Important Steps in avoiding an episiotomy

Get Through Childbirth In One Piece!

By Elizabeth Bruce

Part 3 – Important Steps you can Take

Before Delivery:

Simple, but Effective Preparations Two things that you can do before the birth are to get good nutrition and do kegel exercises. Vitamins C, E and the bioflavinoids all contribute to improved skin elasticity, which in turn will help your perineum to stretch during delivery. Kegels are exercises that you can perform anywhere, anytime. To find the proper muscles, try to stop the flow of urine in midstream. Practice 10-20 kegels a day until delivery. They are also great for toning the vagina after delivery. Just beware of overzealousness – I had one client who claimed to do 100 kegels a day, and she tore badly during delivery. There can be too much of a good thing.

To Massage or Not to Massage?

Perineal massage, in which the perineum is massaged with or without oil in the weeks preceding childbirth gets mixed results in medical studies. Many studies show that massage protects against perineal trauma in first-time mothers. No benefits were found in women who had already given birth once. Other studies contradict this finding, and show no benefits to perineal massage in any mothers. A homebirth study actually associates perineal massage with higher rates of damage. However, these women were using massage during labour, as opposed to prenatally. It is well-known that swelling increases the likelihood of tearing. The bottom line (pun intended) is you should do massage if you’re comfortable with it, but otherwise, don’t feel obligated to try it.

During Delivery:

Position, Position, Position The position you assume when giving birth may be the most important contributor to avoiding perineal damage. The top three positions for preventing tearing are (drumroll, please) hands-and-knees, kneeling, and squatting. Side-lying is better than on the back. The knees should always be about shoulder-width apart during delivery – no wider. Knees should be pointing forward, as the more your knees point outwards, the more closed the pelvic bones are. In a side-lying position, there is no justification for having someone yank the woman’s upper leg up to her ear. Such an assault is uncomfortable and causes damage to the perineum.
My last three babies came into the world on hands-and-knees, and even though they were big, I did not sustain any damage. At least one study backs up my experience, showing a significant reduction in tearing when the mother assumed either a hands-and-knees or kneeling position at delivery. Balaskas supports the use of the all-fours position for delivery. In this position, the baby gets a better supply of oxygen; the mother is comfortable; there is minimal tearing; maximum opening of the pelvic outlet; and relaxation of the perineum. For these same reasons, Balaskas argues that all-fours is the best position to assume should an episiotomy become necessary.

Avoid the Epidural

Avoiding an epidural is also necessary to preventing perineal damage. In one study, women with no analgesia had the highest rate of intact perineums (34.1%), while women who received epidurals had the highest episiotomy rate (65.2%) Another study shows that women who got an epidural were more than three times as likely to suffer third- or fourth-degree tears. Why? For one thing, women with epidurals often end up getting cut because they don’t have enough sensation to push the baby out. Epidurals are tricky, and even the best anesthesiologist in the world can’t predict when delivery will occur, or how different women may be affected by the same dosage of medication. Furthermore, an epidural prevents the mother from assuming optimal positions during delivery. She is denied the natural sensations of an urge to push, and has to rely on external sources to tell her when it is appropriate, instead of listening to the wisdom of her body.

Good Management of Delivery

One Australian medical journal outlines the best way to deliver a baby: “As the birth commences, support the perineum, keep the fetal head flexed, have the mother push gently or pant, gently push the anterior vagina over the back of the baby’s head, wait until the mother pushes the anterior shoulder into view, and deliver the shoulders one at a time.” Using this technique, they were able to lower their episiotomy rate from 78% to 7% (which is comparable to the rate at many birth centers).
At a typical home or birth center birth, a midwife will deliver the baby in such a way as to minimize trauma to the mother’s perineum. She helps the mother assume an upright position, encourages her to soak in warm water, and eases the infant gently into the world, one shoulder at a time. Many midwives use hot compresses and olive oil to further ease the transition. They let the mother know that she can trust her body to help the baby out in his own sweet time, as long as there is no fetal distress.
By contrast, most medicalized births involve at least some sense of hurry. I have heard stories from rushed women whose delivery room was needed; whose doctors’ shifts were ending; and who had arbitrary time limits placed on their labours. Feeling rushed during labour or delivery is not conducive to a healthy outcome for mother or baby. Nor does it help that mothers are placed on their backs during delivery and that the baby has to be pushed “uphill.” While good, relaxed management of delivery is always important, it is especially critical in birthing larger-than-average babies, and those in odd positions.

To Stitch or Not to Stitch?

It is bad enough to get an unplanned-for episiotomy or tear, but sometimes the repair is even worse. Many women don’t even know that stitching after a tear or episiotomy can be optional. Like cuts on other parts of the body, perineal lacerations do not always require stitches to heal. Kristine, a lay midwife in Virginia, says, “I do not believe it always necessary to stitch a tear – sometime it causes more trauma to the tissue than leaving it. The perineum has incredible regenerative qualities and I think we underestimate that like we do many other things about our bodies. A wise older midwife once said to me, ‘Kristine, if you can get two sides of a perineum in the same room they will find their way together!'”
Stitching may help the wound to heal faster. Still, for some women, the discomfort of being sewn up after delivery is not worth it. For women who choose to let their bodies take their course unaided, she recommends that they keep their legs together as much as possible.
If you make it through delivery without lacerations, you may be amazed at how normal you feel. Most women can comfortably get up and walk around the very first day after an unmedicated, intact birth. Your bottom will still be sore, but you might not even need pain medication.

–Resources–

Eisenberg, Arlene et al. What to Expect When You’re Expecting. NY:Workman, 1996. P.285.
Bowes, Watson. “Should Routine Episiotomy be Performed Routinely in Primiparous Women?” Ob/Gyn Forum 5, No. 4 (1991):1-4.
Wagner, Marsden. Pursuing the Birth Machine: The Search for Appropriate Birth Technology (Camperdown, South Wales, Australia: Ace Graphics, 1994), 165-174.
Eason, E. and Feldman, P. “Much Ado about a Little Cut: Is Episiotomy Worthwhile?” Ob/Gyn 95 (4):616-8. April 2000.
Harper, Barbara, RN. Gentle Birth Choices.
What to Expect . ..p.376
Robinson, JN et al. “Predictors of Episiotomy at First Spontaneous Vaginal Delivery.” Obstetrics and Gynecology. 96(2): 214-18, Aug. 2000.
Otigbah, CM et al. “A Retrospective Comparison of Water Births and Conventional Vaginal Deliveries.” European Journal of Obst/Gyn & Reproductive Biology. 91(1):15-20, July 2000.
Harper, Barbara. Excerpt from Gentle Birth found on www.waterbirth.org/whywater.html
Balaskas, Janet. Active Birth. Boston: Harvard Common P, 1992. P. 209.
Klaus and Kennel. Mothering the Mother: How a Doula Can Help You Have a Shorter, Easier, and Healthier Birth. (Old Tappan, NJ: Addison Wesley Longman, 1993).
Cappachione, Lucia & Sandra Bardsley. Creating a Joyful Birth Experience. NY: Simon & Schuster, 1994. P. 132.
Eason,E. et al. “Preventing perineal trauma during Childbirth: A Systematic Review” Obst/Gyn. 95(3): 464-71, Mar. 2000.
Legino, LJ et al. “Third and Fourth Degree Tears. 50 Years’ Experience at a University Hospital.” J Reprod Med 1988;33(5): 423-26. Ibid.
Labrecque, M. et al. “Randomized Trial of Perineal Massage During Pregnancy.” Am J Obst/Gyn. 182(1 pt. 1): 76-80, Jan. 2000. Aikins.
Aikins, Murphy P. and JB Feinland. “Perineal Outcomes in a Home Birth Setting.” Birth. 25(4):226-34, Dec. 1998. Balaskas. P. 192.
Nodine PM and Roberts J. Factors associated with perineal outcome during childbirth. J Nurse Midwifery 1987 May-June;32(3):123-130. Legino, LJ et al. Ibid.
Ibid.
Thompson, DJ. “No Episiotomy?!” Aust. NZ J Obstet/Gynecol 1987; 27(1):18-20.

Elizabeth Bruce, mother of four, is the author of Get Through Childbirth in One Piece!: How to Prevent Episiotomies and Tearing , available through bn.com and amazon.com. She is a CCE with Birth Works, and can be contacted directly at wals01@cs.com Her web address is http://intact-birth.outputto.com

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