Supporting your own perineum

A blog reader recently asked a question about supporting your own perineum:

Reading the post regarding birth plans, I came across the part where you say "I catch my own babies and support my own perineum" and it confused me a little bit.  I am not a mother, never given birth.  I have witnessed a few births but I still have the question... What do you mean when you say you support your own perineum?  Can you explain to me exactly how you support it?  If this is too personal of a question, sorry!  I am just unfamiliar with this and would like to know what it is for future knowledge.  My husband and I are trying for our first and I have to say that I am scared of the birthing process.  Mainly because I am scared that I would tear.  So you mentioning this peaked my interest.

First, I should clarify that what I do is provide gentle counter-pressure against the baby's head wherever I feel too much burning/stinging, rather than touch or support the actual perineum.

Let me quote from Dio's birth story to illustrate:

The baby’s head descended rapidly. When I felt it hit my perineum, I slapped my right hand down to support my tissues while maintaining a death grip on Eric’s arm with my left hand. As I was doing this, this passage from Gloria Lemay’s article Midwife’s Guide to an Intact Perineum flashed through my mind: "The next distinct feeling is a burning, pins-and-needles feeling at the opening of the vagina. Many women describe this as a 'ring of fire' all around the vaginal opening. It is instinctive to slap your hand down on the now-bulging vulva and try to control where the baby’s head is starting to emerge. This instinct should be followed. It seems to really help to have your own hands there."

...With each contraction, the head emerged more and more. I applied counterpressure to the head, varying the pressure between the front and back depending on where I felt more pressure and stinging. As much as crowning, and pushing in general, was wild and crazy and painful, it was amazingly cool to once again support my baby’s head as it emerged out of my body. There’s nothing like feeling your baby’s head come out, bit by bit, into the palm of your hand. Every woman deserves that experience.

Providing your own counter-pressure or perineal support isn't a fancy technique; it's a matter of following your body's cues. You cup your hand over the baby's head once it starts crowning and apply counter-pressure wherever it feels best to do so. Sometimes it will be in back towards the perineum; other times in front near the urethra/clitoris.

During Zari's birth, she seemed to take forever to be born. On the other hand, during Dio's birth I was doing everything I could to slow the pushing stage down. So the counter-pressure was especially useful for Dio's much faster pushing stage (20 minutes versus 2 hours).

If you want to do your own perineal support/counter-pressure, make sure those attending the birth know this and are prepared for it. Every provider has their own habitual practices--some routinely massage and stretch the perineum, others provide counter-pressure, others keep their hands off entirely. Be very clear that you want no one touching you or the baby as it is crowning and that you will be putting your hands on the baby's head instead.

It also helps to be in the right birth position so you can easily reach the baby's head. Variations on a low kneel or crouch work especially well.

"frog squat" from Sage Beginnings

A low kneel from Laura Shanley's Bornfree site

Sitting on the toilet also works; I did this while Zari's head crowned and emerged, then went down to a half-kneel/half-squat on the floor for the birth of her body.

I'd love links to photos or videos of women doing their own perineal support/counter-pressure!
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Mind Reader

Hathor the Cow Goddess has apparently been reading my mind; her most recent comic takes on both lying down and coached pushing! I got to sit near her during a panel discussion about unassisted birth, but I never had time to introduce myself or to chat. Maybe next time?...

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Lie down and PUSH!!

Lying on one's back with legs propped up often comes as part of a bigger "package deal" that includes Valsalva pushing, aka purple pushing, aka coached pushing, aka "hold your breath and tuck your chin and push Push PUSH!" while the staff counts to 10.

A recent post on the Better Birth blog describes what a birth with purple pushing looks like.

Why do we do this? Is it helpful? Is there a better way to push?

The answers are:
A) We do this because of a strange combination of ideas: that women need to be taught how to push, that they won't know how/when to do it otherwise, that the faster the baby gets out of the birth canal the better. It probably evolved from women being heavily anesthetized and unable to feel the natural urge to push, thus creating a need to "coach" women how to push their babies out.

B) Not really, if you look at the risks (several, including more pelvic floor damage to the mother and reduced oxygen supply to the baby) and benefits (not many at all--possibly a slightly shorter pushing stage, but at the expense of both mother and baby). This comment from Dr. Joseph I. Schaffer, a researcher investigating coached vs. physiologic pushing, summarizes the current situation quite well: "Everyone uses coached pushing, but it has no known maternal or fetal benefits, and we found that it was associated with negative effects on several urodynamic indices."

C) Yes: it's called physiologic pushing, in which the woman follows her bodily cues and pushes only when and how her body tells her to. Physiologic pushing has a fairly characteristic pattern: the woman usually will not hold her breath, but instead will push for shorter intervals while exhaling or grunting; she generally uses open-glottis pushing, as opposed to the closed-glottis pushing of the Valsalva technique.

There's lots of research on coached versus physiologic pushing, so I will direct you to just a few:

• Bloom, S. L., Casey, B. M., Schaffer, J. I., McIntire, D. D., & Leveno, K. J. (2006). A randomized trial of coached versus uncoached maternal pushing during the second stage of labor. American Journal of Obstetrics and Gynecology, 194, 10–13. (Available here; you need to scroll down a bit to get to the research summary).
• Less Pelvic Floor Damage Associated With Uncoached Pushing
• Schaffer et al, "A randomized trial of coached versus uncoached maternal pushing during the second stage of labor on postpartum pelvic floor structure and function," American Journal of Obstetrics and Gynecology, May 2005
• MCN Am J Matern Child Nurs. 2000 May-Jun;25(3):165.
• Caring for women with epidurals using the "laboring down" technique. MCN Am J Matern Child Nurs. 1998 Sep-Oct;23(5):274.

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On your back, please

On the heels of this wonderful conference--which I am sure you're all dying to hear about--I came home and heard that my SIL had her third baby, their first boy and born OP! Welcome to the world little one!

I'm going to tell a story about her birth, with her permission (and correct me if I have any details wrong, J.!) My SIL had her second baby with a hospital CNM, but when she became pregnant with her third, the midwife had closed the practice. So she was left with two fairly undesirable options: drive over an hour away to the nearest CNM practice or use a local OB practice. She did the latter, figuring she's done this twice before anyway. No biggie, right? Her second birth was fairly quick and straightforward and she gave birth to the baby on her hands and knees.

So, this third birth was a rude awakening for her. She did almost the whole labor at home and got to the hospital an hour before the baby was born. She was laboring on her hands & knees, as comfortably as you can when a baby is on the way, but when she was ready to push the nurse asked her to flip over onto her back. She didn't want to, and her husband spoke up several times for her as well. The doctor (one she had never met, since she was with a large OB group that rotated call) came into the room and insisted--I kid you not--that she flip over "because it's easier for me." She really didn't want to but she was in no place to argue since she was now in Get-The-Baby-Out-Mode...So she flipped over and then started the most excruciatingly painful experience of her entire life.

Here's a little of what she wrote about pushing on her back:

So...instead of using gravity and an easier position I was forced into birthing on my butt. They wanted me to pull my legs towards me and curve my back and tuck my chin and push. It was the MOST painful experience of my life. And the thing that was killing me is that I knew it would have been better in the position I was previously. So...while I'm going through all this pain. I said something like,...I can't do this, it hurts so much....which in my head was meaning...I can't birth in this ridiculous position, it's too painful. Lovely Angela [her nurse] smirked..."sweetheart, it's supposed to hurt." Had I any expendable energy, I would have drop kicked her. Angela, sweetheart...it doesn't HAVE to hurt...not like that at least. Trust me, sweetie....I've done it before. Brandon eventually almost passed out from all this, and just as the baby was coming, he disappeared...meaning he had to sit down and take a few breathers. I was confused and wondered where my man had gone. He quickly came back to my side and Wade came out soon there after.

I don't want to take away from the amazing experience it is to have a child naturally. But, it is NO wonder to me why women have epidurals if they are required to birth in such a ridiculous and painful position. So...what did we learn?

1. What's easier for the Doctor is best.
2. Labor is supposed to hurt.

Those are two lessons I hope never to learn again.

This kills me. Here we have a doctor and a nurse inflicting pain on someone, for no good reason, just for their convenience! She told me that the ironic part was that she was staring at a framed poster on the wall while having her baby, and the poster said all these things about the hospital being concerned about the patient's comfort and to let the staff know if they could do anything to help make the experience more comfortable.

So, here's to a ridiculous custom that does no one any good--no birthing woman, that is. I vote that we force any doctor, nurse, or midwife who asks women to birth on their backs to do 1,000 hours of the most unpleasant community service imaginable!

So my slogan of the week is...

Stand and Deliver--Don't Give Birth Lying Down!

(my business name and motto, by the way)

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Gloria Lemay classics

Here are two classic articles by Gloria Lemay, a birth attendant in British Colombia:

Pushing for First-Time Moms

Pelvises I Have Known and Loved

In "Pushing for First-Time Moms," Gloria exquisitely describes the stages of pushing. I experienced many of the sensations she discusses. I first had small abdominal pushes that felt exactly like throwing up, except in the opposite direction. I call it "throwing down." I could hear my voice catching in the back of my throat, but I wasn't making any audible sounds.

At that point, I reached inside for the first time to see if I could feel anything. Sure enough, there was the baby's head, still kind of far inside and more backwards than upwards if that makes sense. I felt a small, thin anterior lip of cervix. It felt exactly like the neck of a t-shirt. Because I had read Gloria's article, I knew the lip was nothing to worry about and that I just had a little more dilating left.

I also experienced a sensation of being "stuck" and some frustration that the baby wasn't moving down--especially when my pushing urges changed from mild and slightly pleasant to irresistible bearing down sensations that I had roar through.

Gloria has this to say about the baby's head being "stuck":

I recommend that midwives change their notion of what is happening in the pushing phase with a primip from "descent of the head" to "shaping of the head." Each expulsive sensation shapes the head of the baby to conform to the contours of the mother's pelvis. This can take time and lots of patience especially if the baby is large. This shaping of the baby's skull must be done with the same gentleness and care as that taken by Michelangelo applying plaster and shaping a statue. This shaping work often takes place over time in the midpelvis and is erroneously interpreted as "lack of descent," "arrest" or "failure to progress" by those who do not appreciate art. I tell mothers at this time, "It's normal to feel like the baby is stuck. The baby's head is elongating and getting shaped a little more with each sensation. It will suddenly feel like it has come down." This is exactly what happens.
Given time to mold, the head of the baby suddenly appears. This progression is not linear and does not happen in stations of descent. All those textbook diagrams of a pelvis with little one-centimeter gradations up and down from the ischial spines could only have been put forth by someone who has never felt a baby's forehead passing over his/her rectum!

My full-on pushing urges lasted about two hours, and towards the very end Zari's head descended fairly quickly, exactly as Gloria has described. At this point I was sitting on the toilet and supporting my tissues. Eric says I got very quiet. He thought that labor had stopped. Little did he know that she was starting to crown!

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