I'm a big believer in the body's ability to birth babies.
As a doula, I've attended births of 10-pounders that leave no trace.
I birthed my 9⁺ pound baby complete with a nuchal hand (hand by face), after a 1.5 hour labour with an intact peri.
But, I've also seen mums of 7-pounders experience a 2nd degree tear with ongoing postnatal dramas, unfortunately. And all sorts in between.
Most pregnant, first time mums I work with share their fears around tears, episiotomy and stitches after birth. They also have concerns around how things will heal and if this will go on to impact their sex life and/or their confidence - all valid concerns.
There's no doubt there are MANY factors around birth that influence how your vagina and peri fares.
So let's look at the influencing factors, and some things to consider both before and during the birth itself.
First, let's take a quick tour...
The perineum
To be anatomically precise, the female perineum is 'a diamond-shaped structure inferior to the pelvic diaphragm and between the symphysis pubis and coccyx'.
In other words, it's the space between the woman's vagina and her anus.
But it's not just the external skin area, it's a mass of muscular and fibrous tissue and it's an integral part of the pelvic floor.
It's the central point where both the levator ani (a broad muscular sheet in the pelvis comprising of 3 different muscles) and most of the superficial muscles, unite.
It's involved in both opening our bowels and giving birth. As it's these muscles that need to stretch considerably to allow our babies to be born.
What about perineal massage?
Most pregnant women ask me about this at some point. As a childbirth educator, I do see the value of it and know of some evidence to support it. And, as a doula I've also noticed perineal massage helps women build birthing confidence - something most first-time mums welcome.
What does the research say?
A review of four trials (involving 2497 women) showed that perineal massage, undertaken by the woman or her partner (for as little as once or twice a week from 35 weeks), reduced the likelihood of perineal trauma (mainly episiotomies) and ongoing perineal pain.
The same researchers found it also helped reduced episiotomies by 16% for first-time mothers.
What exactly is perineal massage?
The name is a little misleading as it's not exactly a massage involving back and forth flowing movements that are super relaxing.
Perineal massage is better described as a 'stretching' exercise. It's this practise that may help women learn how to yield to these sensations of pressure, stretch and discomfort.
It provides an opportunity to experience what it's like to release and relax around these sensations.
Having some experience with these sensations prior to the time of birth may help remind women to confidently let go and surrender, as opposed to tensing their pelvic floor and perineum. As this too can lead to perineal trauma.
As with all things in life, performing perineal massage in late pregnancy won't guarantee to prevent perineal and/or vaginal tears, or an episiotomy. As mentioned there are many factors at play with regards to perineums at birth. More on this below.
It may however help to increase the stretchiness of the area and perhaps more importantly, help to de-sensitive the area to this stretching and pressure.
How it's done:
You may begin in the last 4-6 weeks of pregnancy. You can do it yourself or enlist help from your partner. Many women find it a little awkward with their belly in the way towards the end of pregnancy and prefer to involve their partners in the activity.
You’ll need:
- A lubricant, or plant based oil (e.g coconut, almond) or a peri oil.
- Washed hands, freshly trimmed nails, perhaps some pillows
- A supportive partner, otherwise maybe a mirror (if you’re doing the massage yourself, so you can see what you’re doing!)
Step 1: Find a quiet, private place. After a shower or bath may be a good time as the warmth of the water will help with the blood supply to the area and surrounding tissues. Otherwise you can also use a warm compress on the perineum to help it soften and increase the circulation before beginning. Use lots of pillows so that you are comfortable in a semi-reclined position. Legs should be comfortably apart, feet flat and knees bent (like the position used for a pap smear).
Step 2: Apply the lubricant or oil onto your fingers, thumbs and perineal area. Then slowly insert one thumb at a time, about 3-5cm inside the vagina, so they are side by side.
Step 3: Slowly press them back and down onto the inside (back) vaginal wall towards the rectum. Once you have this downward pressure, then use your thumbs to S-L-O-W-L-Y sweep from side to side in a rhythmic “U” shape/movement.
Step 4: After you’re comfortable with the SLOW, sweeping movements then you can hold the stretch at the end of the ‘U’, gently stretching the opening until you feel a slight burning or tingling. Maintain pressure for up to 60 seconds until the area becomes a little numb (you may need to work up to this timeframe). Then rest for a minute. This allows you to recover and let the blood circulate into the perineum again.
This massage can be done with the fingers either moving together in one direction or in opposite directions, according to your preference.
It's important to maintain the pressure deep into the inside vaginal wall, not just the opening.
Apply more oil if required. Continue for 3-5 minutes, 2-4 x week.
For partners: Have them follow the same instructions, but ask them to use their index fingers using the same “U” shape/motion. It's important to tell your partner how much pressure to apply.
Ensure you keep the pressure applied downwards, whilst completing the U shape movement. Use your out-breath as a signal to release into the stretch.
Remember, this is not a ‘back and forth massage’ but more of a gentle, slow and firm stretching exercise.
If you have never done perineal massage before it may feel a little strange initially. It may feel very tight when you first start but each time you do it you’ll be surprised at how stretchy the tissues become, and how used to the sensations you become. It's normal to feel tingling, but it should not hurt.
How often?
As far as how often you should do the perineal massage, the evidence is not super clear.
This review suggests that less-often perineum massage (1-2 times a week) resulted in fewer perineal traumas.
However, the largest study in their review showed that the more often women did perineum massage (3-4 times a week), the more likely they were to have an intact perineum.
The simple answer would be to do perineal massage at least once a week and up to 4 times if you're happy to.
What else affects the likelihood of tearing/episiotomy at birth?
YOUR POSITION:
Research has found that maternal positions at the time birth can influence perineal trauma.
Kneeling and all-fours positions appear to be more closely associated with an intact perineum compared to sitting, squatting or using a birth-stool.
A hands-and-knees position generally means a slower birth of the baby’s head due to less vigorous pushing. In this position the woman can also influence the rate of descent of baby through her postural changes and the assistance of gravity.
This review found that certain upright positions such as sitting, squatting position or using a birth stool may correlate with perineal trauma and greater blood loss.
It also found the lithotomy (on back with legs in stirrups) and supine (on back) position should be avoided for the possible increased risk of severe perineal trauma, comparatively longer labour, greater pain and more fetal heart rate patterns.
Also, when a woman is reclined or semi-reclined her weight is on her sacrum/coccyx. This immobilises an otherwise mobile pelvic joint. As a result, it lessens the space the baby has to move through the pelvis and birth canal. It also takes away the assistance of gravity and birthing in this position puts maximum and uneven strain on the perineal tissues. As they can't fan out evenly in response to the pressure and stretch of the baby's head on them.
Unfortunately, this position is pretty stock standard with an epidural on board. The stirrups are also routinely used for instrumental births (forceps or vacuum-assisted) and/or episiotomies. So it's no surprise perineal damage is likely in these these scenarios.
But, if you find yourself in this position trying to push your baby out and having trouble, you can always ask (insist) to turn over onto your knees and have the bed head raised. This way you can lean over it and make the most of gravity to birth your baby. Sure, there will be a bit of rearranging of IV lines required and adjustments to the CTG monitoring but nothing thats too unreasonable given the intention!
You can even improvise with a birth ball on the bed, as seen here:
Other beneficial positions to consider are hands and knees, one foot/one knee, or side-lying. Side-lying is another, and often better option with an epidural. You'll just need to ask for help getting into these positions.
But if you're unmedicated you'll be able to move around and labour actively. Being upright uses the gift of gravity which in turn helps labour progress overall. When it comes to the birth you'll be able to tune in and sense your body's feedback (ie. *the ring of fire*) and help control the rate of the birth.
I've seen more intact perineums when women birth laying on their side ('left lateral') or on their knees with their body upright, leaning forward slightly. Many women naturally adopt these positions.
What's interesting to note is that their knees are not as wide as if they were on their back/in stirrups/semi-reclining. This makes physiological sense, as it decreases the pressure/tension on the perineal tissues which in turn allows for more stretching to occur.
EPIDURAL:
Epidural is associated with an increase in severe perineal trauma. This is due to an associated threefold increased risk of instrument use (forceps or vacuum) which in itself more than triples the risk of severe perineal laceration.
As well as the common positions for birthing mentioned above, the drugs diminish the sensations of labour (obviously). They also effect how many muscles work, in effect paralysing the pelvic floor muscles. These are important as they help guide the baby’s head into a good position for birth. When an epidural is in place, the baby is 4 times more likely to be in a persistently posterior position (baby's spine against mother's spine) in the final stages of labour.
This persistent posterior position also decreases the chance of a spontaneous vaginal birth. In one study, only 26% of first-time mothers (and 57% of experienced mothers) with posterior babies experienced a normal birth. The remaining mothers had an instrumental birth (forceps or vacuum) or a caesarean.
Even if the baby is not in a posterior position, the disconnect created by the epidural takes away your awareness of your perineal area. When your baby is to be born you're more likely to experience coached pushing by the obstetrician/midwife regardless of your body wanting or needing to.
This unnatural pushing led by outsiders is less likely to allow the perineum to fan out nicely as your baby’s head crowns. Plus as mentioned you're pushing baby uphill, through a ‘closed’ pelvis. The combination of this maternal position and the effects of the epidural to the labouring woman explain the likelihood of perineal trauma.
PANTING NOT PUSHING:
When it comes to the point where your baby’s head is crowning, please remember there is no need to rush this stage. If you remember to - or someone hopefully reminds you to - use your breath to control the overwhelming urge to push your baby out all in one go - just so it's over!
It’s very difficult to bear down and push whilst panting from your mouth at the same time! As they are opposite sensations within the body.
Panting, or saying 'ha, ha, ha, ha', or using your out breath (like you're blowing out lots of little candles) will help slow this process. This allows optimal time for the perineum to stretch and yield for the baby's head. The body will do its best given time and space here.
If you haven’t had an epidural, tune in and follow the lead of your baby and your body. The ring of fire is the signal that tells you to go easy now. Take your time, let it slowly stretch, back off from pushing intensely if you can. Let your uterus do the pushing from above. Allow your peri to stretch and make way for baby. You'll know if you need to physically 'add' to the feeling of pushing your baby out.
WARM PACKS:
In Sydney, Professor of Midwifery Hannah Dahlen conducted the Perineal Warm Pack Trial at two different hospitals.
It was a large, randomised controlled trial designed to investigate the effects of applying warm packs to the perineum during the late second stage on perineal trauma and maternal comfort.
In summary, the trial found:
- Almost the same number of women (79.7%) and midwives (80.4%) felt that the warm packs reduced perineal pain during the birth.
- The majority of women (85.7%) said they would like to use perineal warm packs again for their next birth and similarly would recommend them to friends (86.1%).
- 91% of midwives were positive about using the warm packs, with 92.6% considering using them in the future as part of care in the second stage of labour.
- Women in the warm pack group had significantly fewer 3rd and 4th degree tears and they had significantly lower perineal pain scores when giving birth and on "day 1" and "day 2" after the birth compared with the standard care group.
- At 3 months postpartum, they were significantly less likely to have urinary incontinence compared with women in the standard care group.
Chat with your care provider about using a warm pack on your peri at birth. Is it something that is routinely done where you're planning to birth?
If not, can it be arranged for you? It's a very simple request and not rocket science.
Watch this video with Professor Dahlen and Dr Holly Priddis demonstrating how to make and use a warm pack on the perineum.
NUTRITION:
As a Naturopath this is a no-brainer for me. I'm always encouraging women to be mindful of their pregnancy nutrition. Not just for growing a baby, but also for a mother's increased demands and ongoing nutritional requirements.
Nutrients needed for healthy collagen, stretchy connective tissue and cellular regeneration include zinc, essential fatty acids (omega 3, omega 6), vitamin C, bioflavonoids, Vitamin A and Vitamin E. Having these well stocked throughout pregnancy allows the body to draw on these for all levels of postnatal healing.
Check with a qualified Naturopath or Nutritionist for quality food sources and/or supplements.
CARE PROVIDER:
At the time of birth the approach and skill of your attendant matters. Some have a very ‘hands off’ approach allowing things to unfold and only intervening if deemed necessary.
Some are very hands-on. As a doula - and woman - I've seen fingers far too active in and around vaginas for my comfort!
I'm yet to understand how this kind of meddling or manually stretching vaginas/perineums BEFORE the baby is even beginning to crown is beneficial or even allowed.
The more a care provider stretches/pulls/touches the vaginal tissue or manipulates the baby's head during crowning, the more swollen the tissue will become. This swelling lessens the tissue's elasticity and as a result, increases the chance of tearing.
These women don't feel much of this as they have had an epidural but the (additional) trauma to the tissues reveals itself afterward. Sadly, it's often done without consent or explanation.
When there is a normal, physiological, unmedicated birth occurring many women women naturally adopt an upright/active birthing position for comfort and innate progress. The use of gravity assists the birth and the care provider simply needs to 'catch' the baby (after hopefully having applied warm packs).
👉🏻 Did you know that you can ask what an obstetrician what their episiotomy rate is?
Some hold less belief (or patience) in the peri's ability to stretch than others and/or are more snip-happy that others.
Remember, an episiotomy is an instant 2nd degree tear and it often continues to tear beyond the incision site.
WATERBIRTH:
It's been suggested that waterbirth may reduce the uptake of pharmacological pain relief and as a result, increase the likelihood of an intact perineum.
There is strong evidence that women birthing in water in a high-episiotomy environment will have higher rates of intact perineums.
A prospective study involving 2745 women that investigated risk factors for perineal trauma, found no link to indicate that labouring in water might predispose women to have a perineal tear.
I'm confident the sense of relaxation and privacy that waterbirth provides also contributes to an intact perineum.
INDUCTION:
This often involves the cascade of intervention, including epidural and accompanying factors as mentioned above.
BABY:
This includes the size of your baby, the position of their head, and the speed of their birth.
Some babies come with a nuchal hand or arm - ie. in front of or near their head or neck. This adds to the need for more stretching to accommodate it which can increase the chances of tearing.
In a birth where a baby is coming very quickly, a skilled care provider may help slow it slightly allowing maximum time for the body to stretch. This may be via a couple of fingers on the baby's head with support/counter pressure to the peri (again hopefully with warm packs!)
PELVIC FLOOR MUSCLES:
It's thought that squatting regularly (particularly in the 3rd trimester), regular sex and pelvic floor exercises help encourage good circulation and elasticity of the perineal tissues.
Having sex encourages relaxed perineal tissue with good tone.
Women who have a well-oxygenated, toned and conditioned pubococcygeous muscle (PC) are thought to have better control of this muscle.
A toned and controllable PC muscle means that the baby's head is more likely to be well flexed (chin towards chest). This allows the smallest part of the baby's head to emerge first, gently stretching the perineum for less chance of tearing.
Squats will ensure that the PC muscle remains a long, sinewy muscle and keep it elastic (flexible) and not bulky and rigid.
All well-conditioned muscles have greater flexibility than weak ones, and the pelvic floor muscles are no exception.
There is a misconception that well-toned pelvic floor muscles may become "too toned" and inflexible to facilitate birth, or that strong muscles make tearing more likely. These unfounded beliefs may deter some women from doing these exercises whilst pregnant. When in fact, the the opposite is true.
Muscle weakness and atrophy decreases flexibility and increases your risk for pelvic floor problems. So, please seek guidance during pregnancy for a specific program designed to strengthen and protect these key muscles.
ETHNICITY:
It's been suggested that the risk of sustaining severe perineal trauma may vary by maternal ethnicity.
This review showed women of South/SE/East Asian birth have a higher rate of 3rd/4th degree tears and of episiotomy than Australian-born or West Asian women.
Some theorise it is because of cultural or social upbringing. Others, genetics.
~ ~ ~ ~ ~ ~
I always encourage women to make their own choices around birth. I do my best to present the evidence, whilst offering a holistic framework to refer to. As with knowledge comes insight and confidence.
As outlined, many factors come into play around perineal trauma. Some of which you have a greater control over via your choices. Some of which may fall under the unpredictable.
Even if you have done all that you can to ensure that you come through birth with an intact perineum and you still tear (or have an episiotomy) it's important to remember that your body did what it needed to do to birth your baby in that moment, within those particular circumstances.
Plus there are many supportive measures you can do to help your healing and recovery get off to a great start after the birth.
Kristin x