Tearing, perineum, pushing...Oh my!

[csbwhite]

I posted in my intro that I would like to avoid tearing. I am going to do some refresher reading on this topic, but I would love to discuss this topic. Basically, I was wondering if to truly avoid tearing, must we avoid pushing? Also, I have read that the perineum should be left untouched. This means no hot cloths, oil, and massaging. Does position (squat vs. hands-and-knees) and location (water vs. land) make any true difference? And, what about scar tissue? Will the scars basically keep me from an intact perineum? Please share your opinions and/or experiences. Thanks!

Susie

[sunshinemoma]

VERY interested in reading responses to this.

I don't have personal experience of staying intact after a bad tear, but I am hoping for one this November :) 

Because I had such bad tears, aka episiotomies ;), last time I have done a bit of research and have found plenty of women who have had similar perineal trauma/scarring who HAVE successfully gone on to birth vaginally with either NO TEARING or such little tearing that there was no need for a single stitch.  I don't have links to these but from the advice I've read and what feels right to me I have come up with a loose birth plan (loose, as in I WILL be very open to a change of plans if, for any reason, I feel I should)  If you are interested I can share that with you...

[csbwhite]

"An ounce of prevention is worth a pound of cure." I am going to first make sure my diet is truly the diet it needs to be. Thankfully, as an athlete, I have a strong foundation in my overall health and that includes my diet. I will however, add some special foods that will aid in the total elasticity of my skin (and thus, the perineum). Here is a great article that I wanted to share. http://www.indiebirth.com/nutritional-protection-for-your-perineum/   The author explains how certain vitamins/minerals will help the skin elasticity and prevent tearing the perineum. Sounds promising, yes? Another thing, I will certainly keep up is my overall hydration. I "think" I drink enough, but from now on, I will be keeping my water bottle with me and monitoring my consumption throughout the day. Good first step, I believe.

Susie

[yogamomma7]

I think much of it has to do with pushing too fast. The first time around I tore and needed stitches. I had a midwife. Didn't ever feel like pushing, she told me I was ready, so I pushed hard - too hard. Then she told me to back off and take it easy. Second time, my husband reminded me to slow down and not push too fast. Slight tearing just before his reminder. Easily healed. That's my experience. Don't have any info about positions or water, etc.

[weliveintheforest]

I've never torn so I can't speak from that experience but I have some opinions/thoughts on not tearing!

 I think compresses and are okay if it is being done to your specifications, and it feels good to you, but its probably not necessary, and I would definitely avoid massaging.  You might find you have an urge to put your own hand on your perineum (or not) and its probably best to follow your instincts and not think about it too much.  

Slowing down and breathing or panting while the head is crowning and emerging is important.  Some women get an overwhelming desire to just push with all their strength to get past that 'ring of fire' pain, but if not tearing is really on your mind you will probably remember and know not to.  You could ask your dp or whoever will be there to remind you.

I don't know how bad yours is, but scar tissue should not stop you from staying intact.  I don't know about any stats but I know women personally who tore or had episiotomies and went on to give birth without tearing in subsequent births. 

[mama2myangels07]

with my oldest it was a hospital birth that was completely managed, was cut and everything else plus tore. with my second birth no directed pushing though I did and had 4 tiny tears, no stitches, third birth no directed pushing and a tiny skid mark.

[LadyJennifer]

I have never torn (on my perineum anyway, had a couple tiny labial tears with my dd) either.

With my first we did perineal massage (dh and me) for a few weeks prior to birth, with olive oil (and gentleness!:)).

I only pushed spontaneously, no holding breath, just grunt-pushing. I was semi-reclined and had my mw apply counter pressure with hot compresses, and she poured olive oil as crowing was happening. My dd was over 9 lb. No tears.

My son was a water birth. I was on my knees. Again, only pushed spontaneously, and I instinctively tried to slow down as crowning approached (simply because it hurt!). No tears at all. We did not do perineal massage prior to birth this time (he came too early). I did subconsciously reach down right before crowning to support myself. Ds was only a bit over 7 lb.

[APToddlerMama]

good thread!  I am definitely interested in not tearing or hopefully not so bad this time.

[cottonwood]

Compresses and massage aren't in themselves bad for the tissue (unless it hurts of course,) the problem is the discomfort, distraction, and self-consciousness that many (most?) women experience when that kind of clinical attention is imposed on them. But if you love the feel of a compress or massage and it comforts and relaxes you, by all means go for it!

Position can make a difference a few different ways: being vertical puts downward pressure on the tissues which signals to the brain that certain hormones should be released that (among other things) make the tissue stretchy, it opens up the pelvis so that pushing doesn't need to be so hard, and gravity brings blood flow to the tissues, also helping them stretch. Squatting might be a bit too intense for some women if they're not used to it, and especially if they haven't been squatting all labor and is adopted just for pushing it might be too quick of a manual stretch for the tissues. Kneeling worked best for me because I was could maintain it for a long time so didn't tense up from tired muscles.

I've had one water birth (out of four) and I did like it for the privacy it afforded, but opted to do it on dry land for the next two (getting my privacy in other ways, namely by being alone. ;)) Think about what water does to your skin when you take a bath -- it (over time) washes away the protective oils and the skin becomes water-logged. Also, any lubricating fluids from your vagina will be washed away. (Think about what it's like to have sex in water.) On the other hand, water is relaxing.

The most important thing, whether you have scar tissue or not, is to do everything you can to let the hormones work maximally. Privacy, comfort, love, relaxation, and letting your body guide you in pushing. Attempting to avoid pushing when your body is trying to is a really bad idea, it will tense you up, confuse your body, and interfere with that hormone release.

[ElizabethE]

Susie, (see comments in color)
 

Originally Posted by csbwhite 

I posted in my intro that I would like to avoid tearing. I am going to do some refresher reading on this topic, but I would love to discuss this topic. Basically, I was wondering if to truly avoid tearing, must we avoid pushing? I think that's generally true. That is to say, let your body do the pushing (which always to me feels like I'm pushing...). Also, I have read that the perineum should be left untouched. This means no hot cloths, oil, and massaging. My instinct is definitely to not touch it, but so many people do insist on the hot cloths and the massaging and the oil and all that. Maybe it all just depends. Does position (squat vs. hands-and-knees) and location (water vs. land) make any true difference? YES!!! I honestly feel that the position is crucial, and that water (hot/warm) is much more conducive to not tearing than going dry. And, what about scar tissue? Will the scars basically keep me from an intact perineum? Scars just make it more likely that you'll experience at least a little tearing, but it's not a deal breaker. You may or may not tear, and either way, if you are UCing, it's bound to be minimal compared with the hospital experience. Please share your opinions and/or experiences. Thanks!

Susie

Tore twice on my back in hospital. Oil didn't save me. Tore during my UC; let heal naturally (had been kneeling, in water that could have been hotter, during the emergence of the baby), no stitching... was the best heal down there I've ever faced. I was walking normally the day of, and out and about walking a couple of days later. I wouldn't sweat it. :)
 

[sunshinemoma]

Hey I posted this in your other thread...but I'll quote it here.  If you already read it it's exactly the same so go ahead and skip over this :)

Hi Susie, I also want to avoid tearing:)  I have some compromised(aka scarred) tissue down there and I'll try anything to avoid the need for stitches again.  Here's some of my plans:

-during second stage use positions that slows exit, such as side laying or hands and knees.  NOT squatting as this usually SPEEDS up second stage. Yes it MAY speed stretching due to the direct pressure on perineum BUT on my compromised tissue full of scar tissue I WONT risk putting too much pressure.  UNLESS i am in water and it feels comfortable- the water's counterpressure might be enough to keep things slow and gradual- I would assess this at the time but expect i will be most comfortable in a hands and knees like position in the birthing pool.

-no massage during second stage.  Unless i am doing it (basically easing my own tissue if i feel the need)  Someone else's hands simply cannot do what mine can even if they have the view and the best intentions they CANT have the sensory feedback as its impossible for them to feel what your perineum is feeling.  Think: would you prefer someone else to insert your tampon simply because they can SEE things properly??  NO.  Much more comfortable and efficient to use your own hands cause you can immediately stop stretching/putting pressure on any area the moment you feel it hurts too much rather than having to say "stop" or "move to the right, no not your right, MY right" sorry if tmi  but you get my point? 

-I will have warm compresses and warm oils on hand in case it ends up that i prefer to be out of water.  I will have my support person aware that altho i prefer hands off I MIGHT want them to gently apply warm compresses and towards the end very gently slather the oil as lubricant but no pulling or massaging unless i direct them too.  Which i might if they are very gentle and it feels good.

-no forced pushing.  Breathing calm and peacefully to keep my body as relaxed as possible throughout the "uncontrollable" pushing.  I won't resist my body's pushing (which would restrict the tissue from optimum stretching) but I will not voluntarilly contribute to it...UNLESS my goal is not to keep things slow and gentle on my bottom.  It might change if for any reason I know it is vitally important to get babe out asap I will do all I can stand/squate assist my body in pushing.  I don't anticipate that need will arise but if it does, I obviously will put my bottom's best interests 2nd to baby's best interest, kwim :)

I look forward to more mamas with input.  Anyone here with thick scar tissue go on to birthing intact?

[sunshinemoma]

Originally Posted by csbwhite 

"An ounce of prevention is worth a pound of cure." I am going to first make sure my diet is truly the diet it needs to be. Thankfully, as an athlete, I have a strong foundation in my overall health and that includes my diet. I will however, add some special foods that will aid in the total elasticity of my skin (and thus, the perineum). Here is a great article that I wanted to share. http://www.indiebirth.com/nutritional-protection-for-your-perineum/   The author explains how certain vitamins/minerals will help the skin elasticity and prevent tearing the perineum. Sounds promising, yes? Another thing, I will certainly keep up is my overall hydration. I "think" I drink enough, but from now on, I will be keeping my water bottle with me and monitoring my consumption throughout the day. Good first step, I believe.

Susie

oooh!  this is really good!  I just barely noticed this post.  THANKS for the link!  

ps. I'm going for my waterbottle right now ;)

[ElizabethE]

Originally Posted by cottonwood 

Compresses and massage aren't in themselves bad for the tissue (unless it hurts of course,) the problem is the discomfort, distraction, and self-consciousness that many (most?) women experience when that kind of clinical attention is imposed on them. <-- !!!!!

But if you love the feel of a compress or massage and it comforts and relaxes you, by all means go for it!

Position can make a difference a few different ways: being vertical puts downward pressure on the tissues which signals to the brain that certain hormones should be released that (among other things) make the tissue stretchy, That is really cool. I did not know that. I had a real urge to not be vertical, though. Maybe next time I will try to see if I can stand it a little more. it opens up the pelvis so that pushing doesn't need to be so hard, and gravity brings blood flow to the tissues, also helping them stretch. Squatting might be a bit too intense for some women if they're not used to it, and especially if they haven't been squatting all labor and is adopted just for pushing it might be too quick of a manual stretch for the tissues. Yeah!

Kneeling worked best for me because I was could maintain it for a long time so didn't tense up from tired muscles.Yeah! But man, did my knees hurt.

I've had one water birth (out of four) and I did like it for the privacy it afforded, but opted to do it on dry land for the next two (getting my privacy in other ways, namely by being alone. ;)) Think about what water does to your skin when you take a bath -- it (over time) washes away the protective oils and the skin becomes water-logged. Good point... 

Also, any lubricating fluids from your vagina will be washed away. (Think about what it's like to have sex in water.) On the other hand, water is relaxing. I guess I still keep thinking of the water as lubrication, even though it isn't oily. But yes, relaxing... Maybe the issue you are talking about is instinctively why women will go back and forth between dry and wet when birthing? I know I was in and out of the pool.

The most important thing, whether you have scar tissue or not, is to do everything you can to let the hormones work maximally. Privacy, comfort, love, relaxation, and letting your body guide you in pushing. Attempting to avoid pushing when your body is trying to is a really bad idea, it will tense you up, confuse your body, and interfere with that hormone release.

Love, love, love your input!

[sunshinemoma]

Hey susie, speaking of prevention.  Can't remember where I read it.  But vaginal infections, etc, can cause your skin to be more 'friable', so if you're prone to yeast infection maybe do all you can to clear it up and keep it clear...probiotics....something to look into, right?

[csbwhite]

Wonderful dialog, ladies! I will definitely use the techniques mentioned here to slow down the exit of the baby's head. In my experiences, the head came quickly and I was in that squat position (at first) pushing too hard. I will share this information with my husband so he can also be prepared in taking it nice and slow.

[catholic74]

What oils do you use?  Olive Oil?   I was thinking of warming some wash cloths in a crock pot with a little bit of olive oil.  But if there isn't time, I might have someone just run a wash cloth under hot water.