Episode 153 - How to avoid tearing during childbirth
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD. In each episode, I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey. Welcome to today's episode of the Great Birth Rebellion podcast.
[0:27] Today's episode is all about what you can do to reduce the chance of your vagina, vulva and perineum tearing during the birth of your baby. Of course, we'll also touch briefly on how to avoid an episiotomy and how to prevent a repeat third degree tear again, if you've had one before.
[0:47] Unfortunately, I can't go into the fourth degree tears, partly because I have limited experience with these. And everyone's recovery and circumstances are different. So fourth degree tears are a significant tear. They require very specific repair and recovery and everybody's recovery will be different. And so your intentions for your next birth will also be different. So I would very much encourage you to speak to your trusted care provider about that. I'm also not going to cover today episiotomy because we did do two episiotomy episodes, episodes 72 and 73. So I will link those in the show notes below if you specifically come to get information about episiotomies and you can go directly to those episodes as
[1:33] well as this one. I think they both need to be listened to. So what are we going to cover today? I'm going to give you some practical and controllable options that you can start right away that will help you reduce your chance of your vagina or vulva tearing during childbirth. But first, a very quick anatomy lesson. Let's look at which part of your vulva is most likely to tear during childbirth. And there are four particular areas to be aware of. The most common place for tears is your perineum, and we'll talk about where that is. The second place is inside your vagina or your vaginal wall.
[2:15] Thirdly, it could be your inner labia, the labia minora, or occasionally you can tear towards your clitoris and urethra towards the front. But most commonly, it's the structures lower down at the back versus the ones closer to the front. And I'll explain each of these as I talk through the anatomy of your vulva. And if you haven't already seen your own vulva, this is the time to have a look and understand and what you look like down there. Not because the appearance has any impact on the function of your vulva during childbirth, but knowing what it looks like helps you visualize what will happen to your vulva during birth and also give you a baseline comparison as you track the recovery of your vulva after birth. Sometimes women have a look at their vulva after they've had a baby and they've got nothing to compare it to because they didn't know what it looked like before. So just having a baseline understanding of what you look like can help you gauge your recovery after you've had a baby. So let's explore your anatomy. And if you've seen any of my videos on social media or on YouTube, at Melanie the Midwife, and I also post at The Great Birth Rebellion on Instagram.
[3:33] You'll see I've got a vulva anatomy demonstration, which I use my nude pregnancy suit, my crocheted alter ego. Her name is Pregnancy and I give you a very detailed tour of her vulva so have a look at those it might help you with a visual as I understand this you can go ahead look at your own anatomy if you want to as I describe this if you're somewhere on your own and check this out yourself all right let's get into it not literally let's get into having a look at what your vulva looks like what have you got down there.
[4:09] So all the outside part of your anatomy is called your vulva, collectively. And there are parts to your vulva. And we'll go from back to front. So visualize your anus. That's where we're starting. It's where your poo and your farts come out. And then move forward or up from that. If you're lying down, it'll be up. If you're standing up, it's forward. And if you're at home alone, you can feel free to track this visually with your own fingers or if you're looking in the mirror. And so go forward from that, from your anus. And that's your perineal area, the area between your anus and the vaginal opening. And this can be different lengths. Everyone is different. The length doesn't necessarily correlate to the function. Women with short perineums can still give birth vaginally, may still not have major perineal trauma. Remember, this part is really, it's the really stretchy part of your vulva. It's responsible for extending really far far enough to open your vulva to fit the whole baby out and a portion of women can push baby out with no tearing at all so your perineum is the queen of that stretch she's got really great capacity to ensure that your vaginal opening extends enough to let your baby out without tearing but if she does need to tear she will tear and that's okay because she's made to tear and repair. That's the power of your perineum.
[5:39] Your body is designed to give birth to babies. Your in and out holes were made knowing that it was going to get that kind of attention and they're designed to stretch, tear and repair. The tissues of your perineum are spongy and they heal rapidly because they have a great blood supply, great immune support and your body will have to heal and recover your vulva after birth, but it's designed for that. So even if you do tear, know that this part of your body is specifically designed to accommodate and recover from childbirth. Now for the 1 to 3% of women out there who are listening who have had a third or fourth degree tear and may or may not have some long-term consequences from that, I can see and hear you from here. I can understand that you might be feeling a bit eye-rolly at this part because maybe you feel that your perineum didn't recover in the way that I just described and I totally get that. We're going to talk about third and second degree tears later but for now we're doing just a functional anatomy lesson. We must remember that our bodies don't always function the way that they were designed to but there are some things that we can do to help them function as optimally as possible and that's what I'm talking about today. So how to help your vulva achieve its full potential during childbirth by either not tearing or tearing and repairing efficiently without any long-term impairments.
[7:07] So anatomy, we did our anus, moved forward to our perineum. Now we're moving forward or up from our anus to the perineum. That's the squishy part. And then the vaginal opening, which is at the top of your perineum. And that extends inward to create the vaginal space, your vaginal space and vaginal wall. So the internal anatomy of your vagina is cavernous. It's so big and flexible and capable. We call it a potential space because when there's nothing in there, it's collapsing on itself and it opens up easily to
[7:42] accommodate other things. A little bit like a sock, you know, able to accommodate someone's whole foot can stretch really large or think something like a balloon. It's collapsed when it's not filled with air and it can stretch really large without damage. And it's the same as your vagina, the internal anatomy of your vagina. Your vagina is more than capable of fitting the whole body of your baby through and out and sometimes even more for women who are having forceps or if the clinician's hand needs to assist the baby it's super stretchy super capable heaps of room inside the vagina okay so come out of your vagina and upwards to the next hole is your urethral opening where the wee comes out and inside your urethra which actually you know travels up up to your kidneys ultimately and your bladder.
[8:32] But at the opening of the urethra inside, you've got some glands called skein's glands, which are responsible for the release of female ejaculate fluid, which is released during orgasm. Now, you might have noticed this.
[8:49] When you orgasm, and I hope you are getting regular orgasms, it might feel like you're also going to wee yourself. And for that reason, lots of women during orgasm trying to sort of clench their pelvic floor and clench their urethral opening thinking they're about to wee. But actually what's happening is your skin's glands are releasing female ejaculate fluid during orgasm because that fluid can sort of spurt out when you orgasm. There is vaginal fluid that lubricates your vagina during sex but also there's this fluid and that fluid comes from your urethral opening from your skin's glands which are located inside your urethra. So we can come out there but also that orgasm fluid, orgasm fluid, that's what I'm calling it from now on. Okay, so out of there and upward and forward again, and you will meet the external tip of your clitoris, which is nestled in the clitoral hood, which is also part of your clitoris. It contains clitoral nerves within that hood, and it clothes the shaft of your clitoris. It's not like a foreskin. It's not like the external skin of a penis. It's got nerve endings and sensation in there. So the clitoral hood is not just sort of a raggedy pile of skin.
[10:15] But the clitoris doesn't end there. It's not just the little external beam on the outside of your vulva. That would be like suggesting that male anatomy, that the penis is just the head of the penis. Think of your clitoris less like a little beam on the outside and more like a full organ, more like a full penis anatomy, but the female version.
[10:38] And there's external anatomy but there's also internal anatomy so the rest of your clitoris is housed behind your labia or the lips of your vulva and behind all of your external vulva anatomy the clitoris extends almost all the way down to your vaginal opening and again if you go to my social media pages melanie the midwife and the great birth rebellion you'll see i've got a clitoris model, a one-to-one size clitoris model that shows you what the clitoris looks like. Now, don't feel bad if you didn't know that there was an internal clitoral anatomy. This is relatively new information, believe it or not. I trained as a midwife 17 years ago and they were barely teaching it to us then. I was definitely already a midwife when I understood the full anatomy of the clitoris. So you are not alone if this is new information. Okay, now up from your clitoris, we move up to the pubic area called the mons pubis.
[11:41] And then that's where we're going to stop our adventure from back to front. And now we're going to go front to back, track back down.
[11:49] And notice from your mons pubis on the outside, the outer labia, these are the meaty ellipse that are the outermost aspect and these have hair on them. And then in from there are the inner labia and they're a little bit more flappy. And for most women will hang lower and longer than the outer labia. And they're generally hairless. So that is your very quick vulva anatomy snapshot and there's more to it of course but this is a quick macro level. We haven't even started talking about the internal pelvic structures and organs and muscles and fascia and ligaments. We will have to save that for another day. There's actually an upcoming episode that I have planned with a women's health
[12:33] physio and that internal pelvic anatomy is going to be the focus of that episode.
[12:39] So how do we stop all that from getting damaged or tearing during childbirth. And I've already mentioned that it's made to stretch. It's completely capable in the same way as a penis that goes from being flaccid and then the next minute can become huge and full and perform the function for which it was designed. Now, vulva and vagina are capable of a similar transformation under the influence of childbirth. So don't be scared of the stretch. It's just a stretch and your body can do that. So now the practical steps to minimize damage to your vulva during childbirth. Let's work through those. Remembering that the common places for tearing are the perineum.
[13:25] Space between your anus and vagina, the inside of your vagina, the vaginal wall that's got heaps of space, your inner labia, so the ones, the labia that sort of are nestled right around your vaginal opening, and then less common but can happen some damage or tears towards your clitoris and the urethral opening. Now of all the places that you might experience some tearing, it'll be your perineum and we divide this up into different classifications. So after your birth, your care provider will ask to check if you've had any tears. They'll ask to check your vulva for tears.
[14:04] A little side note here, women find this part potentially one of the more tender and painful parts of medical care. So imagine you've just had your baby in labor for as long as little timers that took and you've got your baby with you and your care provider asks if they can check if you've got any tears. Now you'll be sensitive and tender. For care providers out there there are ways that you can do this that will be less painful and less traumatic for women. Firstly go really slow and explain before you even start what you're going to do. I'm just going to check you for any tears is not enough information, let women know that you're going to check from the top. Explain your procedure. I mean, for me, I go from top to bottom. I explain to women that I'm going to part the labia to see if there's any internal grazes to the inner labia. I'll also check clitoris and urethra for external visual signs of damage.
[15:13] And all the while, if you can do your best to keep your fingers on the outside of the woman's vulva, because every time you put your finger in any of the more internal structures, you risk putting your finger on a tear or on a graze. And those open grazes and open tears are really painful. So if you can go slowly and just try not to put your finger in or on a tear, sometimes it's not always possible, but that's where the tenderness comes in. And women, you see them jumping off the bed.
[15:44] So really super gentle only doing as much as you absolutely need to and us as clinicians we're so used to these kinds of procedures that we forget that it's the woman's first time experiencing anything like this and she's just pushed a baby out of there so really super slow move from the top to the bottom explaining the whole time what you're doing and maybe how long it's going to take So I'll explain to women, okay, can't see anything at the top there. No graze at the top or explain what I'm seeing. Maybe there is a graze. I'm moving down now to check the vaginal opening. Are you okay? You can check in how she's going.
[16:23] Obviously, when we're doing these assessments, we need to be certain of what we're seeing. So sometimes we need to look further up into the vagina, which involves a lot more touching. I mean, that's fine, except you really got to explain that to the woman, and explain what she's feeling. Sometimes your clinician, women, will use gauze, like a little cloth, to dab away any blood because there can still be some blood coming from the birth. And also if there is a tear in there, it could be bleeding. And so they'll be dabbing with a cloth, which again can be tender if there's grazes or tears there.
[17:00] So take your time with this. There's no rush. There's no rush to check. You can just take it really slowly. In fact, I've had clients in the past who wanted to have their perineum checked, agreed that it was a good idea. However, they felt so tender that we couldn't go through with the procedure.
[17:17] And I sprinkled some lignocaine, so local anesthetic, on a cloth and just popped it on the vulva and a little bit inside the vagina and left it there to create some external, like it numbed the area a little bit enough that we could check the woman's perineum. And she found that very effective. So what we're checking for is the degree of tear. So you could be completely intact, which means your perineum is intact. There's been no tears. You might have grazers, which literally is what it sounds like, like falling off your bike and grazing your knee. It's kind of a larger but really shallow area. Those are super stingy. They heal pretty quickly because your vulva is designed to heal after childbirth but the first day or two they can feel a bit stingy. So then you could have a first degree perineal tear which is just the skin. Then the second degree is the perineal muscles as well as the skin. It doesn't involve the anal sphincter it doesn't go that low third degree is where we start to the tear goes from the opening of your vagina tears through your perineum and then also starts to impact on on your anal muscles on the rectal muscles.
[18:36] So we divide those into 3A, 3B, and 3C. And then there's a fourth degree tear, which involves, it's a more complex rectal and anal tear than a third degree. So the third degree starts to involve the anal sphincter. Fourth degree is the next severity level after that. There's also another option for perineal damage, and it's what we call a buttonhole tear. So sometimes, it's exactly as it sounds like, the vaginal opening doesn't tear, but your perineum starts to tear while the vaginal opening remains intact.
[19:16] Or your perineum is intact, but your vaginal wall tears internally and then creates damage to the structures below that and could also involve the rectal muscle. These are very, very, very rare. In fact, I've never seen one, but you know, we're talking about tears today. This is another possibility. So with regards to how each of these tears might be managed, I would actually suggest listening to episode 127 about perineal suturing and healing options. Because although today I can share how we might be able to prevent these tears, in this episode, there's not
[19:55] enough room to talk about how to help them heal and how to repair them. But you can listen back to episode 127 for that and I'll link it in the show notes you can just click on through that'll be linked for you to easily get there and listen to all right now the part that we've all been waiting for how do we prevent these tears from happening what can you do.
[20:18] Now, firstly, of course, if you want to eliminate the chance of tearing completely, you can do that by having a cesarean section. If you have a cesarean section, there is a zero chance of your vulva having a tear.
[20:33] But this feels a little bit like killing a fly with a hand grenade. Unless there's a really specific reason for avoiding vaginal birth, a cesarean section is a massive intervention with significant risk factors when you compare it to the risks involved in tearing during childbirth or even a vaginal birth. There's no mistake that cesarean section carries more options for complications for women who are electing to have a cesarean section if you're not having one for medical reason. So there are lower risk and more beneficial ways to prevent tearing in childbirth and so I'm going to share with these with you today but some women who might choose cesarean section in order to avoid a tear might be women for example who have had a fourth degree tear but it's not always necessary to have a cesarean section after a fourth degree tear but that's certainly an option that's offered to women in those circumstances. So assuming that we're all not going to get cesarean sections just to avoid a vulval or vaginal tear, the next thing you can do is see if you can get access to a midwifery model of care. See if you can be cared for by midwives. And if you have continuity of care, even better. So if you have the same midwife through your age natal birth and postnatal time, even better.
[21:56] But being under the care of a midwife reduces the risk of tearing and an episiotomy. And that's mostly because midwives are more likely to facilitate some of the other things I'm going to talk to you about. And under midwifery care, you're less likely to need a vacuum or forceps or receive an episiotomy. So just having a midwife standing there in the room isn't really enough, but it's just that a midwife is the most likely clinician to help you do things that will reduce your chance of tearing. Again, if you can get your own midwife even better. Now, the next thing is during your antenatal care while you're pregnant, I encourage all of my clients to see a women's health physiotherapist. Now, these are physiotherapists who are specifically trained in women's health and assessing women's pelvic floor and the pelvic bowl. Because just as women need to have a strong pelvic floor that's capable of tensing, they.
[22:59] The most important thing in childbirth is your capacity to relax and release your pelvic bowl and your pelvic floor in order for your baby to emerge. So we will speak very specifically about this when I speak to the women's health physio who's coming onto the podcast in a few weeks. But in the meantime, before that episode comes out, if you're pregnant, I would recommend booking in with a local recommended women's health care physiotherapist for a pregnant assessment, just assessing your pelvic floor to see if there's anything that you can work on during your pregnancy that will assist in your recovery postnatal, but also with your ability to relax and utilize your pelvic floor during the birth of your baby.
[23:47] Now, the next thing is perineal massage during pregnancy. You'll see here I'm moving through from pregnancy through to what you can do during the actual birth. So if you're pregnant, there's heaps of stuff that you can implement now that could reduce your chance of tearing and having damage at the time of birth, but then also assist in your recovery postnatal. So perineal massage is one of those things that you can do during pregnancy. And we know where the perineum is now, got your anus in between your vagina and your anus is your perineal area. I hear a lot of people suggest that perineal massage is not evidence-based or not effective in helping prevent perineal tears but this isn't really true. There is some good evidence that this is beneficial for women but only for those having their first vaginal birth. So first-time mothers or women having a VBAC, so you've had a previous baby, but not vaginally.
[24:51] And after that, the benefits are less dramatic. So if you've already had a baby out of your vagina, then it's less likely that perineal massage is going to make any difference to the rates of perineal damage with this next birth. So while the research is quite supportive for the use of perineal massage in first births, less so for subsequent births. And also, the other interesting thing that I, you know, when you read the perineal massage research is some papers actually suggest that perineal massage has an impact because it stretches the area.
[25:31] I'm not really in agreement with that. And here's why. The recommendations suggest that starting from around 34 to 36 weeks of pregnancy, you can do perineal massage two to three times a week only. And so overall, there's actually not that many occasions of perineal massage during the pregnancy. You know, if you're doing it maximum from 34 to 42 weeks, two to three times a week, You're not getting in hundreds and hundreds of episodes of perineal massage. You're getting in maybe 10 to 20 episodes of perineal massage. That's not really a lot of time to create actual tissue or physical change to your perineum or the structures around them. Yes, it does reduce your chances of tearing, but I don't think it's because there's a physical change. I actually think there's a psychological change and I'll explain how to do perineal massage and then also how you can utilize that to optimize your psychological experience of pushing your baby out.
[26:44] So hear me out. I know this sounds a little bit woo-woo. So perineal massage, you're not doing a vaginal massage. So your fingers aren't going into your vagina. If that's where you are and you're massaging, you'll find that there's just so much space. It feels so flexible and like you're not really doing anything. You're in the wrong place. So you want to come out. It's a perineal massage. So...
[27:06] Think about sort of only going in so far as the first knuckle of your thumb and that first knuckle of your thumb is what's going to be resting on your perineum. So you're putting just the first little section of your thumb into your vagina and pushing downwards with, I would suggest using some kind of oil or lubricant because you don't want to give yourself like Chinese burn on your perineum and pushing down and then rubbing sort of in a U shape back and forth. You can use one finger, two fingers, whatever you like. But the main part of perineal massage that I think makes the difference, and again, this is so much speculation because nobody actually really knows why perineal massage makes a difference, but I suspect that it's because you start to get comfortable and familiar with the sensation of pressure on your perineum. And you're kind of, in a small way, mimicking the pressure on your perineum that will occur when your baby's head is quite close to being born.
[28:10] And so the idea is to push down on your perineum. It's not so much to massage the tissues. Pushing down on your perineum from inside the top of your perineum and pushing down towards your anus and creating just enough stretch to feel like, oh, it's a bit stretchy. And then stop there and massage back and forth in the U-shape way with the lubricant. And the idea is not to massage so that the tissues are stretched. Instead, stretch and then work on relaxing and breathing during the perineal massage. So imagine that this is, in a very small way, preparation for when your baby's emerging. And what you're going to need when the baby is putting pressure on your perineum, you're going to need to soften your body and breathe out.
[29:10] Like big, deep breath out and consciously softening your pelvic floor because when the baby's putting pressure on your perineum, what you might actually feel like doing is tensing up and holding your pelvic floor muscles closed and tightening your abdominal muscles and your jaw gets tight and everything gets tight because it's quite a surprise to have that much pressure on your perineum. We don't have that much pressure very often except for during childbirth. And so perineal massage can mimic that sensation a little bit, the sensation of the stretch. And if you use that perineal massage time to practice some deep, slow breathing and softening and relaxing your body, try and soften your forehead, soften your jaw, soften your neck, soften your abdominal muscles and all your pelvic floor muscles and your bum.
[30:05] Then it's something that you can remind yourself to do when your baby's feeling heavy and pressed up against your perineum and stretching it at full stretch you can remind yourself now's the time to breathe soften relax because it's something that you were practicing so more importantly than the physical experience of the perineal massage is the mental experience and the practicing of breathing and relaxing and softening during that time.
[30:38] The other thing I will say is that it's very tricky to get your own finger to your perineum over your big, huge pregnant belly. I couldn't do it. It hurt my ribs trying to reach that far. Even putting my leg up or changing positions made it really uncomfortable from a muscular level. It was too much. So I would encourage doing this with a partner, someone who will listen to you because you You need to give some feedback about when to stop pushing down and when the stretch is enough to allow you to practice this breathing while the perineal massage is happening. So a willing partner who's up for the challenge, and it doesn't have to be long, you know, two to five minutes.
[31:27] It's a breathing exercise predominantly while there's pressure and massage happening on your perineum. So yes, perineal massage can help, particularly reducing more severe tears. So if it's something that you're worried about, go ahead and do it. But don't be expecting that you're actually creating stretch and more space in your perineum necessarily. That may also be happening. But the predominant aim, you can still get the physical benefits if there is any. But you can also capitalize on the time that you're doing perineal massage by getting your mind ready for birth by relaxing during that sensation all right next you've got to understand that your pelvis is curved like a c shape so your baby is actually born.
[32:21] Forwards not downwards so if you're lying on your back there's going to be more pressure on your perineum so imagine if you're lying on your back your baby is actually going to be born in kind of a j shape and it's going to come the baby comes up not out straight straight out and so if you're lying on your back the path of least resistance is through your perineum your baby will come through your perineum. Whereas if you're leaning forwards, the natural flow of the baby puts pressure more forwards and less on your perineum than if you were laying on your back. So positions like hands and knees positions or forward leaning positions put less pressure on your perineum than leaning back positions.
[33:08] This is a bit different if you're in a pool that the water creates so much resistance and you're really buoyant that this is not necessarily true in that sense but if you're sitting up on a birth stool for example again maybe a bit of forward leaning would help with the flow of the baby and the impact of how gravity is pulling the baby down to create less impact on your perineum but generally forward leaning positions either hands and knees or standing or in a pool are going to put less pressure on your perineum than if you're lying back and side lying is another option that also reduces pressure on your perineum so if you've got an epidural or if you're really really tired instead of giving birth on your back give birth on your side that's going to take pressure off your perineum obviously in this scenario anything that ends you up on your back while you're pushing your baby out, such as an epidural, is going to put pressure on your perineum. So you can mitigate that by adopting the sideline positions if you do end up having an epidural for your birth.
[34:16] So anything that will immobilize you is going to increase your risk of also vacuum or forceps, which will increase your risk of having perineal or pelvic trauma. So anything you can do to avoid being immobilized is going to increase your chances of an intact perineum because you're going to avoid things like forceps, vacuum, pushing on your back and not being able to feel what's happening down there.
[34:43] Okay, so the next thing you can do when you're in labor, you're fully dilated and you're getting ready to push your baby out and you've started feeling an urge to push.
[34:52] There'll be lots of times during that pushing phase where maybe you feel like the baby's not moving down. But what the baby is doing is with each urge and each downward pressure of your uterus, the baby's moving down gradually, gradually, gradually.
[35:10] And it will get to a point where you feel like when you push the baby comes down and then when you stop pushing the baby goes up again and then it goes down and up and down and up very normal that's very very normal the baby's working its way through that c curve trying to get underneath your pubic bone and once it's underneath your pubic bone that's where your perineum will feel really tight with all the pressure of the baby's head on it and you'll be almost at full stretch Thank you very much. Now, at this point, remind yourself, it's okay, it's just a stretch. Your body's capable of stretching. That's what it was designed to do. It's just a stretch. It might feel like it's very tight. It might feel like it's going to tear. But remind yourself, it's just a stretch. Now's the time to practice that breathing and softening and relaxing that you were practicing during your perineal massage.
[36:09] Softening will allow it to open and come away, either tear or move right out of the way in order for your baby to be born. Now, during this time, you want to allow your body enough time to soften, relax, and let those structures move out of the way, your perineer move out of the way. So in this scenario, push only under your natural urges. If you're in hospital what I've seen happen and not all clinicians but this is a really common thing is that you're pushing and your care providers are going push push push push push push push more more more more more more go go go go go go it's it's called coached pushing and it's unnecessary it actually speeds up how fast your baby's going to move through your vagina and out your vulva. And the number one thing you can do to reduce tearing is to do a slow, gradual birth of the head. The baby does not need to shoot up and shoot out of your vagina in order to be born. Just slow down the birth of the head. And the best way to do that is only use the amount of force and the amount of pushing urge that your body is instructing you to use you don't have to add any more behind that you don't have to hold your breath you don't have to go go go go go push push push push.
[37:36] Active pushing and coach pushing techniques are going to increase the risk of perineal damage. The other thing that you might notice, and any care provider who's go, go, go, go, go, push, push, push, push, push, may also have both hands on your vulva. One hand on the baby's head and one hand on your perineum. And it might feel like they're putting quite a lot of pressure. It's called a hands-on technique and a lot of clinicians think that this is going to prevent you from tearing. That's not what the research says. The research shows that hands-on or hands-off doesn't make any difference.
[38:15] So a hero clinician is not going to prevent a tear by putting their hands on and controlling the birth of the head. That's not something that we as care providers can control for you. Hands off or hands on no main major difference but if you think that putting your hands on is making a difference to whether or not this woman's going to tear that's not what the research shows us what we know is a slow gradual birth of the head only under the urge the woman's natural urges can prevent perineal tears especially if you combine that with positions where the woman's off her back and doesn't have an epidural on board so when you're at that full stretch and the baby's putting lots of pressure on your perineum think to yourself i'm going to soften and breathe.
[39:11] Only push under the urge of your body if it's asking you to push like if it's really strong urges to bear down that's totally fine, Your body is clever. Go with your body. You don't have to add anything at this point. And you're imagining millimeter by millimeter slowly allowing your baby to emerge. For some women, this feels really fast. Your body and your uterus is very powerful. It may be trying to eject your baby super quickly. So it's even more important for you to soften your body, breathe out to relax.
[39:48] And if you feel like your body's putting a lot of pressure to give birth to the baby, you can put your hand on top of the baby's head or ask your clinician to put the hand on top of the baby's head, not to change anything significantly. It's kind of counter pressure to avoid sudden expulsive motions of the baby. Just a slow, gradual birth of the baby's head is what you're aiming for. Whatever you need to do in order for the baby's head to be born slow and gradual is what's going to help prevent perineal tears. Things that are going to increase the speed of your baby coming out of your perineum are a deep squat position, laying on your back with your knees pulled up to your nipples. This is called the stranded beetle position. Very, very common and unfortunately so. Also, if you're sitting on the toilet or on a birth stool, this could actually have, the birth could be a bit more expulsive. Birth could be a bit more expulsive. And so you might find it comforting to put your hand on the top of the baby's head just to have some external feedback about how fast the baby's being born. And a note on that on birth stools is.
[41:04] There has been some research that suggests that you're at more risk of a perineal tear if you're using a birth stool.
[41:13] And there's some theoretical thought that if you're sitting on the birth stool for a long time and your perineum has become oedematous, so like full of fluid and a bit swollen, that that could increase the risk of tearing. So go ahead, use a birth stool if that's what's helpful. but just every few contractions stand up do some movements get the fluid you know flowing so that your perineum doesn't become swollen from sitting on the toilet or the birth stool for so long. The other thing that's an option is to give birth in water so it won't necessarily reduce tearing there is some evidence that suggests it could it won't necessarily reduce the amount of tearing but it can help you with relaxation. It can also give less access to your perineum which means zero chance of an unplanned episiotomy and you know over 25% of women are getting episiotomies these days so a water birth where nobody has access to your perineum could be
[42:14] perineal saving for that reason. We talked about the hands-off versus hands-on technique of your clinician and certainly if your clinician has their hands on and you don't want them to, just say to them, please take your hands off my vulva. And they might say, I'm just trying to make sure you don't tear. Just say, please take your hands off my vulva, knowing that the research shows that hands-on versus hands-off makes no difference to the possibility of you tearing.
[42:42] Now, the other thing that your clinician can do, alternatively, without having to put a lot of pressure of their hands on is a warm compress and what that is is half boiling water half cold water, and at that temperature a warm cloth goes into there and while you're pushing so once the head is on view and we can see the top of the head and your perineum stretching putting that warm compress over your perineum while you're pushing has been shown in a randomized control trial to reduce the chances of severe perineal tearing. It's pretty standard practice these days. If your clinician hasn't given you the option of a warm compress, you can ask for one. Similarly, if the warm compress is on, occasionally clinicians will not be cautious of the water temperature. So if it feels like it's burning, let them know that it's too hot. And if you don't like it, just ask not to use the warm compress. Now, mentioning this next thing, not because...
[43:49] It helps, but because you might be exposed to it or it might be done to you because your clinician says that it helps. So this is actual vaginal massage and perineal massage during labor, not during pregnancy. Vaginal and perineal massage during labor. And I have to mention it here because there are some research studies that indicate that perineal massage and vaginal massage during labor have been shown on the surface to make a difference to the chance of tearing. And that might be the case. I'm not saying it's not the case, but hear me out on this one.
[44:30] Being the recipient of a vaginal or perineal massage during labor requires you to firstly be on your back, which we already know increases the risk of you having a perineal tear. Have a stranger in your vagina, stranger's fingers maybe, you've got a continuity of care provider maybe but if not it's a stranger fingers in your vagina during labor while you're either having contractions or pushing out your baby and I'm mentioning this because your medical practitioner might take it upon themselves to start massaging and stretching your perineum or vulva while you're trying to push a baby out during your pushing they will often do this without asking for your permission I'm not making this up I've been in birth rooms for 17 years and seen this happen.
[45:27] Just know that this is common, but it's not normal and it's not necessary. So I don't do it and many other clinicians don't, but if this is happening to you and you don't want them to do that, ask them to take their fingers away and not to do it again. Doctors and sometimes midwives might automatically do this if this is part of their usual practice and they might think nothing of it, but you don't have to accept it. So they might be doing it because they genuinely believe it's going to prevent you from tearing. And it might. But the studies are always looking at women who are lying flat on their backs. Does this perineal massage prevent tears if you compare two groups of women lying on their back, one who received perineal massage and one who didn't? Maybe it makes a difference. That's what some of the research papers suggest. but it relies on you being on your back with your legs up and your vulva fully exposed in a position that in itself increases the risk of you tearing versus if you're in a more upright or forward leaning position. So I'm going to caution you against this one. There are some studies that show it can reduce tearing but the studies compare medicalized births with medicalized birth with the addition of vaginal or perineal massage.
[46:44] Also my high suspicion and I haven't looked into this yet but I highly suspect that the intervention of vaginal or perineal massage in combination with actually pushing a baby out of your vagina will feel like a less acceptable intervention to most women. I'm gonna hazard a guess that women don't like this.
[47:07] So that's why I'm just cautioning you against the necessity of perineal massage during the pushing phase of labor. There is sometimes a place for this with full consent and agreement of the woman but only after discussion and you have to be clear that you've agreed to this but some clinicians will just do it routinely but it's not necessary and they'll tell you I'm just trying to make it so you don't tear, that's what they believe you don't have to accept it though the other thing I'm going to caution against is the need to purchase some inflatable items that you can put into your vagina and inflate and stretch your perineum during pregnancy. So there's a product called the EpiNo, I'm sure there's others. There have been studies done on this brand in particular and one randomized control study concluded that, and this is a quote, the antenatal use of the EpiNo device is unlikely to be clinically beneficial in the prevention of intrapartum levator ani damage or anal sphincter and perineal trauma.
[48:17] Randomized control trial showed that it was not effective, didn't create any changes. If you go on the EpiNo website, there's a full list of other research papers that suggest it does have an impact. This one that I found that showed that it didn't was conveniently left off that website. And so, you know, there are some clinicians who recommend these. I don't personally. There seems to not be major risks or side effects if these devices are used carefully and properly. So if you do decide to invest your time and money into a device like this, it seems that you're unlikely to create long-term damage, but also that these aren't necessarily improving your perineal or pelvic floor outcomes in the short or long term. All right, we've covered a lot. Let's do a quick summary. If you want to reduce
[49:09] the chances of tearing, there are a few things that are within your control. So access to a midwifery model of care if you can. Perineal massage from 34 weeks if this is your first vaginal birth. Avoid laying directly on your back during birth. Favor a forward leaning or side lying position. Birth stool is also fine standing, squatting, whatever you want to do. But the idea is a slow gradual birth of the baby's head with as little pressure on your perineum as possible. So you could birth in water. This would fulfill that criteria.
[49:43] Breathing out and pushing out your baby under your own urges and not listening to your care provider if they're telling you to push push push push push go go go go go go go oh nice slow gradual birth of the head under your own body's strength you don't have to add any, so the idea is slow gradual controlled birth of the head relaxing your pelvic floor so that it's soft and willing to move and you can practice these kinds of techniques with the pressure of perineal massage. Now the final thing I want to remind you of perineal and vaginal tears are damage to an area that is designed for rapid repair. So remember you might tear but you will most of the time all but for a small percentage of women you will repair and recover fully. Your body is designed to heal these areas because your vagina and vulva are designed to tear and repair during childbirth. But the thing that can bring you undone and create a tight and unyielding perineum that's more likely to tear is if you're feeling frightened and unsupported or cold and exposed, this can cause you to stay physically tense and tense in your jaw and in your pelvic floor and then your abdominal muscles. And...
[51:10] It ends in you resisting the birth of your baby. So the baby's putting lots of pressure down in your perineum. Your body's trying to get it out and you are tightening up and clenching up everything, hoping to either slow down the birth or kick the baby in. I know it doesn't make any sense, but this is what you could automatically do. I did it myself. I was already a midwife and I felt myself trying to prevent the birth of my baby. and in that moment had to remember, you've got to let your baby out, soften, open. It's just a stretch.
[51:43] Your body's made for this. Your body is designed to open and allow a baby to come out. The power and pressure of your baby coming out can feel really overwhelming and it only happens to us a few times in our lives. And labor is often about that mental game. So reminding yourself, just to stretch breathe out don't add any extra effort to the top of those contractions your body's capable of letting your baby emerge under its own capabilities your body will put effort behind it and you can go with that you don't have to resist your body's natural urges to push your baby out but the idea is slow gradual birth of the baby's head allow your mind to soften your body so that you're not resisting that whole process. And you've got some really practical tools to do everything you can to prevent damage and tears to your perineum and vulva during childbirth. But remember, if you do tear, you are capable of repairing. Our bodies are soft but strong.
[52:49] To get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com And to support the work of this podcast, wear The Rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @MelanietheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
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