Perineal tearing: the controversy of hands on vs hands off - Page 3

[mezzaluna]

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.

yup, my OB did this : i was also guided into a semi-reclined seated position. 2nd degree internal tearing that not only took a long time to recover from, but also had me bleeding so much after delivery that i got a heck of a lot of interventions to try to stop it, only to realize i just needed more stitching up.

i thought that because i said i wanted to be free to choose my position in labor, that i didn't want coached pushing, and preferred to tear rather than have an episiotomy i'd done all i could do to be on the same page with my OBs. wish i'd had this to read then!

she did say a little regretfully that she would have done an episiotomy right where i tore, but she knew i didn't want that. d@mn straight!

[orangebird]

My midwives never touched me during pushing and I never tore. The midwives I work with OTOH can't seem to keep their hand off (or out) during the pushing phase (which honestly drives me crazy and I'm almost thinking of quitting that job because it bugs me so much) and it seems like they tear about half the time but usually never bad. I can't say I know what the truth is but I believe in my heart it's better to keep the hands off!

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 asked my MW to put pressure there on my last birth too because it felt like he was trying to come out my ass. I think his elbow was the culprit as he came our with a hand by his face. (after the MW pushed it off his head, that was probably the only time she felt down there and it was because his heart tones were staying around 60 and not coming up)

[CalebsMama05]

wow this is amazing. my labor nurse put her fingers on my perineum to let me feel where she needed for me to push at and I liked it cuz it was helpful but she was very hands off and said i was doing a great job without it. my ob stood accross the room until i begged for an episiotomy and then he did that caught my son and stitched me up.

honestly though if i hadn't been ON MY BACK i probably could have done it without the episiotomy. in that situation though it was the only way my son was coming out as he came out in only 1.5 pushes after the episiotomy after 45 minutes of *almost crowning*

so in addition to hands off mamas need freedom of movement as well. I wanted to deliver squatting or sitting like on a toilet since it felt just like a bowel movement and I was more comfortable having a bowel movement (as it were) upright. I was told later (although this was not explained beforehand) that had i NOT gotten the epidural i could have pushed him out any which way.

[cottonwood]

Originally Posted by brisen

With my second babe, I had fledgling hemorrhoids that I didn't want exacerbated, and my mw knew about it and gave support there. [...] That's what butt holding was, in my experience -- counter pressure for the area you're NOT trying to push a baby out of.

Ohhhh... well, that I can understand.

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.

God, this pisses me off.

[homemademomma]

THANK YOU for posting that!
it always seems to me that the less we do, the better the outcome. i hate fingers in the vagina. my preceptor was all about pushing down on a woman's rectum through her vagina "to show her where to push" . oh yes, and the vulvar sweep is great too. talk about irritating to the tissues (and mom!)

[tinyshoes]

Originally Posted by Brisen

That's what butt holding was, in my experience -- counter pressure for the area you're NOT trying to push a baby out of.

Well said!! succinctly said......

Originally Posted by homemademomma

. i hate fingers in the vagina. my preceptor was all about pushing down on a woman's rectum through her vagina "to show her where to push"

yeah--uh....there *is* a baby's head in your vagina, hinting at where the "action" is!

Thanks for your butt-holding feedback, Pam.

[pamamidwife]

it's interesting because I've done some pelvic floor pressure with women who have malpresentations (the worst was the mama with a brow presentation who was complete and pushing twice over a 24 hour period before she really pushed the baby out!). some women really want it, others not so much.

I think the poster who said, whatever the woman wants or requests - is right on. Nothing should be standard.

[NYCVeg]

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.

THAT'S what they call "perineal massage"?!? I thought "perineal massage" was the mw resting her hand on the outside of the perineum to provide counter-pressure and/or possibly rubbing the perineum (again, from the outside only) to relax the muscles.

Um, okay, off to revise my birth plan...

[sapphire_chan]

Ye-eah. Ouchie...

And, um, , wouldn't the fingers there make pooping *more* likely? I mean, it's going to happen anyway, but I'd think that'd push more out...

[cottonwood]

I thought "perineal massage" was the mw resting her hand on the outside of the perineum to provide counter-pressure and/or possibly rubbing the perineum (again, from the outside only) to relax the muscles.

I think different midwives probably do it differently.

I believe that the midwife attending my first birth did a light perineal massage on the outside alternating with support with warm compresses. I don't remember feeling it -- to be honest, I've blocked a lot of it out. What I do remember was feeling very exposed and uncomfortable -- feelings that are counterproductive to getting the baby out. And of course her doing the perineal massage required that I be in a reclining position. So even if perineal massage did relax the tissues (which I don't believe) the other negative effects for me would have nullified that. In other words, the "massage" stressed me out and therefore tensed the tissues.

[minkajane]

Wow, that article was a BIG eye-opener! I’ve heard nothing but good things about perineal massage and things like that. That makes me even more firm in my stance to be a VERY hands-off midwife (I’m a student now). Thank you!

[channelofpeace]

A few questions...

Thanks for this article... it has given me a lot to think about.

I was at my sister's prenatal appt (i am her doula) with the midwife i am considering using and the midwife suggested that she do prenatal perineal massage. She said that it would help her be able to relax the muscles when there was a lot of pressure from the babies head pushing on it and to train the muscles to relax under pressure.

I have a history of sexual abuse and have issues with tensing those muscles anyways (sex took a lot of getting used to and relaxation on my part). Would perineal massage help in this case? I would love some input

[pamamidwife]

Prenatal perineal massage has been shown to never improve the outcome of tearing.

IMHO, keeping your hands on your own body and everyone else's hands away will help you. Especially with women who have a history of sexual abuse, we need to be aware that any touch during labor and birth can be traumatic - not only emotionally, but physically as well.

[tinyshoes]

Originally Posted by fourlittlebirds

So even if perineal massage did relax the tissues (which I don't believe) the other negative effects for me would have nullified that. In other words, the "massage" stressed me out and therefore tensed the tissues.

I agree with you--that probably perineal massage does not relax the tissues.

Furthermore, the concept of perineal massage is just another "women's bodies are broken" message, but this time it is in disguise....."perineal massage" is a suggestion bandied about by the earthy-birth community, especially with CNMs and "crunchy" MDs.

But as we've discussed here, and have come to the conclusion here, perineal massage does not help, it hinders. It can cause a mother to tense up or feel self-concious, and does not prevent a tear.

"I need to massage you because your body is an inherent failure and will not stretch without deliberate intervention." (Or, "massage while pregnant because your body is a failure that will not stretch withough deliberate intervention.")

Anyway--I didn't realize I am ANTI-perineal massage until this point in this thread! Until just now, I've thought massage was silly/unneccesary, but always thought, "whatever floats your boat." Now I deem it another misguided attempt to control birthing women.

The more I think about it, the more I remember the image of the doctor's busy fingers during my friend's birth, I think unwanted vulvar touching is almost as bad as unwanted perineal cutting.

[Arwyn]

My SIL (due in a monthish - really mainstream) was talking about having read "Birthing From Within" the other day (I was a little shocked she read something so out there, honestly), and we had this conversation:

SIL "The author obviously had some biases"

me "Oh, like what?"

SIL "Well, she's completely against episiotomy."

me "As well she should be - all the research says that routine episiotomy is harmful and that barring very very few real emergencies should never be used."

SIL "...... So, you're against episiotomy then?"

me "Yup." And I explained about how tearing was better, that episiotomy lead to more and worse tears than you ever get without it, mentioned that getting upright could help prevent tears, etc. Then she asked "So, how do you avoid an episiotomy?"

This is where I totally blanked. A couple years ago, before I knew better, I probably would have suggested pre-labor perineal massage (by herself or with a partner) or warm compresses or perineal support - all that hands-on crap. Now? After a pause where I marveled at the stupidity of the question (how does one avoid shooting oneself in the head? don't shoot yourself in the head!!!), I told her about an article I had read in Midwifery Today recently that answered that very question: "How do you avoid episiotomy? Don't do one." And told her it really was that simple - just tell her provider not to do an episiotomy under any circumstances without explicit consent in the case of an emergency.

But to someone like my sister in law, I might as well be telling her to jump over the moon. She's planning an epidural, with an OB, in a hospital that has a 40% c/sec rate. "Just do nothing" is not something she's interested in hearing, and there's no way she'll listen to "How do you avoid an episiotomy? Give birth at home with a hands off midwife and no drugs." What am I supposed to say to someone who just doesn't get it??

Anyway - Pamela, I can't believe you wrote that article! I remember reading it in MT and thinking "Oooooo, can I have this midwife, pleeeeeeeze? As midwife, preceptor, personal goddess, whatever!"

[Brisen]

I had my first prenatal for this preg today. With a new midwife, in a new practice (I'm in Ontario, my understanding is they have to work in a group practice, but I could be wrong). She will be my primary midwife.

She was great! I was so happy. She was everything I wanted my past midwives to be but they weren't. I had heard she was very hands-off and I felt really at ease talking to her. She just came right out and asked if there was anything about my past births that I didn't want to have happen again, or that didn't happen that I wanted to have happen. So, I told her that so far, I've done most of the labouring myself, all alone, no fussing, she said she understood. I said that this time, I want to keep on doing it myself for the birth and, if I want to at the time, catch the baby myself. She was supportive of it, but with the way midwives are regulated here -- they have to document everything. She said it wouldn't be a problem, though. I think her biggest concern is the other midwives! She started talking about how some midwives in ontario are former RNs, some were midwives in Britain, and some -- like her -- were practising in Ontario as midwives before regulation. She then suggested that if I wanted, I could use their birthtub to create a personal space to discourage the midwives from interfering with me. She also told me a story she had read in Birthing From Within about a woman in Mexico who would go into a room, lock the door, birth the baby, and when the baby was born she would tell people they could come in now. She didn't say "Hey you could do this," I don't know if she's *allowed* to or not, but it occured to me later, maybe she was dropping a hint to me

She seemed happy to have someone not looking for interventions, too. I declined u/s and doppler, and we had a chat about not using doppler in labour -- midwives in ontario "have" to check heart rate every 15 mins in active labour and every 5 minutes when you're pushing. I said, well, can I just decline? Will you get in trouble? (I figured checking with a fetoscope might be tricky!) She said I could decline, but for her, she would like to check it once to be sure the baby is head down (oh, Ontario midwives also can't home deliver a breech baby : we would have to go to the hospital and have an ob actually do it, and from what I've heard, most are scared to do it and would just do a c-section. : ) She talked about how I could kneel to catch the baby myself best and protect myself from too much interference.

Anyway, I was really happy with how it went!

[the_lissa]

Originally Posted by Brisen

I had my first prenatal for this preg today. With a new midwife, in a new practice (I'm in Ontario, my understanding is they have to work in a group practice, but I could be wrong). She will be my primary midwife.

She was great! I was so happy. She was everything I wanted my past midwives to be but they weren't. I had heard she was very hands-off and I felt really at ease talking to her. She just came right out and asked if there was anything about my past births that I didn't want to have happen again, or that didn't happen that I wanted to have happen. So, I told her that so far, I've done most of the labouring myself, all alone, no fussing, she said she understood. I said that this time, I want to keep on doing it myself for the birth and, if I want to at the time, catch the baby myself. She was supportive of it, but with the way midwives are regulated here -- they have to document everything. She said it wouldn't be a problem, though. I think her biggest concern is the other midwives! She started talking about how some midwives in ontario are former RNs, some were midwives in Britain, and some -- like her -- were practising in Ontario as midwives before regulation. She then suggested that if I wanted, I could use their birthtub to create a personal space to discourage the midwives from interfering with me. She also told me a story she had read in Birthing From Within about a woman in Mexico who would go into a room, lock the door, birth the baby, and when the baby was born she would tell people they could come in now. She didn't say "Hey you could do this," I don't know if she's *allowed* to or not, but it occured to me later, maybe she was dropping a hint to me

She seemed happy to have someone not looking for interventions, too. I declined u/s and doppler, and we had a chat about not using doppler in labour -- midwives in ontario "have" to check heart rate every 15 mins in active labour and every 5 minutes when you're pushing. I said, well, can I just decline? Will you get in trouble? (I figured checking with a fetoscope might be tricky!) She said I could decline, but for her, she would like to check it once to be sure the baby is head down (oh, Ontario midwives also can't home deliver a breech baby : we would have to go to the hospital and have an ob actually do it, and from what I've heard, most are scared to do it and would just do a c-section. : ) She talked about how I could kneel to catch the baby myself best and protect myself from too much interference.

Anyway, I was really happy with how it went!

Where in Ontario are you, may I ask? Feel free to pm me if you don't want to answer publically.

I dind't know about the checking heart tones regulations. My midwives definitely did not check the heart tones during labour every 15 minutes- every few hours they did. They never checked during pushing, but I only pushed for 5 or 10 minutes.

[Momof3Girlz]

Brisen:

Do you mind my asking you *who* is your midwife? Curious to know if we have the same one, Lol...

[pamamidwife]

I admit I do have a bias against episiotomy - it's easy to have one when you have scissors taken to your vagina!

[Brisen]

I had 2 homebirths in London -- they did check every 15 mins. It is once active labour starts, though, maybe that's the diff for you? They are supposed to enter it on the chart. My mw today said that they've only had one mom who didn't want doppler in labour, and they decided that they should ask her every 15 mins and have her verbally decline so they could record it. She said that they could probably just have me say no once & for all when they show up -- I think they just weren't sure what they were allowed to do with the first mom who declined.

I'm in Toronto now.