Do doulas create a physically better birth experience?

[MrsSlocombe]

My friend says she will use her doula again, because the lady was so emotionally supportive, but my desire is primarily for a better physical experience.  Naturally, I want the baby and me to both live and be healthy, but aside from that, I want to come out of labor with an undamaged perineum.  I will do almost anything to create this outcome, including hiring a doula even though my insurance doesn't cover it.  Heck, I've even considered an elective C-section to avoid an episiotomy;  I'm that serious about it.  At seven weeks along, my options are still very much open.

If you had a doula in the past, what was the experience like, and will you use a doula again?  Do you feel you had a better physical outcome (avoiding tears or episiotomy) thanks to the doula, or did you "just" feel emotional supported?  (I put "just" in quotes because it may not seem so mere to some people, but it kind of does to me.  My husband is nice and supportive enough for me, and I will feel emotionally better the next day if I am not severely wounded.)  What can a doula do to help with the physical outcome?  Can she give a perineal massage, or give expert coaching that helps to avoid tears, and if so, is this more than a midwife could do?  (If I give birth at the birth center I am leaning towards, I will already have a midwife there.)

Thanks for sharing your experiences.  (I thought about popping over to the "birth professionals" board to ask this, but I was afraid that was only for the professionals to talk amongst themselves.)

[Nicole730]

Hmmm, I don't know if doulas do that, but both my CNM in a hospital and my CLM at home did perineal massage and I still tore and needed 3 stitches both times.  Have you torn badly before?  Is that where the fear is coming in?  I honestly couldn't tell I was tearing and it didn't bother me in the days following.  I was in lot more pain from some tiny scratches on my labia, that DD somehow snagged on her way out. 

And also would you not consider a c-section scar and recovery being severely wounded?

[MrsSlocombe]

Oh no, you can scratch your labia, too?!  This will be my first birth;  I had one brief pregnancy before, but it ended with a blighted ovum miscarriage.

Thanks for your encouraging words about perineal tears.  I would like to believe they're no big deal, but I've always had a horror of being harmed "down there."  It's almost to the point where I would not blame people for wondering why I was even willing to get pregnant.  When I was a teenager, and I heard about FGM (don't look this up if you don't know what it is and don't want to be horrified;  it has nothing to do with birth and is simply a barbaric practice), I thought, I'd literally rather lose all my limbs that go through that.  I am not leaning strongly towards a C-section because it probably is not best for the baby, but no, I really wouldn't mind it as much as I would a wound in my genital area.  At least, I don't think I would.

I really appreciate your sharing your experience.  Thank you, and it actually did help a bit;  I am beginning (or sort of preparing my mind to begin) to consider that a small tear wouldn't be the end of the world.  If no one has a good doula experience to report, keep the tear-positive posts coming!

[lizsky]

I had a good experience with my doula, but I'm pretty private and wanted the absolute minimum amount of touching of my pelvic area during my birth- so my MW and doula did not touch me at all.  If you are looking for perineal massage specifically, you could ask when you interview doulas if this is something they offer.  I imagine many doulas would be happy to help you find warm compresses to hold against your perenium. 

I had a 2nd degree tear along my perenium.  I didn't specifically feel it happen...pushing was definitely an intense experience, and I'm guessing I tore as my DD crowned, but I couldn't specifically tell when it happened.  

It was definitely tender afterwards, and I remember looking in a mirror a few days postpartum at the stitches and wondering if I would ever look "normal" again.  But after a couple months, I really did look and feel normal.  

Before I gave birth, the idea of tearing scared me too.  The image would make me shudder if I thought about it.  While some tears can be severe, the majority of women who experience tears have 1st or 2nd degree ones, and in my experience my 2nd degree one wasn't as awful as the image I had had in my head.  I think it would be much more traumatic to have my skin, layers of muscle, and my uterus cut open.  

[semmel84130]

I hesitate to share because I don't want this to come across as a horror story. I hope that as someone who had a tear toward the worst end of the scale, I can give you some reassurance that even if the worst case comes true, it might not be as bad as you imagine.

I,too, was very afraid of tearing. It was one of my biggest fears about labor. So as it turned out, I had significant tearing following a forceps delivery - 4th degree. My OB once referred to it as looking like a bomb went off (I loved his sense of humor, and this just tickled me beyond belief for some reason). And yet, it was not nearly as painful as it sounds. Like a PP, I was very sore for a few days - but I hear that even women who don't tear are sore after a vaginal birth. I will tell you that I had some temporary incontinence issues which resolved after a few months of Kegel exercises. I also found that my scar tissue was very tender for a long time - it was well over three months before I was able to have sex. But overall, it was nothing like as horrible as I had thought it would be to tear. I used the peri bottle and a sitz bath with ice packs and Dermaplast for four days. I also took hydrocodone for the first five days (give or take a day), less and less each day until I didn't need it at all. Then I kept just the peri bottle and Dermaplast for a couple of days longer. After that, I used the peri bottle until my stitches were all gone and my tears completely healed, but I didn't need any pain relief of any kind after the first week-ish. I don't think I am a woman with a particularly high pain threshold, either.

Having said that, my doula didn't really provide perineal massage, but she did take care of my physical comfort (i.e., she held the basin while I vomited during transition, she ran for ice chips and ginger ale (all I could tolerate at that point), she rubbed my back, etc), in addition to my emotional comfort. My husband and I found it very reassuring to have an experienced voice in the room, and it was very freeing for my husband to be able to focus on being there for me without worrying about things like getting rid of a basin full of vomit. Our insurance did not cover it, and if we have another baby, there is no doubt in my mind that I will hire a doula for the birth again.

[RosieL]

Here's the most reputable research you will find on the subject: 

A summary of the scientific research including a link to the PDF version of the full Cochrane report: http://www.childbirthconnection.org/article.asp?ck=10128

Research Objective: to assess the effects, on mothers and their babies, of continuous one-to-one support during labor compared with usual care, in any setting. 

The findings showed that having continuous labor support (from a person not in the laboring mother's social circle) leads to fewer cesareans, use of anagesia, and other outcomes. The summary doesn't specifically address episiotomy and tearing. Looking at the statistical results of the meta analysis, it appears that they did not have statistically significant findings on episiotomy and perineal trauma (p21). The raw scores showed that people with doulas had fewer episiotomies and perineal trauma, however the results were not statistically significant (ie. they can't reasonably be distinguished from random). 

If I had your fears, I would take this information as a guide that doulas DEFINITELY physically alleviate childbirth, however the specific question about perineal tearing is left open. My own personal strategy would be to find a care provider who would work with me to help me minimize tearing. My own personal view on that matter is that a midwife (specifically a midwife who adheres to the midwifery standards of care) would probably be the best option to optimize the likelihood that your birth attendant will be very cognizant of this for you.

Bear in mind that any practitioner, ANY one worth her salt, will probably tell you she will try hard but can't promise anything. Birth is spontaneous and natural and can't be controlled. 

Good luck mama, and congratulations on your pregnancy! :)

[RosieL]

Oh, and I strongly recommend Ina May's Guide to Midwifery. You'll learn all about techniques and mom's experiences that you won't reliably find elsewhere. 

[MrsSlocombe]

You ladies are really wonderful.  Thank you!

Lizsky, I love the idea of a warm compress.  I love being warm, and I like the idea of something just being pressed there, without fingers inside me doing a massage.  (I will do the latter if I decide it might work, and I am strongly leaning in that direction, but it doesn't exactly sound fun.)  I'm glad your experience wasn' t too bad, and that you are feeling back to normal.  I really want that feeling, too.

Semmel84130, thank you for sharing!  I am sorry for your pain and glad you are better now.  Yes, it is reassuring that the pain wasn't as bad as you thought, especially considering that you probably thought the tears would be first or second degree.  I forgot that forceps even exist;  I don't think the birth center I am likely to use employs them, as they were not featured in the video I saw.  That's one more thing to research.

RosieL, thank you for the link to the study.  It was hard to get through the pdf on my screen, since for some reason they are always blurry on my computer, but this may be worth printing out to read.  From what I did gather, you're right, that the outcomes seem overall better, but my specific area of concern may not be significantly affected by a doula.  I'll have to give this some thought, and, like I said, maybe print out the report.

I think I have read part of Ina May's book before, but I'll have to check it out again.  Thanks.

LIzsky is probably right about just going ahead and interviewing doulas.  It can't hurt.  My hesitation is the money, especially if she's primarily going to be running to fetch things, etc.  I am taking time off of work (since my job as a nanny is pretty strenuous and requires a lot of household labor) before the birth, so my plan is just to be super-ready with supplies, and my husband can do most basic things (like holding a basin), though I wouldn't want him to have to leave to run an errand.  I basically plan to run him ragged supporting me!  (Mean?)  No, really, he's a super guy who will do anything I ask, the only problem being that he has no knowledge of how to create a physically positive birth experience;  I would have to tell him.  I do think this is his responsibility, since it will necessarily be worse for me no matter how many tasks I give him.  Also, I will have a midwife there (if I don't go the C-section route, which I probably won't), and I know she means to be supportive.

[emmaegbert]

I just gave birth to my third baby last week with no tearing at all. I think it was partly that she was a bit smaller than my others, and that I was more stretchy having given birth before, but also I am pretty convinced that the waterbirth made a huge difference.

My first, I had a natural tear that required stitches, and honestly, it wasn't that bad. Getting the stitches was the worst part- once they were in I felt fine and the healing was not a problem. With my second, who was 9lbs, the tearing was so minor it required no stitches. With her birth I focused on taking it slow (she was born very quickly)... not trying to hurry her out. All my babies actually came very fast, and what I learned after the first was to focus on letting it happen nice and slow and at its own pace. We used no massage and not really any counter pressure or anything- but I've heard a warm wet washcloth can provide counter-pressure/support to the perineum during crowning.

Are you working with a midwife? Talk to her about your fears and what she does to help preserve your tissue integrity.

Being really healthy as you go into labor helps (I have heard) as well as things like optimal intake of Omega-3 fats, that increase skin elasticity...

[MrsSlocombe]

Emmaegbert, I'm happy for you with this great outcome.  I have heard good things about water birth, too, but there isn't a facility for that in my area, so I'd have to make it a home birth, rent the tub, and pay for the midwife and/or doula, myself.  I should, perhaps, consider that it would be worth it, but I am really eager to be able to stay home for the first couple of years, so we are being pretty frugal.  I felt lucky that there was a midwife-run birth center with nice rooms and jacuzzi tubs (though you can't be in them when you are actually birthing), that my insurance DID cover, but now I'm wishing for even more.  I'm trying to decide if having to leave my toddler a couple of months earlier than planned is worth a better, more expensive birth.  It's a hard decision.

[MN BabyDust]

I just had my first baby a little over 3 weeks ago. I too was horrified at the thought of tearing. I had other past issues that really confounded my worries about that area. I had a family practice doc, but she may as well be a midwife in terms of her style (think sort of hippie, hands off patient approach to birth.) I did hire a doula as well and I am so glad. My doula was very knowledgeable about things like tearing. She knew just what positions would prevent it, she told me about how my diet before birth can affect my tissue's ability to stretch, and she encouraged anything during the birth process that would make me emotionally AND physically comfortable, including preventing a tear. As it happened, I ended up on my back during pushing. She encouraged me to change positions, and I refused because I couldn't imagine moving (that phase is so wild - the mental state is very small and I was basically unaware of what was going on around me.) I did end up tearing a little, but it was so not a big deal. I didn't even notice because everything else going on was so intense and awesome. The stitches were kind of bothersome, but NOTHING like the stories I hear from women with c-sections. I also used dermaplast, sitz baths, and the peri bottle. I'm already pretty close to normal down there, and suffered no complications or incontinence. And stool softeners are your friend for a couple weeks. That was the only really difficult part for me - the first poop. I had to really relax and allow things to happen at a slow pace. It's sort of a PTSD thing - my mind didn't want that pushing sensation. But after the first one, it got much easier.

I think if you are carrying a lot of anxiety and worry about tearing, then that IS an emotional issue and you should find a caregiver or doula to help you work through it. I certainly found that in my doula, though I'm sure there are many approaches and styles with doulas. Maybe interview a few and tell them of this concern and ask what they would suggest/do about it, see how they respond and decide from there if it sounds worth pursuing? I interviewed quite a few before hiring one.

And if you do tear, know that the fear of this unknown thing is probably much worse than the actual tear will be.Good luck!

[sarahlynne]

Studies show that doulas increase positive outcomes in all areas of measurement (length of labor, lower interventions, satisfaction with experience...) EVEN if the "doula"was simply present and not offering active help with the labor.  I would highly recommend a doula.  Besides the doula though, if you are concerned about perieum issues specifically I think one of the most important things is how the labor is managed.  Your birth attendant should be able to provide you with statistics about how often they do episiotomy and also how they will help you prevent tearing.  Do not accept "oh, we will worry about that when we get to it" or the evasive "well, every birth is different".  They should be able to have a conversation about it and if they are truly supportive of intact perineums they will have some advice for you and understand your concern (though they may put it into perspective for you if this has really become more of a phobia). 

The management of second stage is very important and I suggest you read/learn all you can about breathing the baby out, not "pushing" during second stage, how to recognize crowning to ease the baby down at that point.  A previous post mentioned Ina Mays Guide to childbirth and that has lots of good info on this.  There is a lot you can do and prepare yourself and surround yourself with caregivers that support your efforts and concerns.  In the end, a small tear that occurs naturally is not nearly the same as an episiotomy or the huge tears that often result from them.  Large tears (3rd, 4th degree) rarely happen in the absence of an episiotomy.  Best wishes for a good birth!

[UrbanMamma]

I primarily utilized my doula as a support for my birth partner who then supported me.  I think this is really common and encourage you to not underestimate the value in this.  He really wanted to be there for me but was/is a bit squimish and easily gets overwhelmed in stressful situations.  For the first birth, having someone to prompt him about how to help me was invaluable.  While that meant that she directed him to physically touch and support me, it doesn't mean you couldn't interview to find someone who is comfortable being more hands on.  Best money I ever spent regardless.

I sustained two small 2nd degree tears (a couple of stitches for each - one to the perineum and one to the labia) as a result of my first's chin 'popping' up during the last moment of crowning.  He was turning the opposite way from how babies normally turn; so even though we were going slow, everyone was a bit confused.  But, I didn't feel the tears at all because both coincided immediately with the relief of him being out.  Healing was fast although I did have one stitch that took a long time to dissolve which was kind of annoying.  I literally walked out of the hospital within 24 hours and was up and about from then on; the tears just were not an issue as long as I used a peri bottle and warm, damp cloth to wipe when on the potty.  So, even though you are fearing this, I think it is something that you can get your mind around; it doesn't have to be as big of a deal as perhaps you imagine.  This isn't to say the fear isn't real.... just that it might be helpful to try and concentrate on working keeping tearing to a minimum instead of avoiding all tears.  Also, I think the chances of you walking out without an epi are really good as long as you screen your providers well; it seems to me providers either favor cutting or don't.  It seems that healing from a small tear is a lot different than a large episiotomy.

For what its worth, I attribute my tears to a babe with less than ideal positioning (lots of back labor), in part because I have a heart shaped pelvis.  I'm confident it would have been a worse presentation if the doula hadn't been there early on gently hounding me to do lunges, etc to help him turn and give him as much room as possible.  In that respect, doulas don't have to be actually touching you to encourage techniques that lead to better presentations.  This should, in turn, minimize tearing.

[artekah]

There are a lot of factors as to whether or not you'll tear, and genetics is one of them, but you can improve your odds.

Water birth is supposed to minimize your chance of tearing, and for a land birth, warm compresses during pushing feel awesome. During both my births (one land, one water) I was in an upright, kind of squatty position (on birthing stool, and on all fours in pool) and both times someone was gently supporting my perineum with a washcloth over their hand. I didn't tear either time.

Diet is really important and often overlooked. You want to make sure to be eating lots of healthy fats and oils during your pregnancy--avocados, nuts, low-mercury fish, and take a vitamin E and omega 3 supplements. All these things will help your skin be as elastic as possible. Being generally healthy and active is super important.

The most important thing is having a care provider who doesn't believe in routine episiotomies--like, interview multiple people and ask them how many of their patients "need" an episiotomy. Both the midwives for my 2 births said something like "none" or "I've had to do that twice in my life, out of 6000 births," and THAT is the answer you're looking for!

The second most important thing is to take your time pushing. Most people experience a "fetal ejection reflex" which is a crazy feeling when your body starts pushing the baby out on its own and you can't stop it. If you make sure to breathe deeply, relax and focus as much as you can, and try to slow the process down when the baby is coming down, you're more likely to stretch instead of tear. Visualize your perineum as a soft pliable ring melting open easily like butter!

I can't tell you how much Hypnobabies helped me to focus and control during the pushing stage (and helped me sleep & be positive my whole pregnancy too!) for my second birth. I recommend the home study program to everybody!

If you're in a position to have a home birth and you can find a great midwife, that will minimize interventions of ALL kinds. I am lucky to have access to home birth midwives where I live. I had both my children at home and I'm SO glad I did.

If I were having a baby anywhere else but home, I would absolutely hire a doula, for all the reasons listed by previous posters!

[lizsky]

Just an FYI, I did have a waterbirth and still had 2nd degree tears.   Delivering in the water could help minimize tearing, but its not a guarantee.  (I'm not at ALL trying to be negative about waterbirth...I think waterbirth is great!  And using water for labor could be an awesome option for you)  I agree with previous posters that working through this fear will likely have a really positive impact on your whole experience.  Fear and tension make it pretty tough to relax.  If your doula is able to help you relax your body and release tension, that could have a big impact on your physical experience even if she is not touching you at all.  

Originally Posted by MrsSlocombe 

Emmaegbert, I'm happy for you with this great outcome.  I have heard good things about water birth, too, but there isn't a facility for that in my area, so I'd have to make it a home birth, rent the tub, and pay for the midwife and/or doula, myself.  I should, perhaps, consider that it would be worth it, but I am really eager to be able to stay home for the first couple of years, so we are being pretty frugal.  I felt lucky that there was a midwife-run birth center with nice rooms and jacuzzi tubs (though you can't be in them when you are actually birthing), that my insurance DID cover, but now I'm wishing for even more.  I'm trying to decide if having to leave my toddler a couple of months earlier than planned is worth a better, more expensive birth.  It's a hard decision.

[onetwoten]

I only read the first half of the replies, so I apologize if this has been repeated. 

I would definitely encourage you to go the midwife route-- in general they are going to be MUCH more versed in positions and techniques to decrease the chances of you tearing. They simply have knowledge of how to do things the natural way, that most OB's lack. 

I would also recommend a very experienced doula. While most doulas in my experience do not provide perineal support or massage, again- they are going to have the benefit of experience and knowledge of all the little things that you can do to decrease the chances of tearing. Like you- I am confident in my husband's ability to be my emotional comfort during labor, but the doula can definitely have other benefits. One of the big things you'll probably find other than position, will be keeping yourself (and thus all your tissues and perinium) relaxed during the birth. An experienced doula will be able to help you with techniques to do this effectively- even if she teaches you beforehand, and then allows your husband tto be the guidance towards relaxation during the birth itself. She will have advice and tips for how to push effectively (or not push! Ask her about breathing your baby down!) to decrease the chances of tearing. 

I wish you luck! It's a hard thing to think about, but I do think with the right support team (husband, midwife, doula) you stand a good chance of not having significant tears. 

[veryhappydog]

I haven't birthed myself, but have been a doula three times now for girlfriends, so take my advice for what it's worth. Reading your post sounds to me like you're going to try to manage your husband (delegate, make your needs known, etc) during the birth. Just in my experience and in the birth stories I've heard and read, that's a hard thing to do. When faced with a first birth and a wife in pain, most husbands aren't comfortable being firm enough to get through to you during a birth. My opinion of the value of a doula is to be able to take charge of a situation when needed and re-focus the mother. My first birth I attended, I felt very much "along for the ride", and I noticed a huge difference in the experience of her second birth, where I felt confident enough to get her attention, re-focus her breathing, change her position, and apply hours of counterpressure only during contractions, but before she asked for it. Typically, husbands don't know how to try different things until something works, whether that's position, warm cloths, counter-pressure, hip squeezes, breathing, moaning with you, etc. It's not because they're bad at birthing, I believe it's that good men have an innate fear of doing anything that hurts their partner, and some of the more productive positions that a doula can get you into that WILL support your perineum may hurt worse at first. I'm one that thinks that doulas have tremendous value, and having someone calm and experienced in the room WILL change the entire atmosphere, perhaps enough to help you open and relax more than you would without that positive, calming energy. Hope that helps, sometimes I feel shy posting here because I haven't birthed yet, but sometimes I get tired of lurking :D

[Babydoll1285]

A doula is a great idea for a first time mom as a resource (or any mom!) and labor support but no, there's not much a doula can do physically to prevent you from tearing.  And I agree with the pps, tearing isn't as bad as it sounds.  I heard Penny Simkin say last year at a conference that she felt that some tearing is normal, just like there is often a little tearing when losing your virginity.  Your body is moving and stretching in ways it hasn't before and it's healthy and normal to open in a different way.

It sounds like you have very real concerns about genital trauma.  Have you looked into seeing a counselor or therapist?  Previous experiences have a lot of impact during labor and birth and speaking with a professional might help.  Good luck!

[Psmythe]

No advice from me on preventing tears, but I had a 3rd degree tear (vacuum assisted birth).  We had a natural birth and without drugs it was not a big deal pain-wise.  It sounds really scary, (45 minutes of stitches) and I thought I'd look and feel very different after I healed but it really didn't.  Pretty much only an OB who was looking for evidence of past tears would even be able to find a scar.  My midwives assured me it was practically invisible at my 6 week post-birth check-up.  My husband says that although my body seems a little different than pre-pregnancy it doesn't look or feel damaged at all.  He isn't the sort who would fib either.

[MrsSlocombe]

Thank you, all!  I am overwhelmed by the amount of support and advice that has been offered since I wrote this post.  I've gotten so many good ideas from it.  Specifically, I love the warm compress idea.  That is exactly the kind of thing that is comforting to me, and I think it would help me relax better than a semi-internal "massage."

Radicaleel, what a useful list of tips!  I'm honestly going to have to print out this whole thread.  It's been that useful.  My diet is very high in nuts, but is void of fish since I am ovo-vegetarian (mostly vegan).  I like avocados, and will start eating more, as well as looking into Vitamin E and Omega 3 supplements.

A couple of people mentioned my husband, and not expecting him to be knowledgable or un-needing in support.  You're right, and you're right that just having him do what I say (which he totally will) won't be enough.  I still want him there, of course, because I find him very comforting, but he has absolutely no experience with births.

Psmythe and others, it really is amazing to hear so many stories about tearing not being that bad.  Being back to normal afterwards is exactly what I want.  I'm glad it happened for you!

(Interesting...I've been able to go from "No tearing whatsoever is exactly what I want," to, "Being back to normal afterwards is exactly what I want."  I wonder if I'll still mean it tomorrow.  :-))

I think the bottom line with me and a doula is that I need to choose a birth venue first.  We are not leaning strongly towards a more expensive home birth.  It's pretty much going to be the midwife-run birth center (90% likely) or the hospital (10% likely).  We are touring/attending seminars for both in the next couple of weeks.  I have asked the birth center about episiotomies before, and got a vague answer about their being a last resort, but not to be ruled out.  Of course, what I wanted to hear is, "No, we won't do that, EVER."  When I attend the seminar, I'll be armed with a differently-worded question, and also ask if the midwife will be doing the things that I am wanting a doula to do (advise on anti-tearing positions, hold the compress, etc.), or if people sometimes bring doulas.  If I go to the hospital, and yet don't go with my cop-out C-section idea, there is no question but that I would bring a doula.