After some discussion with my highly intuitive, wise mama friends about birth this afternoon, I brought out the Midwifery Today issue on tear prevention. (Number 65, Spring 2003)
Sara Wickham, a UK midwife who has mentored me through her writings about birth, asks the question: Who or what are we protecting the perineum from?
Good question. Are we really so sure that we prevent tears? During my midwifery education, I was taught that there are a variety of “techniques” and “remedies” that midwives should use to prevent tearing: “small” episiotomies, prenatal perineal massage, hot compresses with herbs during pushing, warm oil, creative hand maneuvers, four-handed catches, counterpressure on the occiput, slow delivery of the head, etc.
What is the idea behind “saving” the perineum? How many times have we heard midwives boast “over an intact perineum” as if they were the determining factor in whether or not a woman tore?
Over the past few years in my practice, I have begun to have a different take on this issue: that there are very few things I personally can do to really prevent tearing in a client, but there are a whole host of situations and instances where I could actually create an environment for perineal tearing.
Here are a few reasons why I believe this to be true:
As midwives, we know that every woman has different tissue and skin integrity. This is evidenced by the color of our skin and the amount of stretch marks on our bodies. Supplements like vitamin C and omega fatty acids will help strengthen this integrity, but it’s unknown if they make a measurable difference. We’ve all heard the theories about genetics, smoking, proper nutrition, etc., in regard to tissue integrity and pliability.
During a normal, spontaneous labor, free of judgment or negative observation, vaginal tissues respond to hormones by increasing secretions, blood flow and sensation. As the baby moves down, the vagina is more relaxed and open. If a woman feels inhibited or pressured, an interference is created in these hormones and the risk of perineal trauma is increased.
Hydration in labor is vitally important, as we are all aware. However, over-hydration, e.g., IV fluids, can swell the tissues to a point where there is very little give or elasticity.
Positions during Pushing
While we may look at the semi-sit or semi-reclining position as much more “progressive” for pushing than lying flat on the back, think about this:
In a semi-sit or semi-reclining position, a tremendous amount of weight is on the sacrum, which decreases the diameter of the pelvic outlet. More force is necessary, in this position, to move the baby under the pubic bone. This increase in force puts more pressure on the baby and the mother and often slows down the normal uterine expulsion efforts with contractions. Because the mother has to push so much harder, she is often unaware of the messages her body sends to slow down and allow the tissues to stretch around the baby’s head each step of the way.
When a woman is on her back with her legs pulled back towards her shoulders (McRoberts), her sacrum is rounded up and there is no weight on the tailbone. It can move easily to accommodate the baby’s head. The problem with this position overall is the lack of gravity to assist in the birth.
Being upright (standing, supported squat, kneeling, hands & knees, and bending over standing) is the natural, body-led stance for birth. The sacrum bulges out as the head descends; gravity is helping her, and the uterus is perfectly aligned with the pelvis to bring the baby down. If the mother is standing, she will often lean forward as the head emerges. If she is on hands and knees, she may rise to being upright on her knees with the crowning of the head. This intuitive alignment of her body with the baby’s body is amazing to watch.
Birth activists talk a lot about upright delivery, but very few people—even homebirth midwives—see it happen much. Why is this? Could it be that women are just so used to seeing births happen in beds that they assume the culturally conditioned posture in bed? Are we, as midwives, encouraging women to be on the bed, to semi-sit or semi-recline because it’s easier for us? So we are better able to see “progress” and “save” the woman’s perineum by “delivering” the baby? Do we assume that if the mother births upright—and not lying down, with our hands to help slow the birth—that the baby will “blast out” and cause horrible damage to her perineum and pelvic floor? Is this assumption really accurate? Does our role in this process perpetuate this belief system?
The birthing woman is highly susceptible to suggestion—even if very subtle. For instance, a midwife lays a chux pad on the bed. The message received is “sit here”—many women will follow the placement of the chux and reside wherever it is placed, even if there is no spoken direction by the provider. However, left to her own devices, a woman will rarely lie down to push her baby out.
As midwives, are we finding ways to support women’s instinctive behaviors or do we undermine their instincts by directing them? It is important that we honestly think about our intentions during labor, but especially with second stage assistance. Are we genuinely trying to help a woman who wants or needs assistance or are we hoping to facilitate the birth more quickly for our own convenience and comfort?
The Timeline of Pushing
When a woman is at 8 or 9 centimeters, I have observed that there are small grunts of pushes at the peak of contractions. These small pushes appear to be totally involuntary—in fact, women do not realize they are doing it at all. From what I have seen, it seems that this actually helps with the last couple of centimeters of dilation.
In my opinion, one of the most disruptive things a provider can do at this point is to ask, “Were you pushing? Did you feel pushy? Wait—don’t push…let me check you first to see if you’re ready….” Of course she’s not ready—she’s not doing that full-baby-on-the-pelvic-floor type pushing. She’s got a couple of centimeters to go, but she’s close. So, the provider will tell her that NO, she’s NOT ready and DON’T push, not yet.
The effect of this is that she’s now in her head about her labor, no longer trusting her body. Body=wrong. Midwife’s fingers=right. She continues to look to the provider for direction now. Nothing she feels or knows is true. The birth no longer belongs to the mother and the wisdom of her body.
Then again, if she is ten centimeters, there’s movement to get her to pushing, and sometimes cheerleading for pushing: having her hold her breath, then “quick! another breath quickly, now push, push, push push PUSH PUSH PUSH!!!” to counts of ten, whether or not the mother actually feels the urge to push. The “clock of progress” for second stage has started.
It’s okay for mothers to wait—to sleep, to rest, to take a shower, to eat while waiting for a true urge to push. She can let her uterus do the hard work of bringing the baby down until the overwhelming, spontaneous urges begin.
By forcing a woman to push just because she’s ten centimeters—or even take her out of her labor space by doing dilation checks to “see if she’s complete,” we’ve created a situation in which the woman needs the input and direction from others in order to birth her baby. Forced pushing leads to maternal exhaustion and more direction, typically, by the provider. In addition to not being in tune with her body’s messages, there are often more vaginal exams during this time, which interferes with the natural response to second stage.
Fingers in the Vagina
Did you know that your vagina has a built-in protective mechanism? We experience it when we are getting a pelvic exam—fingers placed right outside the vagina or right inside the vagina will result in a contraction of the vaginal muscles. This response to such touch is normal and positive. Yet women are often told to “just relax” at this point, as if it’s completely voluntary.
We may love the midwife or doctor who is performing the exam. This person may be a classmate, friend or trusted provider. It doesn’t matter—their fingers are not our fingers. They are not the fingers of our lover. Our bodies are so wise that they will offer some resistance for touch that is not sensual or our own. A woman who is pushing out a baby will experience that same reaction when someone’s fingers are placed on or in her vagina. The tension of these muscles will be counterproductive to the loosening and opening of the pelvic floor to birth her baby.
What happens when we, as midwives, put our fingers inside the vagina as the baby is trying to emerge? Could it be hard for women to concentrate on pushing something out of their bodies when we’re putting things in? Are we really helping women by dragging down on the perineum? By “pushing” tissue away as the head descends? Is the woman’s vagina instinctively trying to protect her during all this? How does it feel to the mother? Can we expect the body to respond naturally with the desired “fetal ejection reflex” and associated hormones when this is occurring?
When women place their own hands on their vagina during birth, they explore. They touch all the folds, gently inserting a finger to see if they can feel that hard little head that they’re working on bringing down. With every push, they may experience the “two steps forward, one step back” motion as the baby comes down. Then when it’s getting ready to emerge under the pubic bone, women will instinctively put their hands down there, feeling as if the head is “right there.”
The father’s hands, as well as the mother’s, should be encouraged to touch the baby as it is emerging. A father does not need to know anything except not to push or pull on the baby; he can just wait for the baby to slip into his hands. The same could be said for midwives, as well! The maneuvering of the head and body as the baby emerges is not necessary in normal birth. Fathers are skilled at catching their own babies—rather than just catching the bottom and legs after the midwife has “delivered” the head and upper torso.
When the baby crowns, it is helpful for the mother to have her hands on herself (which she will do instinctively if she is unselfconscious and focused on the birth and is not waiting for the midwife to give her directions). She will gently push her perineal tissues around, knowing how much is too much pressure, feeling how each of her pushes brings her baby closer to her arms. She may instinctively apply counterpressure up by her clitoris—usually with counterpressure at the occiput. The “ring of fire” is often felt with a sharp intake of breath. Numbing this sensation negates the natural response women have at this point—to not push while their tissues gently hug, stretch, and yes, sometimes give, around the baby’s head. (The sharp intake of breath and sudden surprise at the sensations often stops pushing for many women.)
These ideas and observations have created a huge shift in my intention around birth. I began midwifery with my own personal account of perineal trauma (third-degree episiotomy leading to perineal reconstruction at 16 months postpartum), so I felt compelled to do anything to protect women from the same experience and pain. Over the years, I have begun to realize that it’s what I don’t do that helps to facilitate normal labor and birth—including perineal protection.
I lovingly offer some of these ideas and points as food for thought. These thoughts have come from observing women birth without direction, lessons from the women who have birthed unassisted (thank you so much for being my real teachers!!) and the logic of anatomy and physiology—as well as the sacred wisdom of our bodies and babies.