One concern that we hear from nearly all of our clients is their fear of tearing or receiving an episiotomy during birth. A vaginal tear is a spontaneous laceration to the perineum that occurs when the baby is coming out the vagina. An episiotomy is when the care provider uses surgical scissors to manually cut the perineum and increase the space for baby to be born. (Thankfully, these are not typically routine practice anymore as the evidence that the body will heal quicker from a natural tear than an episiotomy has become more widespread.) While the vagina is made to stretch and expand to accommodate Baby's passage, it is also made to tear when necessary to allow the baby to pass through. When they do occur, most tears are minor. Our bodies have a miraculous ability to repair themselves and heal from injuries- and vaginal tearing is no different! In fact, similar to oral tissue, vaginal tissue heals relatively quickly. Even still, most of us would rather avoid tearing if possible, and sometimes significant perineal injury may occur and necessitate pelvic therapy. So taking steps to prevent/minimze injury certainly makes sense. Here are some of our best recommendations for minimizing tearing/injury.
Talk to your functional medicine doctor or a nutritionist about the best foods and supplements to support supple, healthy tissue. Don't have access to that expertise? Many local midwives will also offer nutritional consults. (Try South Bay Homebirth Collective or Ronnie Falcao.) Most OBs have minimal training in this kind of nutritional support. Diet and ample hydration have a huge impact on healthy tissue, so start here. Our favorite book is Real Food for Pregnancy by Lily Nichols.
The perineum is the skin between the vagina and the rectum and perineal massage a gentle way to stretch the vaginal tissues, muscles surrounding the vagina, and the skin of the perineum. In addition to preparing the tissue ahead of time, it also serves to familiarize the birthing person with stretching sensations, and may help her to relax as baby is crowing and she is feeling the intense stretching of delivery. We see this lessen anxiety and increase confidence as baby is crowning. The research backs this up and shows decreased chances of an episiotomy or tear when this is done daily (5-10 minutes) after 34 weeks of pregnancy.
You may do this yourself (we recommend relaxing in bed or in the bath) or enlist your partner to help. Using gentle, downward pressure, slowly stretch the vaginal and perineal tissue and hold it gently at the end range. At first it may feel tense or taut, but in time and with practice your tissue will begin to relax and you will be able to slowly stretch the tissues further and further without discomfort. Remember to be gentle and do not press hard - this should not be a painful experience.
In contrast, evidence does NOT show that perineal massage during the second stage of labor (or the active rubbing and stretching of the vaginal tissue that a provider may do during birth) minimizes tearing - and in fact there is some evidence that suggests that this sort of massage may create minor abrasions and tears and make the tissue more susceptible to tearing.
This awesome product has had great success in preserving intact perineums. The Epi-No (which stands for Episiotomy No) is a soft, easily inserted, and naturally shaped balloon that it fits the vagina perfectly. It is gradually inflated to mimic the baby's head. They are not FDA approved in the USA, but are available and approved everywhere else in the world. If you have friend or family member that lives outside of the US, you can have them order it and ship it to you.
Second Stage Pushing & Positioning
The way in which you push has an effect on your pelvic floor health and the degree of tearing you experience. Last year
a hospital in the UK reduced rates of severe vaginal tearing by 85% by simply not asking birthing people to push as hard as they could and by allowing them to choose positions other than being flat on their backs (click here). Even ACOG, here in America, is suggesting that women be encouraged to breathe in the manner that feels best to them (verses
being told to hold their breath and bear down as hard as they can.) While coached breathing and pushing might be helpful if one has an epidural, when a birthing person is able to feel the sensation of birth, the body can often be felt to push the baby out without "pushing as hard as you can." We encourage our clients to "breathe the baby down," listen to the natural urge of their body and let gravity and contractions do most of the work. Standing, kneeling, sitting and squatting are all good positions for second stage. Statistically, the least amount of tearing occurs when birthing people deliver while lying on their side. As your doulas, we will help you protect your perineum by recommending frequent positioning changes during the second stage of labor. Moving into different positions allows your baby's head to apply pressure and stretch slightly different tissues as they descend through the birth canal, helping to reduce tearing. While we usually see images from the media of women pushing flat on their backs with legs up in stirrups, there are actually many positions available to you - and they're frequently more effective and comfortable, as well!
In short, preparing your perineum prior to birth can be quite helpful in reducing tearing if you are willing to put in some time. Did you try perineal massage, an Epi-No, or frequent positional changes during pushing? Do you think any of these things helped you? We'd love to hear from you!