a small fee). There's a one-time fee of $20 to set up an account, and then a per-package fee of $10 (all the payment is done through PayPal, so it's secure). After you sign up (and pay) they will send you an email with the Canadian address you can use to ship things to. Then you just give that address to whichever Canadian pharmacy sells Epi-Nos and you're home free.
Canadian Address- your real address & virtual mailbox in...
Canadian address, virtual mail box
View on www.canadianaddres...
Preview by Yahoo

I ordered my Epi-No from Bescot Healthcare, which sells the Epi-No Delphine Plus. It cost 199 Canadian dollars.

Here's my research report about the Epi-No vs. the inflatable anal plug.

 So here's the Epi-No device ($180 USD – plus who knows how much in international shipping and import fees)

 The Epi-No website

Here's a video of what it looks like as it inflates: (terrible quality but you get the picture of it anyhow)

Here's the link to the PDF guide about using the epi-no
. This guide tells you that the pressure gauge is not used for the prenatal peri stretching, only for the postnatal pelvic floor exercises. To measure your progress in prenatal stretching, you are supposed to birth the ball while still inflated and then measure it with a ruler. They say this gets you used to the actual birthing feeling. Anyway, this same technique could be employed with the anal plug, since there is no special measuring device – it's just a ruler.

And finally, the inflatable anal toys that I hypothesize will work just as well as the Epi-No. The two below are in the $20 - $25 price range including shipping. Since I have firewalls at work, I was only able to shop on Amazon. I’m sure specialty stores would have an even bigger selection. But I'm sure any of the Amazon ones will work just fine.


This one is the one that I think looks most like the Epi-No in its deflated state. Unfortunately there is no inflated picture posted to see if it will get big enough, however one reviewer said that he inflates it to the size of a softball when he uses it. And guess how big a softball is? 9.65cm! exactly the size needed for the peri stretch. And of course, huge bonus, this one comes with a vibe. 

Prenatal Preparation for Perineal Protection

See also: Epi-No

Perineal Stretching Massage by Carolyn Hastie, incorporating information from Anne Frye and the Northern Women's.

In my experience, there are significant things a pregnant woman can do to improve the integrity of the tissues and thus help to prevent perineal tearing.  My primary recommendations are the Collageena protein supplement and a good-quality vitamin C supplement with bioflavonoids.  These are especially important in the last trimester, when the perineum is growing lots of new tissue.  You can learn more about these supplements and the research behind these recommendations at:

The Better Baby Book: Use nutrition, your environment, and your mind to create the healthiest, smartest, autism-free baby possible by Lana Asprey, MD, and Dave Asprey,  "To help parents gift their children with better health and higher intelligence for life." It's available either on Kindle or paperback.

This book was written by a couple who know more about pregnancy nutrition than anyone I've ever heard, met or read about.

The book is finally out as of Jan. 1, 2013.  You can also read their Better Baby Blog.

The Better Baby Diet - distilled from countless research papers, spending more than 10 years working with some of the world’s top health and nutrition researchers, reading over 150 nutrition books, and self-experimenting for 15 years. Just eat the stuff on the left below and watch what happens for you and your baby. No calorie counting, no measuring. Just eat and feel your brain, body, and hormones re-awaken as your effortlessly lose weight and gain muscle on little or no exercise.  Best of all, science shows conclusively that the Better Baby Diet tastes good and is satisfying. It’s not vegan, it’s not low-fat, and you don’t need to limit calories.

StretchEasy Formula from Native Remedies - Homeopathic remedy prevents stretchmarks by improving skin tone, flexibility and elasticity. (Cal flor D6, Cal phos D6, Nat mur D6)

StretchEasy Massage Oil™ - Aromatherapy massage oils promote elasticity and protect against common stretchmarks in pregnancy

Easiotomy Cream™ - Natural soothing cream for the perineum – for use before and after birth

Perineal massage cuts episiotomy rates

There was a 15 percent reduction in the number of episiotomies performed among the women who practiced perineal massage, compared with those who did not, the reviewers found. And whether or not they had an episiotomy, women who practiced the massage technique were also less likely to report perineal pain 3 months after the birth than those who did not massage.

[Ed: The "need" for an episiotomy is primarily the doctor's "need" to minimize his time at the birth.  But if women aren't able to change to care providers who have low suturing rates, at least this is something they can do for themselves.]

Antenatal perineal massage for reducing perineal trauma.
Beckmann M, Garrett A.
Cochrane Database Syst Rev. 2006 Jan 25;(1):CD005123.

BACKGROUND: Perineal trauma following vaginal birth can be associated with significant short- and long-term morbidity.
AUTHORS' CONCLUSIONS: Antenatal perineal massage reduces the likelihood of perineal trauma (mainly episiotomies) and the reporting of ongoing perineal pain and is generally well accepted by women. As such, women should be made aware of the likely benefit of perineal massage and provided with information on how to massage. [Ed: BECAUSE THIS WILL SAVE THE DOCTOR TIME AT THE BIRTH!]

Perineal outcomes after practicing with a perineal dilator by Judy Slome Cohain, MSN, CNM
 SUMMARY In this preliminary study, 233 women who used an inflatable intravaginal perineal dilator to prepare for birth were interviewed on the phone. The rate of intact perineums reported for spontaneous vaginal births to primiparous and secondiparous births after a cesarean for their first births was 43% with another 29% having tears, half of those minor. The episiotomy rate was 29%. This is a higher percentage of episiotomy than would be expected if evidence-based protocols were in place, but a 50% reduction in the episiotomy rate for first births in non-users in Israel. Although the users were aiming to avoid episiotomy, 86% of the women who practiced with the device and had an episiotomy, felt positive about their experience since it taught them how to push and gave them confidence and they believe it helped. Three possible theories are suggested. The perineal dilator may increase intact perineal outcomes in primiparous women by 1. shortening second stage by teaching the woman how to push and/or 2.by stretching the perineum before birth and/or 3.may empower women to participate in the decision not to perform episiotomy.

Antenatal perineal massage for reducing perineal trauma from The Cochrane Database of Systematic Reviews 2006 Issue 1

Homeopathics to Increase Skin Elasticity

To prepare the perineum to stretch optimally at birth, take Homeopathic Calcarea Fluorica 6X, twice a day. This remedy gives elasticity to the skin and is safe to take during pregnancy.  For other tips on homeopathics for pregnancy and birth, see the EMAZING.com archives of the Homeopathic Health Tip of the Day

Castor oil packs for the perineum can help relieve prenatal pain around the perineal region as well as make your tissues supple and help prevent tearing when you give birth.  Castor oil has healing and restorative properties so the relief builds up over time and the heat increases blood flow to the area, relieves pain, improves circulation and relieves venous congestion.  You have to use cold pressed castor oil.  Soak an old washcloth or a flannel in the oil, wring it out and put it right on your perineum.  Then cover that with something waterproof and put a heating pad of some sort on (electric, microwave, hot water bottle, it won't matter.)  I cover the compress because the castor oil will stain and also to avoid shock if you use an electric heating pad.  Leave it as long as you can but at least 30 minutes.  I did it every day, you can't do it too much, it can only help not hurt.

A good foundation in nutrition, vit. E & C and bioflavonoids (at least 1,000 mg.) daily has really made a diff for my clients. Perineal stretching seems to help both psychologically as well as physically.

Exercise and Nutrition

Kegel exercises and good nutrition are obviously important for tissue health and elasticity. 

Preventing Tears - Wheatgerm Oil - Vitamin E

In addition to Kegel exercises, Vitamin E or Wheatgerm oil (very high in E) can be massaged into the perineum daily to help avoid episiotomy.

Birthing Oil - Ayurveda curing purifies, removes enzymes and enhances the natural antioxidant properties of the oil.  "It is the premier birthing oil."  Pure, organic, ayurveda cured sesame oil available to professional midwives.  877 777-4362

Perineal Massage

March 26, 1999

(NYT Syndicate) - Massages performed during the last few weeks of pregnancy appear to be effective at preventing a type of injury that commonly occurs during delivery, Canadian researchers report.

When women give birth, especially for the first time, many experience tears in the perineum, the area between the vagina and the anus. But among women who had never given birth vaginally, massaging this area during the last few weeks of pregnancy significantly reduced the risk of so-called perineal injury, a new study has shown.

Among these 1,034 women, the rate of giving birth without tearing the perineum was 61 percent higher in those who had performed the massages beginning in the thirty-fourth or thirty-fifth week of pregnancy than in women who did not massage themselves, according to researchers led by Dr. Michel Labrecque of Laval University in Quebec City. Seventy-six percent of women who had the massages suffered perineal injury during childbirth, while 85 percent of those who didn't have massage were injured.

A normal pregnancy lasts from 37 to 42 weeks. However, massages did not have a significant effect among the 493 women in the study who had delivered a child vaginally in the past, Labrecque and colleagues reported in the March issue of the American Journal of Obstetrics and Gynecology. Learning how to prevent damage to the perineum is important, since such injuries can cause pain and sexual problems in the months after delivery, according to the researchers. Massage appears to prepare a woman's body for delivery somehow, they noted.

Performing a massage during the last few weeks of pregnancy may help some women during delivery, but "it's not the end of the world" if a woman chooses not to do so, according to a Baltimore expert.

Although the reduction in perineal injury among first-time mothers was statistically significant, it was not very large, noted Dr. Adam Duhl, an instructor of maternal-fetal medicine in the department of gynecology and obstetrics at Johns Hopkins Hospital.

Up until the 1980s, almost all women were given an episiotomy, during which a doctor makes a cut below the vagina to make it easier for a baby to be born. Proponents of the procedure believe that it often prevents tearing during delivery, he said. When these tears occur, a physician repairs them with stitches. But Duhl said that routine episiotomies have fallen into disfavor with some physicians, who believe that the cut made during an episiotomy may take as long or longer to heal as a tear that occurs during delivery.  [This is classic cultural denial of the fact that there is extensive scientific evidence that episiotomies cause more harm than they provide benefit, yet episiotomy rates in the U.S. are still over 50%.  Note the way this article talks about the way some physicians "believe", as if it's merely a matter of opinion.  The truth is that most practitioners continue to cut episiotomies despite overwhelming and readily available evidence that it is harmful to the woman.]

The Johns Hopkins physician said that the benefit of massage appears to be small, but the technique is not harmful for most women. However, he stressed the importance of discussing massage with a doctor, since it could be dangerous for women who have bleeding or infection around the vagina or who are otherwise at risk for premature labor.

Dr. John J. Botti of Hershey Medical Center in Hershey, Pa. agreed that the benefit of massage appears to be modest. However, he noted that most women did not perform the massage each day. According to the study, 66 percent of the first-time mothers performed the massage four or more times a week for at least three weeks. Botti said it would be interesting to see if the rate of perineal tears declined further if more women performed the massage every day.

In the study, the researchers asked the women to massage themselves every day. To perform a perineal massage, a woman or her partner places one or two fingers about an inch to an inch and a half into the vagina. The researchers recommend applying downward pressure for 2 minutes, and then applying pressure to the either side of the vaginal opening for 2 minutes each. Women were given sweet almond oil to use for lubrication.

Copyright 1999 The New York Times Syndicate. All rights reserved.

The July [1997] issue of British Journal of Obstetrics and Gynecology has an article on antenatal perineal massage. I didn't have time to read anything but the abstract, but I was surprised by the observation that perineal massage reduces the risk of instrumental deliveries, particularly in women over 30 years of age.

Naturally, the authors also reported that massage decreased the incidence of second and third degree tears and episiotomies.

Whenever I see this research about perineal massage to prevent birth injury, I think of the Biblical quote, "And why do you look at the speck that is in your brother's eye, but do not notice the log that is in your own eye?"  Why do they blame the victims of the injury instead of considering the fact that over 50% of birthing women are intentionally injured through episiotomy?  Why don't they consider that the birth attendant is the largest factor in perineal injury?

Yes, maybe regular extensive perineal massage could reduce the perineal injury rate somewhat, from 85% to 76%, but birth attendants who put effort into assisting the woman in preventing tears at birth seem easily able to bring their injury rates down to 10 or 20%, without hassling the poor woman about doing regular perineal massage for the last six weeks of her pregnancy.

Why don't those researchers just put the responsibility where it belongs . . . with the birth attendant?

Prenatal Perineal Message

Perineal Massage - Excerpt from The Birth Book By William and Martha Sears

I tell my primips that they need to do the perineal massage and that if they get the first one out without a tear, their chances of ever tearing with subsequent births will be nil and they never have to do the massage again.  To date, that has always held true.  Even if they push those kiddos out with one push, with subsequent births,  they do not tear.

Now if someone comes to me with, say, baby number 3 and they have torn in the past or had all episios, then, again, I recommend they do the massage.  Then, again, they do not tear with later births.

Prenatal Care of Old Episiotomy Scar

For old epis scars I advise the women to rub in a comfrey hypericum ointment prenatally. It renders the scars more pliable. Yes I do see tears right down the old scar path. It seems that if a woman is going to tear that is the spot that gives.

SCAR SO SOFT is an herbal lotion that helps to soften an old episiotomy scar so it doesn't tear again with a subsequent birth.

Castor oil and vitamin E. Can wear on a cloth menstrual pad during last month of pregnancy.

Striae Gravidarum as a Predictor of Vaginal Lacerations at Delivery [ Medscape registration is free ]
[In my experience, the attendant's guidance of the woman in breathing the baby's head out and skill in supporting the perineum for both the head and the shoulders have a lot more to do with preventing tearing than striae gravidarum, i.e. stretch marks.]

Birth Chairs / Birth Stools

Was wondering...how many of us are using birth stools and what do we all think about them?

I have used a couple of different ones and found I like the "joy chair" best..mostly because the woman can sit back and rest while using it and it is padded nicely. A woman in one of the Christian communities my preceptor worked with had/has one that has been passed around to all the ladies in the church and has withstood LOTS of use really well... I found the metal ones just didn't feel sturdy enough ( to me...personal bias) and the little bitty wooden ones haven't held up too well.

I am working together with a woodworker friend of mine in an effort to build my own chair/stool ..(to use for clients..not to market) and would welcome ideas and or dimensions that others think are best for such things.

I was using a birth chair made by a fellow midwife. Another midwife I used to work with still has and uses hers. Many, many women used it and really liked it. It is wooden with a low padded seat with an opening for the presenting part ( like a horseshoe) The back folded open making an upright position while pushing.

I am now working with another midwife who does not use a chair or stool. I began to notice she had very few tears and this stirred my curiosity.... I also remembered hearing how few tears other midwives had...why was I having so many? I was using the same techniques in delivery of the head, etc. I did an experiment and left the chair in the car...low and behold I had fewer tears.

I agree with the one person who wrote that she uses a chair or stool and only has tears if the women sit in it for long periods of time during pushing. Well most women don't like to move once they plant themselves in it. When on the bed, floor, or where ever women move more during second stage.

The final straw..I again attended a birth with the midwife who has the same type chair: Multip with history of fast labors...quickly to second stage...got on the chair....halt, halt, halt....push, push, push....oh! the midwife says, you need to tilt your tailbone towards me...out pops baby leaving Mom with a good sized tear. Baby was same size as last child.:-(

Now the chair sits in my garage and the suture material is used much less.

I also like having a woman in bed when they begin to hemorrhage...moving her from the chair to flat was always a hassle.

The advantages as far as I have experienced were for me..less mess on the bed, got her in one place, easy access to perineum, etc.

I have to agree; I have noticed a lot more tearing with my stool (a deBy- I know it's spelled wrong but I can never remember the right way) than with women who give birth without it. I have started to leave it in the car until it seems that it will be useful, such as a primip with long pushing stage. My stool also makes the women swell tremendously if they are on it for more than 45-60 minutes, and once they swell up they tear! I also hate moving a bleeding woman around, and what do you do with the placenta if the cord is too short for it to reach the ground??? I think that birth stools have their place in difficult 2nd stage labors, but for the majority of women I am encouraging hands and knees and sitting.

I used to use a birthing chair but have recently quit. since quitting I have experienced practically no tearing...which is why it sits at home. I think the freedom of movement contributes to the infrequent tears. any comments? ( Of course we also do a slow delivery of the head, flexion if needed, support the tissues, etc.)

I agree that I see more tears when a birth stool or squatting position is used for delivery. But I like having a birth stool around; they're good for support on hands and knees, too.

Also, I've said this before, and probably no one agrees with me. But I don't see tear prevention as the be-all and end-all of the birth experience, or even as a big mark of a great midwife. Of course we should try to protect the perineum, but tears happen. If I have a woman who prefers to be upright, I probably won't try to get her to do otherwise. If a tear is cared for properly, it won't interfere with the woman's enjoyment of the postpartum period.

I have a birth stool, made for me by wonderful clients from Germany. It is a c-shape, padded upholstery, and about a foot off the ground. My incidence of tears has gone way down since I started using it. I just love my birth stool. Now, I don't leave people on them forever, though. I firmly believe in walking around, squatting, shower, whatever- while pushing. I like them on the birth stool for the actual birth. I hate doing births in beds now. I feel awkward, and I feel like I can't ever get them in a good position. I hate the way the perineum stretches -- get a lot more tearing in a semi-sit - in my opinion, at least.

We used the DeBy stool and I liked it just fine. I don't think it changed the tears much one way or the other. I do tend to keep hands off pretty much anyhow and especially on the stool, and found mostly no or 1st degrees. They sure look worse though while they're still sitting on the stool! We tried to avoid long periods on the stool without standing, walking or lying. Usually they just used it to bring the baby down or to get it out.

In a pinch, a couple of phone books in a bag is a good alternative to a stool. Gives mom something to sit back on (just her "sit bones") between pushes, then she can get into a squat to push.

I think women with previous epises are more prone to tear w/ birth stool, but primips w/ great preparation for easing babies out slowly seem to do ok. We keep them moving, standing, lying back cradled in someone's arms, not squatting all the time. Have the small, short horseshoe padded stool and a DeBy. Love the small one for dads or midwives to sit on if mom isn't!

We talk prenatally about positions possibly increasing chance of tearing (see fewer tears in sidelying than any other position). That way the mom's instinctive choice of position can be influenced by what is important to her when she's feeling rational :-). We also use the stools during dilation or sometimes to bring the baby down, then mom moves to chosen birth space.

I love the stools for the placenta! The DeBy can be high, but we usually have 3 attendants and someone just holds the fracture pan up.

I tend not to use my birth stool much, also find that it causes perineal swelling, aggravates haemorrhoids etc.etc., if used for too long in second stage. It is just the right height for me to sit on if I have to suture at home, though' [GRIN]. We tend to use lots of positions for long second stage, and are fond of hands and knees, side lying, lunging, squatting etc. Can go through the entire repertoire, sometimes. The other thing that works is initiating the "well, you aren't making a lot of progress, we may have to go to the hospital..." talk. Seems to give the mom an adrenaline boost that gets the baby born!

I also see fewer tears when they stay on the side. But it seems like my ladies always flip to their backs at the last minute.

The common consensus here on birth stools seems to be that more tears are experienced with them and I would agree with Paula's comments below re: tear prevention = good MW. I think you will see that with both squatting and the birth stool, which is really like a supported squat, the problem lies more in the fact that most women from the "industrialised" countries don't sit in squatting positions much and therefore their peris aren't used to being stretched like that, which of course, is what squatting does - stretches the peri enough that it doesn't have more stretch to stretch! Perhaps if women gradually did more squatting during their pregnancy and or sitting, without undies, on the birthing stool to tone their peris more the tear rate with both squatting and birth stools would decrease. I certainly found when I first moved out to Australia into the bush where for the first few years we didn't have a toilet and had to hike and squat that my ability to squat for long periods increased and I would gather that so did the tone in my perineum.

I haven't really found an increase in tears with the birthing stool (mine is just an old IKEA kitchen chair cut down to about 10 inches high, the back off and a scoop out of the seat). I do see tears (?more???) when the woman has a very long second stage and spends it all on the stool - I prefer to have them change positions frequently, but some just want to stay put. My stool has a wider sit on part than my partner's and I find she has more tears than I do on the stool - but she is also more of a hands on kind of second stage person than I.

I have used both the dutch stool and the deBy. Both have their advantages and disadvantages.

The dutch stool is heavy. Lugging it around is a pain, make sure you get the carry bag with it if you get one. It does have a nice pan for the placenta. I like the height of it. It is solid and women don't usually push themselves off it or tip over. My main problem with it is that it is hard to see what is happening on the perineum and there is not a lot of room for many hands.

The deBy is a little tall for some women. It is open on all sides and it is easy to see what is happening and to get to the baby. It is so light that sometimes you need to hold it down if the woman is pushing away from it. It is a nice height to support a woman squatting. The seat is padded and tends to be more comfortable than the dutch stool. The thing I like the most about it is that I can carry on my back like a backpack and with straps on all of my other equipment I can carry everything in one trip.

Both are easy to clean. Women either love them or hate them no matter which type. The deBy is Much cheaper than the dutch stool and comes with a nice video to loan out to clients. I prefer the deBy but if someone offered me a dutch stool half price I would take it too.

Regarding midwives dream of someone inventing a toilet type birth stool, our dream has come true. I have done many births on the Dutch white heavy plastic one. It was good for the woman, but the opening in front was too narrow for me to maneuver sometimes when necessary, and also if the Mom moved around too much she got off-centered and the plastic corner seemed to be pushing into the babies head. I have purchased the stool advertised in Midwifery Today Magazine, called "The Birth Stool", made in solid oak by Steve's Woodworking, 6 Camp Swatara Rd.,Myerstown, Pa. 17067 tel. 717-933-4336, costing $75.00. I have done about 20 births so far and am in seventh heaven. The height is perfect, the gripping handles are great, it is sturdy enough yet light enough to carry , and the opening is nice and wide for me to maneuver as needed and nothing to smush into babies head. I highly recommend it and the price is affordable and the wood is beautiful and most important of all, my Mom's really feel comfortable and think it's great. I put an extra large garbage bag around the whole thing and push the middle down so that all the fluids and gook are collected and there is no clean up necessary. Try it--you'll like it!

The best one for the money ($50) is Spirit-Led Childbirth.

Technique for Preventing Tears

Warm Compress During Labor Prevents Trauma [Medscape, 12/10/2011] - The use of warm compresses on the perineum during the second stage of labor is associated with a decreased incidence of perineal traum

Use of hyaluronidase to prevent perineal trauma during spontaneous delivery: a pilot study.
Scarabotto LB, Riesco ML.
J Midwifery Womens Health. 2008 Jul-Aug;53(4):353-61.

"The present findings suggest that perineal injection of HAase prevented perineal trauma. These findings provide strong rationale for a larger follow-up study."

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

Conclusions: The practice of perineal massage in labour does not increase the likelihood of an intact perineum or reduce the risk of pain, dyspareunia, or urinary and faecal problems.

A randomised controlled trial of care of the perineum during second stage of normal labour.
McCandlish R, Bowler U, van Asten H, Berridge G, Winter C, Sames L, Garcia J, Renfrew M, Elbourne D.
Br J Obstet Gynaecol 1998 Dec;105(12):1262-72

This was the 1998 HOOP trial, which was looking largely at pain 10 days postpartum, rather than the extent of perineal damage, which is what the new study document

Traditional care of the perineum during birth. A prospective, randomized, multicenter study of 1,076 women.
Mayerhofer K, Bodner-Adler B, Bodner K, Rabl M, Kaider A, Wagenbichler P, Joura EA, Husslein P.
J Reprod Med 2002 Jun;47(6):477-82

I have the full text of the new study and it is interesting that the vast majority of women were supine for birth - 73.8% in the hands on group and 60.9% in the hands poised group.  The next most common positions were lateral recumbent and squatting. Who knows how much this influenced the results?

Reducing perineal trauma: implications of flexion and extension of the fetal head during birth.
Myrfield K, Brook C, Creedy D.
Midwifery. 1997 Dec;13(4):197-201.

In this paper a critical analysis of two popular perineal management techniques used during birth, flexing the baby's head and the Ritgen manoeuvre, are presented. Each technique claims to reduce perineal trauma by reducing the presenting diameter of the fetal skull through the woman's vaginal opening. These two techniques are, however, contradictory and act against the normal mechanisms of labour. In normal labour, the smallest diameter of the fetal skull, the suboccipito-bregmatic, presents through the woman's vaginal opening. In order to negotiate the 90 degrees curve in the birth canal, the baby must change from an attitude of flexion to an attitude of extension during birth. The Ritgen manoeuvre encourages early extension of the fetal head which causes a larger fetal head diameter, the occipito-frontal diameter, to present. Flexing the fetal head cannot cause a smaller diameter to present, and the pressure the birth attendant applies to flex the head serves only to retard the emergence of the baby and unnaturally force the emerging fetal head down toward the stretched perineum. The discussion outlines the implications of this analysis for practice.

I encourage my clients to bring the knees together as the head is crowning to help prevent tears.

Have you been with a woman having a water birth? If you are with her, as the baby is being born, just watch. As the baby is born, you can float the baby through her legs (if she is leaning forward) and say to her to pick her baby up. Next time you are with a woman having a baby not in water, have your hands poised to take the baby so it does not fall on the floor (if the woman is standing or kneeling up) and pass the baby to the mother. If the woman is on her back or semi-prone, just watch the head be born. Women left alone will usually hold back from really forceful pushing because of the discomfort of the head coming out into the world, all on their own too! Many women tear and there is not always very much we can do about that. Just trust the women, they usually know best. You know when to intervene if someone is pushing very hard and fast, but I must say, that most women at home do seem to know exactly what to do all on their own.

A doula taught me a wonderful technique to help women in second stage stop pushing when we are attempting intrauterine resuscitation (or waiting for the MD).  Instead of telling her to "Stop Pushing!" over and over.  I have her rock her hips side to side and tell her to "Rock your baby."   The motion of the hips keeps the abdominal muscles from coming fully into play for a push effort and prevents an all out bearing down.  Besides it is much nicer to say gently "Rock your baby."  than commanding "Don't push, don't push."

If people bring their own olive oil I use that. I like the slippery quality it gives the perineum. It feels like my hands move more easily over the skin without dragging or causing irritation. I also use verbal imagery when applying the oil. "I'm going to put some oil down here now to help the baby slide out." I think women find it a relaxing and reassuring image and it seems to help them believe in their ability to deliver intact.

We have S L O W crowning and head birthing, and something else we do different is whoever is supporting the tissues does not catch the baby. Either the Dad does, assistant or someone else. That way supporting hands are there for the shoulders. I also think it is important to ease shoulders thru slowly, arms close to the chest.

The longer I practice midwifery, the less I do to (or for) the perineum, and the lower my laceration rates get.

I continue to use oil, mineral oil in my setting, as the hospital pharmacy supplies it and it seems to be quite adequate to the task. It makes the tissues slippery and facilitates my hand maneuvers. It also seems to decrease the tiny surface tears which can progress into larger lacerations. When using oil of any type, remember that oils degrade latex. I use vinyl gloves over latex gloves for this part of the birth. I remove the vinyl gloves only if I need oil-free gloves on for deLee suctioning (in case of meconium) or for suturing. The clean dry gloves are underneath.

I do almost no massage any more and see fewer lacerations all the time. I think it can add to edema of the tissues which then predisposes to tearing. Prenatal perineal massage has been theorized by some researchers to contribute to the breakdown of elastic fibers in the connective tissue and could possibly decrease elasticity and inhibit the return of those tissues to normal after the birth. Just a theory, but since it's never been shown in any studies to actually improve outcomes, why risk it?

The most important factor in helping to avoid lacerations is assisting the mother in control of her pushing. The key concepts during those last few pushes are: gentleness, relaxation, and control. This is achieved by making a profound connection between the midwife and the mother via voice and touch at this time.

I personally think stretching (straight down) helps, but massage breaks down the tissue.

The topical lidocaine can have the effect of decreasing the burning sensation that accompanies crowning enough to help some women who are panicking have a more controlled birth, perhaps avoiding a tear or epis. It doesn't cause swelling the way injected lidocaine does which I believe contributes to potential problems with tearing. I have used topical lidocaine on myself and didn't feel that it caused the deep numbing of sensation that injected lidocaine causes.

I agree. I use the gel when someone needs a diversion from the pain. I don't want to interfere if things are going well. I prefer oil, or a neat liquid called "Slippery Stuff". Also checked with a pharmacist. He said Americaine has more numbing effect than Lanocaine. I can't even find the other gel others have mentioned. And now I have forgotten the name !!

I also refer to the Journal of Nurse-Midwifery article on perineal integrity which suggested that the more one does towards preservation of perineal integrity (ie oil, massage, stretching etc), the greater the incidence of tears.

I agree with this if they define it as "stretching massage" etc -- pulling the tissues as the head is coming down.. I DO think it contributes to greater tearing.. but compresses and a little oil poured over the stretching perineum seems to help -- or at least I'm CERTAIN it doesn't hurt....

We just pour the oil directly over the mom (onto the mom?), letting the oil "drizzle' over the birth area; if I need any I just stick my gloved fingers under the stream. We'll usually put the oil in a peribottle well before birth, so we can control it better, and is less likely to spill[Grin]. (This is during crowning of course...)

I honestly don't know if oil helps or not. I don't usually do perineal massage, just use the oil to "slip things up a little". It "may" help prevent abrasions ("rugburns") and splits, and tears. It certainly feels GOOD; I think every single mom has commented on how it reduces the stinging and burning feeling -- we're often commanded to "Pour more oil"! -- and if it makes mom more comfortable that's a good enough reason to use it! (Never seen a problem--- infection, irritation etc).

Some prefer almond oil to olive oil. I think any good, non-scented "food grade" oil is fine (this eliminates Baby Oil of course!)

I have found that most women do better if they lie on their left side to avoid tearing. I also use a ginger infusion at crowning & lotsa olive oil before and after crowning to s l o w l y ease out head, when head is born guide it downward after checking for your cord, of course, then rotate out anterior hand pressing gently toward baby... then gently lift out baby upward by flexing shoulders forward toward his/her chest. My tear rate is low to minimal. If you have watched lots of hosp. birthings gen. docs seem to oft times rush the baby out from the point of crowning. We have to unlearn so much of what we have seen that is wrong. If fht's & head color look good you have time, don't be nervous and rush... and remember those shoulders are to be birthed w/ slow gentle care!

Some women just tear no matter what you do, although I find that to be an exception. Women w/ friable skin I can spot a mile away. They almost seem translucent to me. Oft times those seem to be red-heads &/or fair skinned women.

I would like to see another round of discussion on tears. Most of the mothers I help deliver on hands and knees. This is the position they choose and I will not persuade them to take a position other than the one they take spontaneously. I find this a difficult position to do good perineal support. Do you experienced midwives feel that perineal support really makes a big difference in tear prevention or is a controlled delivery of the head (i.e. mother's pushing efforts - or lack thereof - at the critical moment) the deciding factor? I know it's hard to tell what the deciding factor might be but I want to hear more.

Basically my method is to flex the baby's head and encourage the woman to resist pushing as the baby crowns. But I also have a problem with encouraging her to do something that is in direct opposition to what her body is telling her to do at this time. I know we discussed pouring lots of oil over the perineum but with a baby coming out looking up at it I am reluctant to do this in case it aspirates oil. It has been a long time since I have had a tear free birth and they are mostly second degree. I don't suture (yet) and am tired of fretting over how the tear is healing and nagging women to look after them.

From what I have seen in my short experience, controlled delivery of the head seems to be the best way to prevent tears. We also use oil and hot compresses but that slow delivery with time to stretch seems like the determining factor. We encourage women to do vaginal stretching exercises in the last few weeks of pregnancy. This helps them to get used to that burning feeling and lets them practice relaxing to it. Then, at the birth, when the babies head is coming down, we remind them that soon we will need them to really listen to us and only give little pushes. We have recently had several women who did great with this. They brought their babies heads out so slow that I felt the burn !! No tears and they were all thrilled with that !!!!

I have heard that there is something in coffee grounds that helps prevent tearing.  [Ed: It's not clear whether it's really a chemical component of the coffee or the heat; perhaps coffee grounds hold the heat particularly well?]  Apparently Midwives use it in Germany and it really helps. So, I have asked our couples to bring in some used coffee grounds (they are free at Starbucks) and then I have been putting them in a cloth and warming them up. They have to be moist and the juice must be able to leak out - they retain the heat extremely well too unlike water based pads.

I also try to deliver my women with their knees together if at all possible giving more room for the perineum to give.

Most of my ladies who have torn have torn with the shoulders, not the head. Seems like they just want the baby OUT and don't let those shoulders ease out gently. Any comments?

I really feel that slow, controlled delivery of the head and warm compresses are the two greatest factors for preventing tears. Ever since I read Onnie-Lee's book, vowed I would use those compresses! As an intern at Casa, some called me "Onnie-Lee-of-the-North".

Anyway, my intact rate is pretty high, so that's a happy thing.:^)

When the baby's head extends the perineum to the point you can begin to flex it you do so by placing the fingertips on the occiput and using a kind of down/out motion during the contraction. This is not that gentle flexion you read in Varney. This is firm. I always feel a little strange as I do it because it is a lot of down-out pressure. So it is a flex-release, flex-release type of very firm pressure during the contraction. You can't put too much supportive pressure on the perineum because that effectively negates what you are doing anteriorly.

These type of perineums seem to be sort of thick, but at the same time pliable, and have amazing stretch. I have seen them in both caucasian (as this one was) and NA.

Don't get too worried about whether you doing things just right - hand maneuvers and such. The main thing to remember is to keep the head flexed and the mamma pushing slowly and the scissors out of your hand. To get her from blasting the head out, I usually tell her to roar like a mamma moose, then as she pushes, I say, "louder, louder". This keeps her from pushing too hard and fast, and gives her permission to make lots of noise.

I, too, have watched perineums slowly split from the outside in. It is a awe inspiring testimony of the womyn's strength. I think it just happens, and not a lot one can do about it. That same woman will probably deliver intact with a bigger baby next time.

I'm still working on this technique, since the need for it arises so infrequently (5 or 6 times out of ~1500 births), but I use firm flexion, try to gently massage the anterior maternal tissues a millimeter or two across the occiput, then release the flexion and let the head extend a bit. Then I do it again. That's during the contractions. Between contractions I try to ease those anterior maternal tissues a bit further back over the occiput, as well. These perineums stretch paper thin, then just stay that way. The opening is just very rigid. But if I can just get the kid delivered to the nape of the neck, the perineum will slide across the forehead and face and be just fine. So I concentrate on what's happening anteriorly, trying to free the baby in that direction without putting too much stress on the maternal tissues.

The first time a head hung out there like that for 40+ minutes, I have to admit I kept fondling the scissors, then putting them down. I couldn't believe she wasn't going to tear anyway, and the suspense was killing me. Plus, the woman was very uncomfortable (you can imagine!). but she really didn't want to be cut, so I was patient and learned an important lesson.

My routine is that when I see the head I do some perineal massage during pushing, maybe a little in between pushes, with a very high grade (edible) Vitamin E oil. I use gobs (our bottle is 4 oz. and it is usually almost gone when I do a primip). I have not had ANY problems with baby's aspirating it or anything. Usually by the time the head is crowning, the Vitamin E oil is pretty well absorbed. If there is a lot on the baby's face, I just wipe with a 4x4 and then bulb suction. But it hasn't been a problem and this is the way I've always done it (from when I was apprenticing). When the baby is crowning I have the mom blow and just let her own body (without extra pushing), ease the baby out. I will sometimes be very "aggressive" with holding the side skin back around the head. I put a lot of downward flexion on the head (which is real confusing when I do a hands & knees) birth. Whenever the skin gets red and tight or if it is blanched I put a lot of oil there and rub it in and get Mom to blow for a contraction. My hands are smallish so I can slip my fingers in and around without causing a tear, to do some more massage. I keep watching for pink skin - that is what I want to see. On the inside I feel for tightness and try to gently rub it away. I always try to do my massage evenly and as gently as possible. If the Mom is pushing too fast then I get a little stronger with it. Sometimes I'll get my assistant to support the perineum, but usually I can do it myself. I don't use heat or warm compresses -(occasionally warm, but not normally). I have no difference between the birthing stool and other positions. I like the birthing stool better. (I can see better what I'm doing) I'm pretty hands on, I admit, but my clients like my intact rate. When a Dad wants to catch I let him help but I do head/shoulders and then will let go for him to do the rest. My worst tear so far (of about 50 primaries in my own practice), was a 2nd degree that was a sunny-side up OP baby, born in side lying position. I transported her for sutures to her family practice doc in his office that day, because my partner didn't want to stitch her with the big vulvar varicose vein she had right next to it. My next two face ups were born intact. My experience is limited (obviously), but my resolve is strong because I HATE TO SEW!!! I am not a seamstress, and I hate needles. I can't bring myself to do it. (yet) So if someone needs or wants stitches - they get one of my partners. Sometimes I get a Mom who doesn't want very much perineal massage, I totally comply with what they want, but they invariably are the ones who wind up with the tears. I always do some massage though somewhere. The only times I haven't are the ones who "preciped" and I didn't see the baby coming down that fast, like the one I caught as the Mom was getting out of the shower (no gloves on even) or the big stretchy multips who don't need a thing from me. It happens. But I'm real proud of my primip intact rate (out of 10 primips, 9 have been totally intact). They listen to me very carefully and we work as a team. I feel so responsible on a first time Mom - I don't want them to have any scar tissue to deal with later on... Just one of my "things" I guess.

I try to be real thorough when looking for tears - I do an internal exam of course and use a high powered flashlight to look. I don't visualize the cervix though (as we talked about previously). I also give out a handout on prenatal perineal massage, but most don't do it. Probably a good thing, since the early MANA stats are showing an increase in tears on women who have done prenatal perineal massage......

BTW, are "skid marks" labeled as 1st degrees in your personal statistics charts? Or do they have their own ranking? I call them first degrees - since they go through skin and mucosa.

P.S. If I think a particular position is not good for the Mom - I will tell her she needs to move. If she doesn't want to, well, that's her choice of course, but if she wants to avoid a bad tear and possible trip to the hospital for sutures then she'll listen to me. And they always have so far.

Most of my ladies who have torn have torn with the shoulders, not the head.

Important things for me: Mom's preparation prenatally for birthing shoulders 1 at a time ("smaller than head") and then likewise coaching at the time, and telling mom prenatally to enjoy that time of (usually) no pain with just the head out; catcher holding arms close to baby's body when they come; no pulling up or down or out; easing out with natural direction.

We do 2 person (4 handed) catches -- 1 doing counterpressure on baby's head if needed, and supporting mom's tissues the whole time (till born to the waist), the other supporting baby as it comes, holding arms close to body.

I call anything through the skin and into mucosa a 1st degree. Skid marks to me are just scrapes or abrasions of the skin surface, not tears through it into mucosa, so I record them as "none or superficial", not 1st degree.

We do very little massage during the birth, mostly just oil, support of tissues, counterpressure of head if it feels like it could burst through, coaching to blow, and compresses if they feel good to the mom.

Anyone else feel like {side lying} position has anything to do with the controllability of the urge to "blast?"

YES! We do most births (actual emergence) with moms sidelying. Discussed prenatally as best position if you are really concerned about tearing.

In my experience, the best way to avoid or at least minimize tears is to teach moms to maintain control during pushing. I try to stay very connected to her and encourage very little pushing and lots of blowing. Really work with her (this is a great place for the dads to get involved). It can be very intense, for them (mom) because it feels so contrary to what their bodies are demanding they do but it results in more efficient stretching of tissues and no abrupt trauma. There is no rush. It is especially important to maintain this control when delivering the shoulders...you have to work to keep the moms attention and prevent her from just pushing the rest of the baby out to get it over with. Discuss this in detail ahead of time. This coupled with a little veg oil, perineal massage and warm compresses works great for me no matter what position they birth in.

When I first started practicing I went almost 3 years with NO tearing of clients of my own. (It was weird luck of the draw, I have since learned!)

I think that this is an important thing to acknowledge, lest we think that it is entirely our skill level that contributes to tear prevention. As Susan mentioned a few posts back, sometimes it just doesn't make sense why sometimes women tear and other times they don't. Although I have noticed these things: sometimes we see worse tears with little babies (I think because they are so easy to "blow out") than big ones. Also, I have to wonder about tissue "quality" as reflected in the extent of stretch marks on the mom, and how it relates to tearing. Saying this because I had a birth this am with a primip who had lots of stretch marks and some varicosities. She was doing beautifully, and well-controlled, but as the head started to emerge, I felt the perineum "give" (I hate that feeling, don't even have to look to know she's torn). She had a second degree, with what looked like couple of small hematomas in the vagina. Consulted with the OB and then I repaired, but it definitely did not feel like nice, elastic tissue. I've seen this before, too, where the mother's tissues just felt less than optimal, and just give at the point of maximum extension, no matter what you do (or, at least, while doing all the things which normally work).

Also, I have to wonder about tissue "quality" as reflected in the extent of stretch marks on the mom, and how it relates to tearing.

This is a conversation I have had with other midwives re stretch marks. I can't say that I have noticed a correlation but I do think there is something to tissue quality whether or not stretch marks have any bearing or not. I am one of those people who has never had stretch marks, even with my 10 lb baby last time around but have always torn no matter what. However, I have a condition called lichen sclerosis which as far as I can tell may have been with me since childhood -- however, it has only been in the past few years that I had a firm diagnosis. I have noticed that women with frequent vag infections seem to be more predisposed to tears.

I did an 11# baby last year over an intact perineum. This is one of those that I delivered, not caught. I inched the baby out every bit of the way. I thought she would tear because I stopped giving perineal support. He was huge. This was a mom who had had only 6 1/2 and 7 #rs. But she never had a tear and never had any stretch marks. I also think some women have those elastic skins and would never tear. I would like to see more of those. Wish wish! In the mean time we do all we can to prevent tears.

I agree that a lot of tears come with the shoulders. Learned this as a student when a mom had a bigger baby (10-4) than we expected and the posterior shoulder make a large tear. AS i learned to flex the head well and support the shoulders as they come out, I have had to do a lot less sewing. And a slow delivery if possible. WE have a lot of young girls who hate the burning and will just push as hard as they can at the end to get the head out. And with the shoulder support especially, I think the perineum does pretty well.

I don't have a statistic re. amount of tears so I will just guess maybe about 4-5%. I will go for a while with none and then have 2-3 in a row. I would like to not have any but we all get them. I find that moms who don't have any are more comfortable with themselves and are more uninhibited. If they are very relaxed with their sexuality it only makes sense that they would have none. Have you found this vein with tears or not tears? Just my observation but could be only my perception.

sure have wondered about a link. Certainly, tend to think I see a connection with ease of second stage....

Set yourself down on a nice comfortable chair or stool and relax! Let the mom do her thing; we don't need to do perineal support/massage etc. -- just observe and advise.

By this do you mean that the mechanics of the perineum are so altered in waterbirths that support/massage is not needed? If that is the case, do you have an opinion as to how the mechanics have been altered?

I don' think the mechanics have been altered. Though there's a cute theory running around that the pressure of the water gives "just enough" support to the perineum!

I do think that water allows a more natural paced birth and perhaps gives us permission to get "out of the way" of the mechanics.

I was taught that we must massage, oil, position, coach, press, flex, squeeze, "support" and control the perineum or women would rip to pieces in birth. Research, some experimentation, and experience, finally led me to believe that our interference in the process and timing of birth was perhaps increasing the likelihood of perineal injury. I now think women need very little help from us to prevent tearing.

In order of importance in CAUSING tears, I believe we see:

The collective experience now of those of us who began to "do less" perineal management is -- we see less tearing than we did before! We see some tearing, yes. About 10% have a first degree and need a few stitches; a second degree tear is extremely rare. This is a lot less than we used to see when we were using every trick known to midwiferykind.

As far as water birth goes, I think it encourages "good mechanics"...

A mom can float into a very natural relaxed position. She can push as she feels a need to. She may be more relaxed -- no one is flexing the head or has their fingers in her vagina. The warm water soothes and takes away the sting of crowning, so she is more able to slowly birth the head (some women push like gangbusters just to get the crowning over with!).

We see very few tears in water births. This goes against the experience of some others; but we are (generally) keeping hands off and out of the water. Some of those who report the same rate of tearing are still doing the same perineal management in the water as they do for air births.

Some women are going to tear. I think we can increase the natural rate by our interference (such as lithotomy, or coached pushing), but we can do only a little to reduce it.

I agree with the "theories" re fewer tears and waterbirth. In my practice - about 1/3 of our births are waterbirths - we certainly see far less tears in the waterbirths. And I know that the amount of hands on is certainly less. It is too hard on the back to do much hands on with waterbirths. My partner is a 100% of the time hands on midwife, but she can't keep up with this for waterbirths. I also think that because we can't see as well with waterbirths, we aren't quite as impatient or "coach-like" with waterbirths - maybe it is a combination of hands and eyes off!!??? And maybe the warm water does what the warm compresses are meant to do. I know we had some discussion a while back about warm compresses increasing tear rates - but maybe it is all the other activities that go along with the warm compresses that cause more tearing - e.g. physical pressure on the perineum, the friction of terry if using face clothes, the inconsistent temperature - starts off almost too hot then becomes cool - more theories I guess.

Most midwives find it hard to sit on their hands and just be still. I hate coached pushing and valsalva pushing, the methods hospital birthing still holds sacred. Even with epidurals most babies come out without moms ever having to be told to push. The uterus does the work dilating without us having to yell "CONTRACT!!!! 1-2-3 CONTRACT!!!!..STRONGER!!! LONGER!!!...why shouldn't it continue to work if we don't yell "PUSH!!!! PUSH!!!! Then again, maybe if we did yell from the very beginning of labor we wouldn't have to use Pitocin...now that would make an interesting study... Just kidding.

We do most births (actual emergence) in sidelying position and see very few tears anywhere. I think the labial tears you are talking about might be avoided by a little slower emergence - more stretching time, blowing and patience.

I'd like to echo this. I think my experience is worth noting because I didn't have as much training as most of you in perineal support, so the effects of position are more likely to be seen with me, since I don't know as much about how to make up for bad positioning. Sidelying, my tear rate is darn close to zero, and this includes when working with unsympathetic L&D nurses and also, believe it or not, when teaching residents how to catch from that position. They know next to nothing about perineal support.

On the other hand, due to the "hostile" environments in which I do a lot of my work, a ton of women are delivered in dorsal lithotomy, and even with my best efforts I hardly ever see an intact from that position.

I also agree that minimal perineal stuff be done, I just use a warm compress, no massage, and minimally oil. Of course flexion and support. I will try the flex and release method next time.

I have discovered that the very best thing for preventing tears is to have the mother side lying with her legs together and pushing gently as she normally would. When the time is right for her she will lift her leg so her baby can be birthed, if not you can move her top knee slightly forward(you can support it on a pillow or have the support person gently support her knee) so her perineum is visible and have her gently breathe the baby out. She births her baby with her legs still together!

Birthing in this fashion is the most amazing thing to participate in. Keeping the woman's legs together helps to prevent undue stretching and pulling of the perineal tissue. For some of you disbelievers, you may need to lift the woman's leg once or twice to really believe that the baby is coming down. With the legs together you will see her pushing but you don't get the visible reward of seeing caput to assess her progress. I don't know about you but that's okay with me. I find second stages to be shorter. I believe that it is because the woman can push without feeling so vulnerable and open so she actually pushes more effectively.

Many woman are able to birth their babies with their legs together. I still have the woman reach down to bring her baby up towards her. One last thought I also birth the shoulders by what I call the toothpaste maneuver.(I didn't coin this phrase) Which is to keep the baby's arms together until they are past the perineum and of course lifting up along the curve of carus. You slide your hands down along the shoulders holding them against the baby's side thus preventing them from flailing out.

Cool - someone else does this! First time this happened was on a severely sexually abused woman who could tolerate NO exams in the final bit of labor. she del through closed legs, slightly lifting the top one when the baby was at maximum crown. Could only tell baby was coming by the "positive poop sign" and rectal dilation. No tears, either.

I just completed my thesis which examined (among other things) the difference in tears between 75 water births and 75 bed births. All women were delivered by the same CNM, in the same hospital. There was no statistically significant difference in the degree of tears between groups. The water birth group had 52% intact, 40% 1st degree, and 19% 2nd degree, 1% 3rd degree and 7% other tears. The bed birth group had 40% intact, 35% 1st degree, 23% 2nd degree, 3% 3rd degree and 4% other tears (P=0.54). There were no epis. in either group 8-). When factors including baby weight, # of prior term deliveries, maternal birth position, delivery complications and baby position at birth were controlled for, only # of prior term deliveries was significantly related to the degree of tears -the # of prior term deliveries, the lower degree of tears (p=0.0005). The midwife's technique for water birth is generally hands off. For bed birth-(defined as any delivery not occurring in water) she uses warm water compresses to support the perineum. I know that other studies have found increased and decreased tears with H20 births. This is just my 2 cents.

A lot of my ladies deliver hands and Knees also. A lot on their sides too. The things I have seen that seem to work best is to flex the head carefully. On hands and knees I put fingers on the occiput and Pull / press upward fairly firmly. I do a lot of rocking the head out, esp. with primips. {to do this, you flex-release, flex-release, during the push} I NEVER iron/stretch/mess with the perineum, other than a little support with a warm wet cloth, if there is time. I do make sure she blows the baby out, encouraging her to make A LOT of noise. If she is yelling, she can't push very hard. I occasionally use Astroglide on primips or womyn that had bad tears with first kids.

I don't have any problem encouraging womyn to change positions if I think she is more likely to be intact in a different position than she is in. If I explain between contx my reasoning, she will nearly always cooperate. I nearly NEVER let her birth in either supine or semi-sitting position, because I really feel that this position contributes to tearing by flattening the sacrum. Also, it is a bad position if you get a SD.

I have a 60% no sew rate (intact, minor 1st degree [not bleeding], labial abrasions, etc.). I rarely cut epis (2 last year, both for fetal indications, 1 this year for vacuum).

I will try the rocking. I do flex the head the way you describe but haven't "rocked". Also I think it is a matter of time as someone else stated. Mums get impatient with that "ring of fire" sensation. Glad to hear you don't mess with the perineum as I don't do this either. It seems distracting and invasive to me. She's already got so much sensation happening down there I don't want to add to it or distract her from focusing on what's happening. But how do you apply the Astroglide? Rub it around gently?

Also it seems like we have similar philosophy about position. I discourage supine or semi-sit (though oddly enough chose semi-sit for my own births!) for the reasons you state.

Do you sew all 2nd degree tears? I really have to get practicing and one day bite the bullet and just do it!!!

You can put the Astroglide in a cup of warm water to warm it first; this works especially well with those little sample tubes.

Astroglide is the same consistency as, to put it crudely, snot when you have a real bad cold. Almost watery. So I squirt it on the head between contractions and it juices every thing up real nice.

Yeah, with 2nd degree tears, I always put at least a few stitches it to close the dead space and, if she will let me, get the edges at least close together. Stitching just isn't that hard. Get a chicken and start sewing. : - ), or maybe try again on a turkey... wasn't that you a while back?

I think perineal support matters very little. Try a few births using only hot packs, and not encouraging pushing at all (don't direct it in any way).

It's OK to encourage panting/blowing to ease out the head. I encourage you to give up flexing the head for a few births... Maybe it doesn't need to be done. Maybe it could be actually increasing your tear rate...

I use little or no oil in hands and knees births -- partly for that same worry of baby aspirating, but also because it just doesn't stay!

I think most of us using a more hands off approach are seeing the direct opposite. It's been a long time since I've had a birth with any significant tearing and we almost NEVER see second degrees! Second degrees are truly uncommon, usually we see small nicks and splits - - seldom enough to suture.

But there is something crucial about hands and knees. I think it is important to continue the curve of carus whenever we assist a birth. This means we help lift babies "upwards" towards moms tummy when she is on her back, or upright. But it means we should scootch the baby DOWNWARD toward her tummy -- or the bed - when she is on hands and knees. When we are lifting the baby out from behind the mom, I think we are putting a lot more tension on the perineum. We should help the baby come out downwards, or forwards into moms arms when she is on hands and knees. I often observe on videos, the midwife delivering a mom on H & K , bringing baby out towards herself, and then passing the baby through moms knees to the mom... I think it's better for the perineum to birth the baby DOWN between moms knees (and if she has good support she can help catch the baby this way too).

If you aren't already doing this, give it a try and see if your tear rate drops.

Foundation of good nutrition in pn period.

Use warm ginger packs and olive oil. (Move into this slowly w/ the hosp.)

Lotsa women love the soothing nature of the oil and ginger. Wait until beginning of crowning for ginger washcloths. Oil - I start as soon as there is clearly occipital pres. and she is "full on" pushing. Try and ease out head w/o ctx from beginning of crown. (have her push between ctx). Pant for ctx or deep "breathe the baby out". Don't forget to gently flex the head downward in an OA pres. to avoid labial tears.  [Ed. Note - Pushing between contractions may damage the pelvic floor and increase the risk of rectal incontinence.]

Main thing is to be willing to take the time w/o letting the time get to you.

I have noticed in a hospital setting sometimes people get a little more nervous about "how long it takes" to birth the head. Of course this is w/ a babe you can take the time on. In other words one that is not distressed already.

It is an art that we all have to develop, yes? It is wisdom to ask w/ the great resources from the list. Works the same in whatever position she is in. Side lying - I would pull up her upper leg more than hyperflex it; to avoid any undo stress to her labia.

When I was interning, I learned many good techniques for preventing tears. The women there were out of bed for almost their entire labors, upright, walking, etc. They were not permitted into the bed until pushing was well established, until they felt a very, very strong urge to defecate. By this time we could generally see the baby's head. We waited until almost crowning, doing nothing until then, but then we were instructed to REALLY flex the baby's head with one hand ( with more concentrated effort than I had been taught or shown here, although the midwives I trained with here also have very low rates of tearing) )and kind-of "milk the perineum down" over the baby's emerging head with the other hand. We formed a "U" or a "V' with our other hand, placed so that we could visualize the entire perineum and if there was a place at which stress was noted we milked the skin towards that area. It is difficult to describe this - and it doesn't sound in words all that different than what goes on here, but it was!

I developed my own technique eventually.  I place the 'little-finger edge' of my hand near the periurethral area and sort of shape my hand into a cupped form, a "C" shape. The crowning head then sort of slips up into the cup of my hand.  I then apply significant counter-pressure to the head as it is emerging.  I believe that the use of the larger surface of the palm of the hand provides more effective control and pressure than the localized pressure of the fingers.  It’s just physics.

Significant pressure is a great way of putting it.  If the mom is supine you can see the head go back toward the sacrum.  The pressure is strong enough that you almost feel you are going to keep the head from coming out.  The Jamaican midwives use the thumb, index and middle finger to flex the head.  My preceptor showed me another method using the heel of my hand on the vertex with my fingers pointing toward the perineum.

When mom is on hands and knees, I am pulling the head into flexion with my fingertips on the vertex.

I really think it helps.

Sometimes it feels like I am pushing the head down so much that it won't come out.  Then I let up a little and a little slips out, then flex it again and hold.  Thus rocking the baby out.

my experience and discussion with people is that preventing tearing is a combination of things. As much as we would all might like our clients to give birth on their own feet,  alike to the Birth Reborn series, having the ejection reflex and the mother in a trancelike state as the baby emerges naturally from her body, well it just isn't always like that.  Although we could work towards that kind of birth more by setting the right environment and preparing/helping women to tune-in to the more instinctual aspects of birthing. Many need to let go of their rigid ideas of what women must do to give birth. I worked with a homebirth doctor that "insisted" that all his women use a birth stool that the husband was assigned to build. Once he announced that they were "complete" they were hauled to their feet and put on the stool and told to push. Well, I was pretty amazed at this rigid way of giving birth, it sort of felt like women in the hospital all made to take the same position. The more we can give women space to do it their way the mroe they will become instinctual to birth and be more able to "tune" into that sometimes elusive "natural" baby birth energy. What keeps tears from happening in reality is controlled head delivery and/or relaxed perineum.  Now relaxed perineum has a lot to do with the mothers position. On her back or sitting up is a very difficult position to relax for the mothers we are most concerned about, I think the only women who belong there are the multips who lay down instinctually to slow the birth. First time moms feel more in control on their feet, be that on a birth stool, on all fours, standing or squatting with support. The perineal massage prenatally makes sense due to our lack of exposure to the elements in that area of our body and the lack of squatting and stretching of the perineum by our posture and lifestyles. Perineal massage in labor is a different story... my personal preference after watching a lot of differing ways of practice is to gently use downward stroking internally to help the mom relax and open. Recognition of and how to help with soft tissue resistance is an important skill, that takes time to learn the feel for.   One may feel tightness and "sometimes" by feel you can see whether a small amount of counter pressure and massage will help it release, for some women it only causes tension. I like some oils to help the tissue be "slippery" (this very well could be my fantasy that this has any affect). But I use very little perineal massage once the head is on the perineum, then it is about helping the mom get in the right position and to slow the birth, heart tones provided.   One important measure with perineal massage is to work with the mother, start very very gently so as she not feel "intruded" on. Communicate and ask permission and tell her to tell you what feels right or what doesn't and that you will stop at any time just tell her to signal. You dont want a woman to come away from birth feeling that you "did" something "TO" her without her desire, consent. She should feel that you were working together toward the goal. It is her body and your hands dont belong inside her without her wanting them there, and that may mean a lot of discussion, eye contact and telling her what you're feeling in the moment and what you might be accomplishing and that she feels it is in her power to have it stop instantly if she doesn't want it.  I have agreed with those that say that perineal support causes more tears than it cures and have taken on the practice of controlled head delivery. I keep my hand on the baby, not the perineum and apply counter pressure to assist slow emergence of the head and prevent quick expulsion. Helping the mother birth the baby slowly through dialog and direction is probably more commonly needed than anything when it comes to preventing tearing. (This is ALL just my opinion and experience), and if someone really can pass on an effective skillful perineal massage practice then I support that wholeheartedly. Any midwifery skill is personal and what we are able to learn well and adopt to our practice is very unique to each of us.

Perineum of Steel

I usually have the mom breathe the baby out slowly, 3 short pushes then 3 slow blows, to allow the perineum stretch really well. This, of course, if all is fine with mom and baby. I go over this technique at the prenatal visits in the last month and in the childbirth ed class.  I have had a couple of really thick, strong perineums w/ minimal damage by using this technique. We even prevented tears in 5 out of 6 nuchal hands that we had in a row last month with this technique. Sometimes though, a perineum is going to tear no matter what you do!

What Women Can Do To Protect Themselves

Ina May Gaskin has observed that most women who smile during expulsion do not suffer from perineal rupture, presumably because smiling relaxes the pelvic floor muscles.

IMPORTANT - Recent discussions postulate that routine use of the Ritgen maneuver to force premature delivery of the baby's head increases the likelihood of shoulder dystocia.  Ask your practitioner whether they routinely use the Ritgen maneuver and at what percentage of births they have used the Ritgen maneuver.  [The Ritgen maneuver is performed by applying moderate pressure from beneath the baby's head to the baby's chin to force premature extension and delivery of the baby's head.  Co-incidentally, it was traditionally used with an episiotomy; when the Ritgen maneuver is done to a mother with an intact perineum, it inevitably tears the perineal tissues because the unnatural extension of the baby's head widens the diameters significantly.]

I have heard that the biggest single factor in how well the area fares is how long you have to spend pushing, that the longer a woman pushes, the more the area swells, which reduces the ability to stretch. 

There are several phases to "pushing" - some are better avoided altogether and some are better prolonged rather than shortened.

The first phase is unnecessary pushing.  This is commonly encouraged by impatient care providers and involves pushing before the mom feels an urge to push or before the head is reasonably low and is mostly rotated into the optimal orientation for birth.  This is best avoided altogether.

The second phase is true pushing - the mom feels an uncontrollable urge to push because the baby's head is putting pressure on the nerves of the pelvic floor.  This almost certainly means the head is low and rotated into birth position.  This takes however long it takes for the mom to get the hang of it and to push the baby out.  If the mom's instinctive pushing efforts are moving the baby, it doesn't make sense to mess with it .

Olympic-style pushing, where the mom is encouraged to hold her breath and use all the muscles in her body, may occasionally be helpful; but it also can impede venous return and cause the swelling mentioned above.  I would suspect this style of pushing is generally uncommon in midwife-attended births.

The last phase of "pushing" is crucial to preventing tears - this is the time when the head has been pushed through the pelvis and is beginning to stretch the perineum.  Once the head is through the pelvis, it's just the delicate perineal tissues that are holding the baby in, and this is where a woman's perineum is either protected through careful coaching and hand maneuvers or allowed to tear through ignorance or a rush to get the baby out.

Ideally, the care provider is maintaining a good connection with the birthing woman and lets her know through words, tone and manner that this is the time to stop pushing and simply to breathe the baby out, i.e. avoid putting any voluntary efforts behind the uterus, which is "pushing" all on its own.

I just wanted to write all this to help people understand that "there is a time to push, and a time simply to breathe".  Prolonging the unnecessary phase of pushing may contribute to tearing, but prolonging the very end of pushing is likely to reduce tears, rather than cause them.

Tears from Baby's Shoulder and Body

Does anyone think that having mom do her own delivery might lead to weird midline tears? I think these weird tears are due to weird angles of the baby as it exits the vagina.

Interesting. One MW I have worked with has a lot of midline tears. She is also great at suturing. At birth, she always pulls baby up toward mom's abdomen as he is being born, just as you described the mom doing herself. I had never associated the tearing with that practice.

Most of the births I do the mom catches as the body comes through, lifting her infant directly onto her abdomen. I do not see very many tears at all and certainly no evidence that this causes any increased tearing. I have also never (knock on wood) ever cut a cord on the perineum, using whatever technique is appropriate to get the infant past the cord entanglement and once again see no increase in tissue damage with "somersaulting". 21 years trying it all out.


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