Saturday, February 23, 2008

The perineum

The topic for today is perineums (perinea?). Let's start by reading Sara Wickham's classic articles Perineal pampering - before, during and after birth and Is prevention always the best cure?

There's a great visual example of an upright birth with no one messing around with the perineum from Sage Femme. (It begins after the 3rd or 4th slide and is definitely not work appropriate. Unless, of course, you are a midwife, doula, or childbirth educator!)

So, let's talk perineums!


  1. while I loved (re)learning about all of these techniques, theories, and historical explanations of why hands off might be alot better for Mothers....I could do without all the 'clever' comments having to do with *If we needed help we would have been born with hands inside our thighs*, or *born with hot packs built into our labias*. I thought all of that was stupid and a bit shaming. Do we say stuff like "if we needed chiropractic care, we'd all have self-cracking spines", or "If we needed herbs we would be bron with them growing out of our skin?"

    I dunno. I think sometime less is more, and in this case, simply stating that we do not need to stretch our pereniums with oils, or dig around to get (most) babies out would have sufficed. Saying all that other stuff just makes me feel bad for wanting and needing all my ice packs, hot packs, herbal baths, arnica, and letsbe honest here, motrins, tylenols, numbing I am not a "nature Mama" because there is stuff out there to help my pain. Would we begrudge men the same helpful devices?

    So, while I totally get it that messing with the perenium can do much more harm than good beofre the baby comes, I dont think there is any reason to take issue with whatever it takes to help us afterwards.
    If knowing this about me helps, I had 2 vaginal deliveries: One purple pushing my firstborn on my back in the hospital with a sizable episiotomy, and one an 11 pound homeborn baby who had one hand behind his back, one hand in front of his head, and was completely tangled in an extremely long cord. My midwife did use her fingers inside me to hook them under his armpit and corkscrew him out, and though I did not tear, I was sore and used all kinds of things to help me get better ASAP. In my world, Daddy got 5 days off work and then it was just me and the 3 I did what I could to get back on my feet.

    I love Sara Wickham, and I love this topic, I just have an issue with some of the tone these articles can take. Hope this made sense!

  2. Wow lots of typos...sorry!

  3. Yes, I agree about the clever comments. And I think that after-birth care/comfort measures is a different animal altogether than what happens while the baby is emerging. I wish I had been more pro-active in doing ice packs or hot packs or whatever because I was really really sore.

  4. Ice packs are good preventative stuff after delivery. I have seen perineums swell to the size of a footballs the day after delivery.
    Ouch.....Mothers have to take care of themselves in order to care for their children.

    "like I am not a "nature Mama" because there is stuff out there to help my pain. Would we begrudge men the same helpful devices? "

    No, we would not begrudge men. For years women were coming thru the emergency room having heart attacks and we told them it was all in their head until they died of cardiac failure. Fortunately, we realize now that woman present differently with a heart attack. Many times it comes as back pain.

    I remember when we first started offering water births at one of the hospital I worked at, we nurses started thinking "Maybe the perineal swelling is part of having a water birth? I mean we were brand new at it and didn't have a lot of experience. And when a Mom is in the water, it is harder to get at her perineum...Harder to get at = less messing with it.

  5. Great topic!
    Prenatal perineal self-massage: I just don't get it. I'm one of those women who fails to feel more in touch with my body after inserting a thumb or two up my vagina; it feels rather silly and somewhat uncomfortable. I'm guessing I'm not alone. It probably doesn't hurt though... does it? It's still far enough from the cervix I hope that there is no risk of pushing germs up? Has this been studied???
    My history: first birth, average size head, pushing on birth stool with midwife stretching/massaging the perineum before crowning; superficial tears (periurethral too), big sore swelling, couldn't sit for a week. Not my recipe for a happy bottom. Second birth, same size head, pushing kneeling in water, hands off, no tear, perineum good as new by evening.
    Aftercare: I did frozen comfrey pads and sitzbath first time around, second time I didn't do a thing for my perineum (I hated the afterpains though!)

  6. I've never done any prenatal perineum care, and I've had varying results. I tore front and back with my first, but he was my biggest, and I was underwater and pushing as hard as I could to get him out. No. 2 - no touch, and no tears. No. 3 - no touch, but he shot out so fast that I got some minor tears on the inside.

    I don't really see the point of all the stuff beforehand, though I really, really like the frozen pads afterwards. I'll have to make sure to make a few of those this time around. That, and stock up on the ibuprofen for the afterpains. Ouch!

  7. Oh, and my first baby was posterior. I think that influenced the tearing.

  8. I got "massage" at my first birth. It. HURT! And I was still victim to a sizable episiotomy to get the posterior, forehead baby out.

    After that, hands off the perineum, people! Except that I like to apply STEAMING hot washcloths to the whole area when I'm working to get a baby out. That made the bulging much more bearable. And with most things, I say, whatever works for the Mama and to Hell with what everyone else thinks.

  9. I think it's pretty clear what I believe.

    Upright birth lends itself to a mother supporting her own tissues. This is the ONLY person that can truly help with a perineum...she offers support and counterpressure where she feels she needs it.

    I feel that doing massage, counterpressure or stretching routinely at births increases the risk of larger tears simply because it applies pressure to areas of the perineal/vaginal area that wouldn't normally be pressured.

    I also think that maybe it's about time we stop thinking that no tears is the ideal. Somehow our body, when it tears a bit, is really helping keep things from getting too big, right? Small tears offer release before the damage gets worse in more fragile areas. Does that make sense? So, in essence, the drive to 'prevent tears' is about as easy as the belief that we can prevent stretchmarks.

    I'm tired, so it's likely none of this is making sense. I am MORE than willing to help a woman in any way that makes her comfortable in birth - but I've never had a woman tell me that she wished I would have had my hands on her as she was pushing her baby's head out.

  10. Thanks for bringing this up, and for linking to the other papers. As a prenatal yoga teacher (and a doula), I get a lot of questions about how to "prepare" the perineum for birth, and how to "recoup" it afterwards. Prenatal perineal massage seems to be a popular piece of advice right now. More and more, however, I question whether such techniques are truly necessary, or just another way in which to feel like we are *doing* something (as in, doing rather than being).

    A new mom recently shared that she had a 2nd degree tear during her (non-medicated) delivery. Overall she was very pleased with her birthing experience, but she is quite concerned about "down there" and if it would *ever* heal. I intuit that her deeper concern is really whether her perineum will ever again be as it was...Right now it is, perhaps, the focal point for her concerns about this huge life change, in addition to being a legitimate concern as to the future health and tone of the pelvic floor.

    I'd like to take this opportunity to thank you, Rixa, for helping get the word out about the Trust Birth Conference. I first read about it on sagefemme and my interest was piqued. A little while later you wrote about it and I decided that I *needed* to be there! One of the classes which I am particularly excited to attend is "Hands Off the Perineum". :-)

  11. honestly, i have had no problems with my perineum but i got skid marks on either side at the top of my vagina. THOSE hurt.

    I never did perineal massage, because frankly i stuck so far out i couldn't reach myself, and it really bothered my husband to stretch me like that. so we just didn't do it.

    first baby 7lbs 10oz.
    second baby born 5 days ago 9lbs 5oz. i never tore, and didn't even get skidmarks this time around.
    i used the birthing pool both times to labor and just as birth would have it, decided to get out last minute. i had warm compress this time around, but not the first.

    who knows, perineums differ... but i do believe that the way we push can affect it.

    this birth i sat on the birthing stool and pushed with my urges. i never felt any urge the first time around so this was new to me.
    i'm just amazed and feel like WOMAN that i birthed a much bigger baby this time around. he didn't feel 9lbs. he felt 7lbs coming out.

  12. My doctor (later mw) and I did an 'alternative' perineal massage. It consisted of lubrication, warm cloths for comfort and no manual stretching.

    With my first, I had a horrendous 2nd degree episiotomy that continued into a 4th degree laceration. My scar tissue is so thick that every one of my care-givers has said that they were SURE I would tear with how thick and unpliable my scar tissue is/was.

    NONE of my subsequent babes caused any tearing... not my posterior nearly-8lber. Not my nearly 9lb, 43 week babe who had shoulder dystocia because of his HUGE shoulders and chest...

    No hook-and-pulls for me. But a nice lube and soft touch is good in my book.

  13. with my son i had an epidural (weirdest physical experience ive ever had!) so i pushed in bed, in an way that i was not in control over because i had given up my ability to be connected with my body's cues you know? i pushed on my back and had a 1st degree tear. oh he was a compound presentation too (right nuchal hand) and came in just 15 minutes of pushing.

    second round i did things at home, in a tub. my daughter was brow presentation so i had to push almost an hour, which is still not that long but in comparison to my first, i thought it took quite a bit longer than expected. only after she was almost out did i realize her position. anyways because i was delivering in water, with no ones hands all up in my vagina, was able to listen to my body, and wasnt being barked at how to push and for how long i delivered over an intact perineum.

    i think most people just expect to have an episiotomy so they dont invest a lot of time into educating themselves about how to prevent tearing, etc. that makes me sad

  14. Seattle Yogini,

    Perhaps your client might be comforted by my experience! I had a 2nd degree episiotomy with baby number one. It was very painful to recover from and took probably 3 months before it lost the 'tender' feeling and many, many more before I really didn't notice it any more. After 6 years time, and 3 more heads have gone through and stretched:

    1) I never tore/got cut again


    2) I no longer notice the scar tissue. I think number 3's big head and SLOW stretch helped with that. :)

  15. I have read most of these comments and have noted that a lot go the same way- 1st one had episiotomy/tear and the rest didn't. Did anyone ever stop to think that once your body goes through that stretching it is usually easier for your body to stretch again in the future. Thus, less tears in future births. It's not all related to perineal stretching/lack of massage, etc.

  16. I tore with my daughter's birth a few days ago. She is my first, about 8.5 lbs, born in water while I floated on my back/side... I chose the position to push, and pushed only with ctx, but by the time her head was sitting there I remember thinking "I don't care if my butt explodes, I want the baby out!" I had a hard time telling what was happening and just pushed when I felt the urge and relaxed in between. I think I did have some handling by the midwife, I don't really remember.

    At any rate -- post partum I've been using arnica regularly as well as ibuprofen. I use witch hazel in my peri bottle. I made frozen pads but have been too busy to really use them!! Same w/ herbal baths - love the idea in theory but in practice it's been hard to make the time. I've had only mild discomfort so far, and am optimistic about my body's ability to heal up and bounce back. I don't regret my choices/actions during the birth since I was doing what I wanted to do... *shrug* I did nothing to prep my perineum, I didn't see the need.

  17. I had a small tear with one stitch with my firstborn after three hours of pushing. I also had a lot of swelling due to the long pushing stage and I sat on icepacks and did sitz baths to help feel better.

    My second one I had a second-degree episiotomy with four stitches.

    My third I had three stitches.

    My fourth I finally dodged the bullet and only has a small skidmark, with no stitches :)

    I never have had an episiotomy. I am pretty adamantly opposed to those unless it is a case of the baby being in distress and needing to come out NOW. I would much rather have a natural tear. Thank God the midwives I had agreed completely and could count off on one finger how often they had even cut one in their lifetimes.

    I did perineal massage beforehand with my firstborn, nothing with the other three because I figured I didn't need it since a baby had already been through there before. I also found, with my third baby, that comfrey tea baths are AWESOME for relieving perineal pain! I wish I had known about them with my first two. The midwife who delivered my third grew her own comfrey and you steep the leaves and make a tea and put about a cup of it into a shallow bath. It really works wonders.

  18. Whoops, just editing my post above, with my second child I had a second degree TEAR with four stitches, not an episiotomy. I've never had an episiotomy.

    I should also add that with my second child, dh and I "did the deed" just 16 days postpartum! And it didn't hurt AT ALL, even with the tear and the stitches. Although I was still pretty "open" from the birth so I cannot imagine it was much fun for dh!

    We wouldn't have hopped in the sack so soon after her birth but he was leaving for Iraq for four months in a few days, well before the six-week mark, so we "broke the rules" a bit!

  19. I had a home waterbirth and I was floating/laying on my back when the baby was born. I had a 1st degree tear; basically the skin just split from vagina to anus. Both of baby's hands were alongside her head, and this was probably part of the reason. The only "messing around" that happened was my midwife checking for the cord after the baby's head was out.

    I do believe that upright birth is superior, and the second attendant suggested I might want to get up at the end of the pushing, but I was too exhausted to bother, so I just laid there. I'd brought the baby almost all the way down while standing up (and without any conscious pushing on my part), but at the end, for that last inch and that last half hour, I just had to lay down. And I don't think it did my perineum a bit of harm. It DID do my tailbone some harm, I think, and for that reason I'd get up next time.

    The only thing I did to prepare my perineum was daily deep squatting to strengthen/stretch the muscles. Had stitches (wouldn't again for a tear like that) and healed up fairly quickly afterward, not much pain and no aftercare whatsoever. Very little swelling.

    In my midwife's opinion, the water may have prevented worse tearing. She strongly believes in hot cloths applied to the perineum during landbirths. I think I agree with her.

    I have an aunt who gave birth to 5 babies while lying flat on her back in a hospital bed (in the 60s-80s) and she never tore once. I think everyone's anatomy is a bit different and tearing is just part of the deal for some women.

  20. I just wanted to say thanks for the links and I've enjoyed reading everyone's comments.


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