Tearing: How not to?
This is a bit of a wince-worthy topic, and not necessarily top of my list to teach for pure interest factor but, unsuprisingly it is exceedingly popular with pregnant women. When women are quizzed as to their fears about birth, top of the list is usually pain followed swiftly by the possibility of tearing. And yet whilst some places quote horribly high statistics for incidence of tearing, midwifes who are more of the natural birth persuasion speak rather proudly of how few women ithey have who tear.
As with so many other aspects of birth, there is an assumption by many that its just luck of the draw, whether you tear or not. You might, you might not, you never can tell. Yet thankfully there are an awful lot of things to consider to help protect the perineum and stop you from tearing, or to limit it to a little nick at most. Like all these things, there are no hard and fast rules, nor guarantees, but with some preparation beforehand and care during birth, you can help lay good foundations and significantly reduce your chances of tearing- and that has got to be a good thing.
The first thing to consider is perineum massage. Somewhat suprisingly, the ‘perineum’ made headlines back at the beginning of the year. But the furore wasnt over a woman’s perineum, nor was it in the context of birth- all the fuss was over the perineum of Nicholas Sarkozy. Quite apart from the fact that a vast majority expressed surprise that a man even had one, his particular body part made the news because he had been instructed to work on it!
And in the lead up to birth, we need to work on our perineum too……but for different reasons.
A lot of the books advise getting your partener to perform this particular little massage trick. However, as it is one of the least sexy things you will ever do, my advice is to go it alone on this one! The choice, however, is all yours…..
You need to consider this particular little technique from about 34 weeks pregnant- dont worry if you are beyond that point and this is the first you’ve heard of it…just get on with it now. Week 34 and 35 you can give yourself the massage several times a week, and then from 36 weeks try and do it every day. If you do it religiously, you will feel the difference even before you give birth. And whilst the science is a bit ambivalent about the impact of the massage, anecdotal evidence is overwhelmingly positive. In my opinion, as it cant hurt, its worth a try…..
You’ll need to get yourself some unscented massage oil – dont bother with the branded stuff that says perineum massage on the label. Just get some base oil or some other simple oil from any health food store and use that. Make sure your hands are lcean and fingernails cut short, and then get yourself into a position where your perineum is accessible. So squatting if its comfotable, standing with one foot on the edge of the bath or loo seat, or even straddling the loo. Just see which position is best for you. Put some oil on your thumb and forfinger and then insert your thumb into your vagina at its base. It is the skin at the bottom of the v- if that makes sense- that your are looking to stretch and make more elastic. You can then alternate between two techniques. The first is massaging the skin between your thumb and forfinger for about 3 to 5 minutes- the first time this will probably feel like an eternity but when you get nimble at it, you could always read a book or a magazine at the same time to while away the minutes. The other technique, which you can do for another 3 minutes or so, is just using your thumb, and applying pressure to the perinuem, stretching it away from you until you feel a mild- and only mild- burning sensation. Be careful with yourself, as in no way are you menat to cause yourself undue pain. But what you’ll find, is the perineum will begin to become a bit more elastic, and stretchy, so that with the same stretching there is far less burning.
As well as being physically of benefit, it also helps pschologicallly to actually see and feel an improvement in how much you can stretch, and will give you confidence in your ability to stretch around your baby’s head when the time comes. It is a notorious birth fact, that the second stage of labour takes much much less time in second and subsequent births, and whilst there is obviously a physical reason for this I. E you’ve stretched once, so it is easier to do it again, I am convinced that there is also a psychological element to it. First time round, there is a little part of us, that simply cant quite believe that we can get a baby out. Knowing we can stretch will help us believe.
So you’ve prepared the perineum- what else can you do?
Listen to your midwife.
As I said before, midwives pride themsleves on helping women to birth without tearing. Whilst Michel Odent talks about the ‘foetal ejection relfelx’ which is effectiveky and involuntary second stage, for most wome there is some effort involved in bearing down and helping birth your child. Whilst the best possible midwife during the first stage is one who is off in a corner, present and available and reassuring but ultimately unobtrusive, during the seocnd stage her guidance is essential. Not only will she ensure that you do not push until you are ready- which will help you no to tear- but she can offer up different positions which harness gravity or reduce it a touch depending on what you need, and which ensure the baby puts even pressure on the perineum, enbling it to stertch more evenly and gently. She can also ancourage you to ease the baby gently through the perineum by directiong your psuhing efforts as seems necessary for a gentle birth.
In fact Michel odent believes position is essential, because the position of the mother impacts that of the baby…..In his book The Caesarean he says ‘ I have never had to repair the perineum after a real undisturbed foetus ejection reflex. One of the many reasons probably is that in such a context the mother is more often than not bending forward, for example on hands and knees. In such postures, the mechanisms of the vulva opening is different from other postures. First the anterior part of the vulva opens more quickly; then the deflexion of the head tends to be delayed, and when the face comes out the chin is more lateral’.
Consider using water.
The incidence of tearing tends to be reduced with the use of water as the water softens the perineum enabling it to stretch more easily around the baby’s head. It also really reduces how the experience of crowning feels, taking a lot of sting out of it! Rest assured that in water or out of it, actual full crowning happens in moments, and passes as soon as the baby’s head is through, so dont be afraid of it.
Continue to ctreate best possible conditions for physiological birth,
We need to think in terms of reducing physical and mental tension during labour, to allow the body to open up. This is just as important during th second stage of labour- so all the things we need for a positive first stage are also necessary for pushing- comfort with who is in the room is essential, as is darkness, security, a feeling of not being observed or judged. With less tension, there is less risk of tearing.
Question whether you’d like an epidural
Whilst epidurals are the rolls royce of anaesthesia, and the perfect option for some, they come with their downsides. One of them is increasing the risk of tearing- in one study women with no anaesthesia had the highest rate on intact amaesthesia whilst women with epidurals had the highest rate of episiotomy. And you are apparently three times as likely to have third and fourth degree tears. And it makes sense- with an epidural the pain is gone, but so too is sensation that can act as a guide to pushing and doing so gently.
A podcast of this will soon be available to download. Stay tuned…..