Avoiding Tears and Episiotomies

Presented with revisions on NotJustSkin.org by permission from the contributing author:
Rachel Silber, CCE, CD, CD(DONA), CLE, CPD, CPDT
perinatal educator, doula, lactation educator, postpartum doula trainer
www.beautiful-births.com

Introduction

An episiotomy is an incision in the vagina. Episiotomies have been marketed as a preventative to vaginal tearing during childbirth, however no research has shown them to be effective. Recent research has confirmed the assertions that childbirth assistants and educators have been making for years: Episiotomy is harmful whether you prepare to avoid tearing or not. An episiotomy is almost always worse than a natural tear. The most serious tearing is almost always initiated by an episiotomy incision.

The remainder of this page is information is a collection of thinking about how women can prevent or minimize vaginal tearing during childbirth.

Choice of Birth Attendant and Birth Place

  • Doulas: Hiring a doula can help you to avoid an episiotomy, especially if you plan on a hospital birth. Research has found that having a doula cuts requests for epidural by 60 percent and has a 40 percent reduction in forceps deliveries; both procedures are major contributors to high episiotomy rates.
  • Midwife-assisted Birth: Births assisted by midwives rather than by obstetricians have lower rates of most interventions, including episiotomies.
  • Birth at home or in a birthing center: Here you and your chosen assistants/partners have more control over the progression of birth. Also, if you are giving birth in a place where you can be most relaxed.

Nutrition

Good nutrition and hydration are very important for tissue health and elasticity. "Good nutrition is vital to your body's work in preparing the perineum for stretching during birth. Hormonal changes during pregnancy cause the tissues of your cervix and perineum to become extremely thick and elastic. Crucial to this process is an adequate intake of protein, vitamin E, and short-chain fatty acids, which consist of two types of 'good' fat, Omega-3 and Omega-6. Short-chain fatty acids are found in nuts and seeds, cold-pressed oils, all types of beans, and fish such as salmon and tuna" "Avoiding an Episiotomy", Nancy Griffin, Mothering Magazine, # 75, summer 1995, (p 60).

Vitamin E can be especially helpful (at least 1,000 mg per day). Food sources include: Wheat germ oil, wheat germ, sunflower seeds, almonds, pecans, safflower oil, peanuts, corn oil, soybean oil, and lobster.

Vitamin C is also very beneficial for tissue health, cellular integrity, elasticity and regeneration.

Bioflavanoids. These are the compounds that make oranges orange, blueberries blue, and cherries red. These crystalline compounds give foods their bright colors and great taste. More than 4,000 flavonoids are known. While sometimes-called vitamin P, they are not truly vitamins. The medicinal effects of many foods and herbs are due to their flavonoid content. The most well known flavonoids are PCOs (proanthocyanidins), quercetin, citrus bioflavanoids, and green tea polyphenols. Some foods rich in flavonoids are blueberries, cherries, citrus fruits, pears, grapes, cabbage, legumes, plums, and onions.

During Birth -- Positioning

Recommended positions:

  • Water birth encourages "good mechanics" A mom can float into a very natural relaxed position. She can push as she feels a need to. She may be more relaxed -- no one is flexing the head or has their fingers in her vagina. The warm water soothes and takes away the sting of crowning, so she is more able to slowly birth the head (some women push like gangbusters just to get the crowning over with!). There are very few tears in water births.
  • Squatting (can be done with a birthing bar or directly on the bed with support from labor partners) helps reduce tearing. It shortens the length of the vaginal canal and increases the diameter.
  • Lying on left side Most women do better if they lie on their left side to avoid tearing.

The following positions and techniques can actually CAUSE tears:

  • Any back lying position, including semi-sitting
  • Widely flexed legs -- lithotomy position or any back lying.
  • Coached pushing -- Standard American births, we coach to PUSH HARD until full crowning -- then tell the mom to slow down. This is TOO LATE!
  • Rushing the shoulders -- standard in the US.

During Birth -- Understanding Pushing

Avoid unnecessary pushing. This is commonly encouraged by impatient care providers and involves pushing before the mom feels an urge to push or before the head is reasonably low and is mostly rotated into the optimal orientation for birth. This is best avoided altogether.

True pushing occurs when the mom feels an uncontrollable urge to push because the baby's head is putting pressure on the nerves of the pelvic floor. This almost certainly means the head is low and rotated into birth position. This takes however long it takes for the mom to get the hang of it and to push the baby out. If the mom's instinctive pushing efforts are moving the baby, it doesn't make sense to mess with it.

Be wary of olympic-style "purple pushing" (the Valsalva maneuver), where the mom is encouraged to hold her breath and use all the muscles in her body, may occasionally be helpful; but it also can impede venous return and cause the swelling mentioned above.

Stop pushing when the head has been pushed through the pelvis and is beginning to stretch the perineum. Once the head is through the pelvis, it's just the delicate perineal tissues that are holding the baby in, and this is where a woman's perineum is either protected through careful coaching and hand maneuvers or allowed to tear through ignorance or a rush to get the baby out.

Ideally, the care provider is maintaining a good connection with the birthing woman. By letting her know through words, tone and manner that this is the time to stop pushing and simply to breathe the baby out, i.e. avoid putting any voluntary efforts behind the uterus, which is "pushing" all on its own. "There is a time to push, and a time simply to breathe". Prolonging the unnecessary phase of pushing may contribute to tearing, but prolonging the very end of pushing is likely to reduce tears, rather than cause them.

"When your baby's head no longer disappears back inside you after a contraction, it is about to slip out. At this point, not pushing can allow you to stretch without tearing. You may feel pressure, heat or burning. This too shall pass!"

To help women in second stage stop pushing when we are attempting intrauterine resuscitation (or waiting for the MD). Instead of telling her to "Stop pushing!" over and over, rock her hips side to side and tell her to "Rock your baby." The motion of the hips keeps the abdominal muscles from coming fully into play for a push effort and prevents an all out bearing down. Besides it is much nicer to say gently "Rock your baby." than commanding "Don't push, don't push." We want to have S L O W crowning and head birthing, supporting the tissues as the baby is born. It is important to ease shoulders through slowly, arms close to the chest.

Preventative: Exercises and Tissue Health

A good foundation in prenatal exercise is helpful. It is beneficial for circulation, which keeps tissues supple.

Kegel exercises for tissue health and elasticity. A Kegel is the name of a pelvic floor exercise, named after Dr. Kegel who discovered the exercise. These muscles are attached to the pelvic bone and act like a hammock, supporting your pelvic organs. To try and isolate these muscles, try stopping and starting the flow of urine. Once you have located the muscles simply tighten and relax the muscle over and over, about 200 times a day. These are basic Kegels. There are many variations on Kegels: elevator Kegels (Where you tighten slowly, in increments going in and out, like an elevator stopping on several floors.), you can hold the muscle tightened for five seconds, you can bulge the muscles out at the end, and many other variations.

Sexual activity, especially orgasms, help increase blood flow to the area thereby enriching the health and stretching ability of the tissues.

Perineal Massage

In a study, researchers asked women to massage themselves every day and found 24% of first time mothers did not tear, while only 15% of those who did not do the perineal massage did not. Perineal stretching seems to help both psychologically as well as physically. Most women (85%) who preformed the massage would recommend it to other pregnant women!

To perform a perineal massage, a woman or her partner places one or two fingers about an inch to an inch and a half into the vagina. Use almond oil, K-Y jelly, pure vitamin E oil, wheat germ oil or other lubrication. Gently stretch the lower part of your vagina, gently stretching the perineum, until you feel a slight burning or stinging sensation for several minutes. Concentrate on relaxing the tissues through the stretch. Then, gently, massage your lower vagina with your thumbs for several more minutes, avoiding the urinary opening.

In addition, oils can also be massaged into the perineum daily to help avoid episiotomy.

During Birth - Breathing

Focus on your throat while giving birth. The throat has a connection to the vagina. As you breathe deeply, try to open and relax the throat. As you relax, imagine all the oxygen getting to the cells of the vaginal walls… nourishing them with rich oxygen and making them more resilient and stretchy.

During Birth - Perineal support, compresses and oils

Olive oil or mineral oil gives a slippery quality to the perineum. It feels like hands move more easily over the skin without dragging or causing irritation. Use verbal imagery when applying the oil. "I'm going to put some oil down here now to help the baby slide out." Women find it a relaxing and reassuring image and it seems to help them believe in their ability to deliver intact.

Warm compresses at the perineum feel great and encourage relaxation of tissues. Do not use hot compresses, as temperatures that are too warm can bring excess blood flow and cause swelling.

Castor oil packs for the perineum can help relieve prenatal pain around the perineal region as well as make your tissues supple and help prevent tearing when you give birth. Castor oil has healing and restorative properties so the relief builds up over time and the heat increases blood flow to the area, relieves pain, improves circulation and relieves venous congestion. You have to use cold pressed castor oil. Soak an old washcloth or a flannel in the oil, wring it out and put it right on your perineum. Then cover that with something waterproof and put a heating pad of some sort on (electric, microwave, hot water bottle, it won't matter.) Cover the compress because the castor oil will stain and also to avoid shock if you use an electric heating pad. Leave it as long as you can but at least 30 minutes. You can't do it too much, and it can only help not hurt.

Additional practices to avoid:

  • Multiple vaginal exams -- irritating the tissues.
  • IODINE SOLUTIONS ARE IRRITATING AND MAY BE DAMAGING. Toss out your betadine!
Published Sunday, December 13, 2009 - 20:06; Last updated Sunday, January 24, 2010 - 07:19