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Perineal tearing: the controversy of hands on vs hands off - Page 2

post #21 of 87
great article! i loved it, you inspire me. i strive to be a very hands off midwife (i'm a student right now). i think the more we stay out of it and let the mama birth, the better it is. women are amazing and powerful, we need to trust them!
post #22 of 87

my reply turned into a vent

Wow, I read all the replys to this thread before reading the article and though, yeah ,yeah, nothing I havnt seen.
WOW! That was so nice to read, really got me thinking about the births I experienced with my own kids.

Now dont mind me, I just have to share and vent now!!!!!!!!

I can recall so clearly with my last baby(all OB care, although I still love that OB, in hospital), she was much more difficult than my first 2. When I finally got through all the hours of labor after refusing against drs orders the pitocin more than once, my very good and helpful nurse got my up on the bed on my hands and knees semi leaning over a pillow with the bed raised nearly upright.
I was 7-8 when I got up there, 3 VERY strong, long contractions(and lots of low screaming) later I felt my baby crown. I didnt want to stop. I didnt want to move, I wanted to be left alone to push this baby out as I wanted. The nurse looked when I yelled "It hurts and I cant make it stop!". she said oh, theres the baby! and told my DH to help me turn over while she got the dr.

It was this very moment that I said to my mom, "I wish I would have just gone to the midwives at the birth center, or let them give me that epidural!"

Over an hour later, most of which I spent with the largest part of my babies head nearly out, I delivered her. I was in so much pain from the prolonged crowning and the delayed turning of her head to the best direction that I could hardly even concentrate to nurse her right away.
If I could have been left to deliver on hand and knees semi upright as I was when she finally came down, I feel she would have turned soooner before I was forced to push her so far and would have been much faster.

*long sigh* I have always had an interest in pregnancy and birth but never thought I could do anything with it(the "Im not good enough, smart enough, wealthy enough, to do what I *want* syndrome I have always suffered from).

After that experience I really started rethinking and began reading. I will someday follow through and be a midwife with as good of values as yours. I will help women have the best experience they can have how they want to have it.
Thank you for sharing Pam.
post #23 of 87
This needs to be said again and again and again:

Quote:
Did you know that your vagina has a built-in protective mechanism? We experience it when we are getting a pelvic exam—fingers placed right outside the vagina or inside the vagina will result in a contraction of the vaginal muscles. This response is normal and positive. Yet women are often told to "just relax" at this point, as if it’s completely voluntary.

The midwife or doctor performing the exam may be a classmate, friend or trusted provider. It doesn't matter—the care giver’s fingers are not our fingers. They are not the fingers of our lover. Our wise bodies resist touch that is not sensual or our own. A woman pushing out a baby will experience the same reaction. The resulting tension is counterproductive to loosening and opening the pelvic floor to birth her baby.

What happens when we midwives put our fingers inside the vagina as the baby is trying to emerge? Could it be hard for women to concentrate on pushing something out of their bodies when we are putting things in? Are we really helping women by dragging down on the perineum? By "pushing" tissue away as the head descends? Is the woman's vagina instinctively protecting her? How does it feel to the mother? Can we expect the body to respond naturally with the desired fetal ejection reflex and associated hormones when this is occurring?
I am just sick to my soul of reading birth stories in which midwives have their hands all over women's vaginas, and of women believing that it's good and necessary. I would like nothing better than to see the demise of this harmful myth.
post #24 of 87
Fabulous article pamamidwife!

My last birth was hands free, except when I told midwife ds' head was crowning she did brush her fingers to see (NO ONE realized I was pushing ) that yes, ds was crowning. I liked it that way. My first birth (OB w/perineal massage that hurt like hell and then an episiotomy) was not like that at all. I definitely prefer hands-off!
post #25 of 87
hands-off

for sure.


BUT

are there other crotch-preserving interventions that are welcomed?

For example, I think of my own experience birthing my ds, and I wanted my mws hands "holding my butt" if you will. There was so much outward pressure/force from my baby's head, that I wanted counterpressure in the form of holding my a$$.

Is that hands-on? or hands-off? or requested hands: all hands on deck!

Another intervention, specifically aimed at preventing tears: puh puh puh breathing.

Am I grateful to my mws, for encouraging a "long crown" as they said? to help prevent a tear? (my mws are of the 30/30/30 Rule: tears are prevented 30% diet, 30% stretchy skin luck and 30% baby's position luck. that is their admitted bias.)

Could that "hands-off" yet completely interventive act really prevent a tear (causing a "long crown" to allow skin to stretch?) (PS I still had a small unstitched tear...and I indicated anticipating and wanting these interventions during prenatal visits.)

I read this cheeky advice for OBs somewhere: Don't just do something--SIT THERE!
Seems it can apply to "helpful" mws, too, I guess.
post #26 of 87
Quote:
Originally Posted by tinyshoes
Is that hands-on? or hands-off? or requested hands: all hands on deck!
Sorry, this just had me rolling this morning.
post #27 of 87
Quote:
Originally Posted by tinyshoes
are there other crotch-preserving interventions that are welcomed?

For example, I think of my own experience birthing my ds, and I wanted my mws hands "holding my butt" if you will. There was so much outward pressure/force from my baby's head, that I wanted counterpressure in the form of holding my a$$.
Glad to know I'm not the only one!
post #28 of 87
Quote:
Originally Posted by LoveChild421
Glad to know I'm not the only one!
Yeah--I remember being pregnant at a prenatal appt., asking my mws what they would do during labor.

They mentioned something about, "well, mostly we do a lot of holding women's butts."

and I thought, Hunh? I could understand English, and what they said....but indeed----after having that baby, I really understood what they meant! And when they said it, they suggested it was more or less a popular request from birthing mamas....so I'm interested in hearing that you appriciated that too, LoveChild!
post #29 of 87
Quote:
Originally Posted by LoveChild421
Glad to know I'm not the only one!


For #3 I told my MW to "HOOOOOOOOOOOOOOOOOOLD ME!!" He was a big ol' baby presenting with a nuchal arm. I couldn't NOT be held. But there was no perineal massage or any of that. I just needed someone to hold a warm cloth to my bottom as I pushed out my 10lb baby with his hand up by his face! I actually feel like they could have been more attention to the "holding my butt" job! FWIW, I had a small tear along the epis scar from my first birth and a labial tear (which REALLY!!! hurt).

With #4 no one touched me, what so ever. I was in the kiddie pool and started pushing when my body felt like it. I felt his head before it started to crown and felt a thick rubber band like thing on his head (cervical lip). I told my mw and she encouraged me to either pant through a couple ctx or hold it with the next ctx as I pushed, which I did. And the baby's head slipped past that bit of my cervix, he came very quickly. I didn't want anyone's hands on me this time. I think being in the pool hand alot to do with it. There was already a warm presence around my bottom and didn't need anyone to "hold me" with a warm cloth like I did with the previous (land) birth. No tears, skid marks or anything. Totally intact... even with the almost 10lb baby being born. It was much harder for me to take the down time new mamas need because within 4 days I did NOT feel as though I had just had a baby.

I think it most important for any birth attendant to respect the needs and wishes of the mother. If mama wants someone to hold her bottom, then someone better be ready to hold her. If mama doesn't, they better be sitting on their hands if it is what it takes for the attendant to be hands off. It's all about listening to what the mama needs, not doing what they think it "best".
post #30 of 87
Quote:
Originally Posted by pamamidwife
I swear the goal here is NOT to give myself kudos - believe me, I still have plenty to learn in midwifery. I really wanted to let women know that the idea that somehow someone else can "prevent" tears for them may not always - or most times - be true.
...I completely have to agree with you because during my pregnancy I did what my doctor said to prevent tearing, the massaging and everything (even during labor she massaged my perineum (very unhelpful) ) and I had 2nd degree lacerations anyways.
post #31 of 87
Not to derail the thread, but what exactly does "butt-holding" entail? And why did you need it done?

If it just made it feel better, well shoot, I know Pam's not saying that you shouldn't do what makes you feel better. She's just making the case that perineal massage/support does not prevent tears and that it can actually create conditions for them to be more likely and/or hinder the birth if it inhibits the mother or causes her to tense up.

But if it feels better to have the midwife have her hands on your vulva or butt or bellybutton or whatever , great!
post #32 of 87
Quote:
Originally Posted by Desdamona
I think being in the pool hand alot to do with it. There was already a warm presence around my bottom and didn't need anyone to "hold me" with a warm cloth like I did with the previous (land) birth. No tears, skid marks or anything. Totally intact... even with the almost 10lb baby being born. It was much harder for me to take the down time new mamas need because within 4 days I did NOT feel as though I had just had a baby.
Yes, yes, yes! That's an interesting point... I didn't need perineal or butt support because I did have the warm cushion of water. I was surprised I didn't tear because I was 9cm around 4am and then suddenly I could tell ds was past my cervix, he crowned at 4:32 and was born at 4:34 and I birthed the placenta at 4:36 so he and the placenta roared right through my perineum... I think it was thanks to the water softening my tissues and cushioning his head, and also the fact that no one was coaching the pushing phase.
post #33 of 87
Quote:
Originally Posted by fourlittlebirds
Not to derail the thread, but what exactly does "butt-holding" entail? And why did you need it done?

If it just made it feel better, well shoot, I know Pam's not saying that you shouldn't do what makes you feel better. She's just making the case that perineal massage/support does not prevent tears and that it can actually create conditions for them to be more likely and/or hinder the birth if it inhibits the mother or causes her to tense up.

But if it feels better to have the midwife have her hands on your vulva or butt or bellybutton or whatever , great!
Very good question.

I've doula'd at my friend's two births, and both times, she liked counterpressure on her back during some of her laboring contractions (before 10 cm.) Technically, I gave this pressure on an area some would concider her butt. Pants off, buttcrack involved, but you know--it's low and on the coccyx area/what have you.

"Butt holding" is the next level....a bit lower than the above scenario (which I mention b/c I think we can all imagine counterpressure during labor more easily than this butt hold phenomenon) and during active decent.

The uterus is pushing, pushing, pushing that head out--powerful fundal force moving DOWN AND OUT.....to help counter that, my mws hands (3 of their hands) were supporting my bottom. My hand was in front, and their hands were literally on my butt, more butthole/butt/coccyx...not so much vulvar-area.

I wanted my butt held because it felt right at the time. In my homebirth video I demand "do what you're doing!" in a slur, when one of my mws was trying to adjust her position (crunched on my wood floor w/ her hands on my butt, which was elegantly draped over the couch back ) because it felt good to have the counterforce and solid-feeling support to balance the powerfully contracting uterus. (I always laugh at that part--it's such a classic LaborLand Demand!)

Maybe it's like a cough---when you have a violent, coughing cough you can't "control" it is less tolerable than a regular cough you can "work with", if that makes sense.

Totally different from the vulvar-sweep that these OBs and CNMs are constantly doing--blech. YET buttholding *is* hands-on.

I brought it up not to derail Pam's thread, but to add this aspect, because I thought it was a tangent that might be applicable to a lot of women who are in the "hands off!" boat but did appriciate butt holding during birth.

Also, I wanted Pam's esteemed opinion on this matter in particular--could such butt-holding actually prevent a tear? or is it an activity that simply supports a birthing mama (which in itself could prevent a tear, one could argue.) Does Pam hold butts? Does Pam have a comment on butt-holding?

HTH, 4 lil' birdies
post #34 of 87
Quote:
Originally Posted by tinyshoes
Totally different from the vulvar-sweep that these OBs and CNMs are constantly doing--blech. YET buttholding *is* hands-on.
Can you explain what a "vulvar sweep" is? Eek.
post #35 of 87
With my second babe, I had fledgling hemorrhoids that I didn't want exacerbated, and my mw knew about it and gave support there. With my third I don't think the mw did, but I was *really* pushing with my second -- my water didn't break until I had been pushing for a bit and I just wanted it to pop so the contractions would become more effective! So I think that had something to do with the hemorrhoids getting worse; with my third babe, I pushed on hands and knees and she came quickly without much actual pushing. That's what butt holding was, in my experience -- counter pressure for the area you're NOT trying to push a baby out of.

I also might want counter pressure on my labia because I have extensive labial varicose veins, and I would tense up and shy away from pushing if it were bothering them -- but again, birthing on hands and knees didn't really bother them. Squatting probably would.
post #36 of 87
Thread Starter 
I've been known to hold butts, but it seems to be more an issue of "grounding" a woman or because of the fear of poo, not to help prevent tearing. I've had women in water ask me to put my hands down there, but I do lightly and then as the baby crowns, I pull away. I think that's a grounding thing, too.
post #37 of 87
Thread Starter 
Quote:
Originally Posted by NYCVeg
Can you explain what a "vulvar sweep" is? Eek.
where the head is coming down the birth canal and the provider inserts the first two fingers and reams the tissues inside the vagina back and forth, while exerting pressure downwards. some providers call this massage, others call it "making room". i call it OUCH.
post #38 of 87
Quote:
Originally Posted by Kathryn
You know, I had no ring of fire. I slowed down horribly because the sensation of my bones moving to let the baby pass was overwhelming. The actual crowning didn't hurt at all. It was just the moving bones. It was scary because I had no idea to expect that, they'd never touched on it in prenatals or class. It was always only about the "ring of fire" which I never had.
This is kind of what I experience as well....no burning, just spreading of my bones.
post #39 of 87
Quote:
Originally Posted by pamamidwife
where the head is coming down the birth canal and the provider inserts the first two fingers and reams the tissues inside the vagina back and forth, while exerting pressure downwards. some providers call this massage, others call it "making room". i call it OUCH.
I watched a CNM do this in a hospital birth until the mama bled. When I expressed concern, she said, "Within normal limits."
post #40 of 87
Quote:
Originally Posted by pamamidwife
where the head is coming down the birth canal and the provider inserts the first two fingers and reams the tissues inside the vagina back and forth, while exerting pressure downwards. some providers call this massage, others call it "making room". i call it OUCH.
OUCH only begins to describe it! She called it perineal massage!
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